ASUHAN KEPERAWATAN PADA..................................

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A. PENGKAJIAN
1. Data Umum
Identitas Klien
Nama : .........................................................
Umur : .........................................................
Agama : .........................................................
Jenis Kelamin : .........................................................
Status Marital : .........................................................
Pendidikan : .........................................................
Perkerjaan : .........................................................
Suku Bangsa : .........................................................
Alamat : .........................................................
Tanggal Masuk : .........................................................
Tanggal Pengkajian : .........................................................
No. Register : .........................................................
Diagnosa Medis : .........................................................

Identitas Penanggung Jawab

Nama : .........................................................
Umur : .........................................................
Hub. Dengan Klien : .........................................................
Pekerjaan : .........................................................
Alamat : .........................................................

2. Riwayat Kesehatan
Keluhan Utama :
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Riwayat Penyakit Sekarang :
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Riwayat Kesehatan Dahulu :
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Riwayat Kesehatan Keluarga :
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Genogram :
 Riwayat Sosiokultural :
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3. Pola Fungsi Kesehatan Gordon

a. Pola Persepsi dan Manajemen Kesehatan :

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b. Pola Nutrisi-Metabolik :
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c. Pola Eliminasi :
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d. Pola Aktivitas dan Latihan :
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e. Pola Kognitif dan Presepsi :
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f. Pola Persepsi-Konsep Diri :
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g. Pola Tidur dan Istirahat :
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h. Pola Peran – Hubugan :
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i. Pola Seksual-Reproduksi :
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j. Pola Toleransi – Koping :
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k. Pola Nilai – Kepercayaan :
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4. PEMERIKSAAN FISIK

a. Keadaan Umum :
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b. Tanda Vital :
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c. Kepala :
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d. Mata :
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e. Hidung :
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f. Telinga :
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g. Mulut :
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h. Leher :
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i. Dada dan Punggung :
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j. Abdomen :
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k. Ekstremitas :
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l. Genetalia :
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 m. Anus :
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5. DATA PENUNJANG (Pemeriksaan Diagnostik) :

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6. DATA TAMBAHAN :
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7. THERAPI

No. Tanggal awal Nama Dosis Rute Indikasi

diberikan

B. ANALISA DATA

Data Etiologi Masalah Kolaboratif/

keperawatan
C. TABEL DAFTAR MASALAH KOLABORATIF / DIAGNOSA
KEPERAWATAN

No. Tanggal dan Jam Diagnosa Keperawatan Tanggal dan jam

 ditemukan teratasi

D. DIAGNOSA KEPERWATAN BERDASARKAN PRIORITAS :

1. .............................................................................................................................
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 2. .............................................................................................................................
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3. .............................................................................................................................
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4. .............................................................................................................................
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5. .............................................................................................................................
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E. PERENCANAAN KEPERAWATAN :

No. No. Tujuan dan Kriteria Intervensi Rasional

Diagnosa Hasil

No. No. Tujuan dan Kriteria Intervensi Rasional

Diagnosa Hasil
F. IMPLEMENTASI KEPERAWATAN :

Hari/tgl/ No. Tindakan Keperawatan Evaluasi Nama

jam Dx dan
 TTD

G. EVALUASI

No. Hari/Tgl No. Dx Evaluasi Nama dan

TTD
LEMBAR PENGESAHAN
 DENPASAR, .........................................

MAHASISWA

(..................................................................)
NIM :................................................

PEMBIMBING AKADEMIK/CT PEMBIMBING RUANGAN/CI

(...........................................................) (......................................................)
NIK :.................................................. NIP : .............................................