Format Askep Ners
Format Askep Ners
DENGAN......................................................
DI...............................................................
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 : .........................................................
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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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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6. DATA TAMBAHAN :
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7. THERAPI
B. ANALISA DATA
1. .............................................................................................................................
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6. .............................................................................................................................
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E. PERENCANAAN KEPERAWATAN :
G. EVALUASI
MAHASISWA
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NIM :................................................
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NIK :.................................................. NIP : .............................................