FORMAT PENGKAJIAN KEPERAWATAN

MENURUT TEORI KEPERAWATAN VIRGINIA HENDERSON

Asuhan Keperawatan pada ( Tn/ Ny..... dengan Diagnosa Medis :

Di Ruang .......................... RS/Klinik kota......
Tanggal ..... bulan..... tahun.......

A. PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama : Tn/ Ny /An ......................................................
Umur : ..... tahun ( tanggal lahir ---/---/-----)
Agama : Islam Kristen Budha Hindu dll.........
Jenis Kelamin : laki-laki perempuan
Status : belum kawin kawin Janda/duda
Pendidikan : Tdk Sekolah Tdk Tamat SD SD
SMP/sederjat SMA/sederjat PT
Pekerjaan : PNS Swasta IRT Dagang Buruh
dll.......
Suku Bangsa : Minang dll....................
Alamat : Jln............................................................... RT..... RW....
Kota ........................ no. Telp. ( .... ) ...........
Tanggal Masuk : ---/---/----
Tanggal Pengkajian : ---/---/----
No. Register :
0 0

Diagnosa Medis : ...............................................................................

b. Identitas Penanggung Jawab

 Nama : Tn/Ny...........................................................
Umur : .......... Tahun
Hub. Dengan Pasien : suami/ isteri/ Anak/ Ortu/ kerabat
Alamat : .................................................................................

2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
Saat MRS : ....................................................................................
.....................................................................................
.....................................................................................
Saat ini : ......................................................................................
......................................................................................
......................................................................................
......................................................................................
2) Upaya yang dilakukan untuk mengatasinya
...........................................................................................................
.............................................................................................................
.............................................................................................................

b. Satus Kesehatan Masa Lalu

1) Penyakit yang pernah dialami
............................................................................................................
Pernah dirawat ............................ dengan
penyakit ...................................
Alergi : Ya, dengan............................................... Tidak

2) Kebiasaan:
Merokok, perhari.......... batang/bungkus
Kopi, ..... x gelas perhari
Alkohol, .....x hari/minggu
Dll ......................................
 3) Riwayat Penyakit Keluarga
....................................................................................................................
4) Diagnosa Medis dan therapy
...........................................................................................................

3. Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)

a. Pola Bernapas
Sebelum sakit : .........................................................................................
Saat sakit : .........................................................................................
b. Pola makan-minum
Sebelum sakit : ..........................................................................................
Saat sakit : ..........................................................................................
c. Pola Eliminasi
Sebelum sakit :..........................................................................................
Saat sakit : .........................................................................................
d. Pola aktivitas dan latihan
Sebelum sakit :...........................................................................................
Saat sakit :...........................................................................................
e. Pola istirahat dan tidur
Sebelum sakit :...........................................................................................
Saat sakit :............................................................................................
f. Pola Berpakaian
Sebelum sakit :...........................................................................................
Saat sakit :...........................................................................................
g. Pola rasa nyaman
Sebelum sakit :...........................................................................................
Saat sakit :............................................................................................
h. Pola Aman
Sebelum sakit : ...........................................................................................
Saat sakit : ..........................................................................................
i. Pola Kebersihan Diri
Sebelum sakit :..........................................................................................
Saat sakit :..........................................................................................

j. Pola Komunikasi
Sebelum sakit :.......................................................................................
Saat sakit :.........................................................................................
k. Pola Beribadah
Sebelum sakit :........................................................................................
 Saat sakit : .......................................................................................
l. Pola Produktifitas
Sebelum sakit : ........................................................................................
Saat sakit : . ......................................................................................
m. Pola Rekreasi
Sebelum sakit : ........................................................................................
Saat sakit : ...... .................................................................................
n. Pola Kebutuhan Belajar
Sebelum sakit : ......................................................................................
Saat sakit : ......................................................................................
4. Pengkajian Fisik
a. Keadaan umum :
Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma
GCS : verbal:……….Psikomotor:……….Mata :……………..
b. Tanda-tanda Vital : Nadi = ……......…, Suhu = ………….,
TD =…....…....…, RR =…..........……

c. Keadaan fisik
1) Kepala dan leher : ...................................................................
2) Dada :
 Paru:
Inspeksi :......................................................................................
Palpasi :.......................................................................................
Perkusi :......................................................................................
Auskultasi : .................................................................................
 Jantung
Inspeksi :......................................................................................
Palpasi :.......................................................................................
Perkusi :......................................................................................
Auskultasi : .................................................................................
3) Payudara dan ketiak :
Inspeksi : ..........................................................................................
Palpasi : ...........................................................................................
4) Abdomen :
Inspeksi :...............................................................................................
Palpasi :................................................................................................
Perkusi :..............................................................................................
Auskultasi : .........................................................................................
5) Genetalia : ..........................................................................................
6) Integumen :.........................................................................................
 7) Ekstremitas :
Atas : ................................................ kekuatan otot: -----/-----
Bawah : ................................................ kekuatan otot: -----/-----

8) Neurologis :
Status mental dan emosi : .........................................................................

Pengkajian saraf kranial :

Nervus I (Olfaktorius)
Nervus II (Opticus )
Nervus III ( Okulomotorius)
Nervus IV ( Trochlearis )
Nervus V ( Trigeminus)
Nervus VI ( Abducen )
Nervus VII ( Facialis )
Nervus VIII ( Vestibulocohlearis):................................................
Nervus IX (Glosoparingeal)
Nervus X ( Vagus )
Nervus XI ( Asesoris )
Nervus XII ( Hipoglosus)
:......................................................
: ...................................................
: ..................................................
: .................................................
: .................................................
: ................................................
:..................................................
: ................................................
: .................................................
: .................................................
: ...................................................

Pemeriksaan refleks Fisiologis :

a) Anggota gerak atas : biceps, triceps, radio periostal, ulna,
periostal, brachio radialis: ............................................................
........................................................................................................
.
b) Anggota gerak bawah: reflek patela...: .........................................
...........................................................................................................

* Pemeriksaan reflek Patologi (Refleks suoerfisial ):

Hoffman ( hoffman tromkmer ), babinski, variasi babinski
(openheim, gordon schaefer, chaddock), rossolimo dan Mendel
Bechterew: ................................................................................
 Reflek Superfisila ( Superfisial-cuyaneus refleks ): Refleks dinding
perut (abdominal), refleks cremaster, bulbo cavernosus, anal &
gluteus: ................................................................................................
............................
 ..............................................................................................................
......
 Pemeriksaan Tanda Rangsangan Meningeal: ( kaku kuduk, burzinski
I,burzinskiII,Kernigsign,lasex) : .........................................................
..............................................................................................................
.
d. Pemeriksaan Penunjang
1) Data laboratorium yang berhubungan:
a) Darah lengkap
b) Kimia Darah
c) Faal Hepar
d) .......
2) Pemeriksaan radiologiz : .........................................................
3) Pemeriksaan .............................................................................
B. ANALISA DATA
A. Tabel Analisa Data
DATA Etiologi MASALAH
C. Tabel Daftar Diagnosa Keperawatan /Masalah Kolaboratif Berdasarkan Prioritas
D. Rencana Tindakan Keperawatan
NO TANGGAL
Hari/ /DIAGNOSA
No Dx Rencana Perawatan KEPERAWATAN TANGGAL Ttd
Ttd
Tgl JAM Tujuan dan NOC NIC TERATASI
Kriteria Hasil
DITEMUKAN
E. Implementasi Keperawatan

F. Evaluasi Keperawatan

Hari/Tgl
No No Dx Evaluasi TTd
Jam