FORMAT ASUHAN KEPERAWATAN

JURUSAN KEPERAWATAN POLTEKKES KEMENKES PONTIANAK

A. PENGKAJIAN
1. Pengumpulan Data
a. Identitas pasien
Nama : …………………………………….............................................
No. RM : ………………………………………………………………….
Umur : …………………………………….............................................
Jenis kelamin : …………………………………….............................................
Agama : …………………………………….............................................
Suku : …………………………………….............................................
Pendidikan : …………………………………….............................................
Alamat : …………………………………….............................................
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Pekerjaan : …………………………………….............................................
Tanggal masuk : …………………………………….............................................
Tanggal pengkajian : …………………………………….............................................
Diagnosa medis : …………………………………….............................................
Dokter penanggung jawab : …………………………………….............................................
b. Identitas penanggung jawab
Nama : …………………………………….............................................
Jenis kelamin : …………………………………….............................................
Hubungan dengan pasien : …………………………………….............................................
2. Riwayat Penyakit
a. Riwayat Penyakit Sekarang
1) Alasan masuk rumah sakit sakit
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2) Keluhan saat dikaji
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b. Riwayat penyakit dahulu
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c. Riwayat kesehatan keluarga

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3. Genogram
(Gambarkan)

Keterangan :

 : Laki-laki : Pasien

 :Laki-laki meninggal : Tinggal Dalam Satu Rumah

 :Perempuan

 :Perempuanmeninggal

4. Data Biologis
a. Pola nutrisi
SMRS : ………………………………………………………………………………………..
MRS : ………………………………………………………………………………………..
b. Pola minum.
SMRS : ………………………………………………………………………………………..
MRS : ………………………………………………………………………………………...
 c. Pola eliminasi
SMRS : …………………………………………………………………………………………
MRS : …………………………………………………………………………………………
d. Pola istirahat/tidur
SMRS : ……………………………………..............................................................................
MRS : ……………………………………..............................................................................
e. Pola hygiene
- Mandi
SMRS : ……………………………………..............................................................................
MRS : ……………………………………..............................................................................
- Cuci rambut
SMRS : ……………………………………..............................................................................
MRS : ……………………………………..............................................................................
- Gogok gigi
SMRS : ……………………………………...............................................................................
MRS : ……………………………………...............................................................................
5. Pola aktifitas
SMRS : ……………………………………..............................................................................
MRS : ……………………………………...............................................................................
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Aktifitas 0 1 2 3 4
Mandi
Berpakaian
Eliminasi
Mobilisasi ditempat tidur
Pindah
Makan dan minum

Keterangan : 0 = mandiri
1 = dibantu sebagian
2 = perlu bantuan orang lain
3 = perlu bantuan orang lain dan alat
4 = tergantung orang lain tidak mandiri
6. Data Sosial
a. Hubungan dengan keluarga
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b. Hubungan dengan tetangga
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c. Hubungan dengan pasien sekitar
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d. Hubungan dengan keluarga pasien lain
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7. Data Psikologis
a. Status emosi

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b. Peran diri

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c. Gaya komunikasi

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8. Pemeriksaan Fisik
a. Keadaan umum : …………………………..
Kesadaran : E…. M …… V….. (GCS = ……) = ………………..
TTV : TD = ………….. mmHg
N = …………... x/menit
RR = …………... x/menit
S = …………...ºC
b. Kepala
Inspeksi : …………..................................................................................................................
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Palpasi : …………..................................................................................................................
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c. Mata
Inspeksi : …………...................................................................................................................
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Palpasi : …………...................................................................................................................
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d. Hidung
Inspeksi : …………..............................................................................................................
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Palpasi : …………..............................................................................................................
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e. Telinga
Inspeksi : …………..............................................................................................................
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Palpasi : ………….................................................................................................................
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f. Mulut
Inspeksi : …………................................................................................................................
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Palpasi : ………….................................................................................................................
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g. Leher
Inspeksi : …………..................................................................................................................
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Palpasi : …………...................................................................................................................
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h. Thoraks (paru-paru)
Inspeksi : ………………………………………………………...............................................
Palpasi : ………………………………………………………...............................................
Auskultasi : ………………………………………………………...............................................
 Perkusi : ………………………………………………………...............................................
i. Thoraks (jantung)
Inspeksi : ………………………………………………………...............................................
Palpasi : ………………………………………………………...............................................
Auskultasi : ………………………………………………………...............................................
Perkusi : ………………………………………………………...............................................
j. Abdomen
Inspeksi : ………………………………………………………...............................................
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Palpasi : ………………………………………………………...............................................
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Perkusi : ………………………………………………………................................................
Auskultasi : ………………………………………………………................................................
k. Genetalia
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l. Ekstremitas

Kanan Kiri

Keterangan: …………………………………………..

9. Data Penunjang
LABORATORIUM
…………….. Hasil Nilai Normal
 RONTGEN

b. Pengobatan
 ANALISA DATA

NO. DATA ETIOLOGI MASALAH

NO. DATA ETIOLOGI MASALAH
C. DAFTAR MASALAH

NO. DIAGNOSA KEPERAWATAN TANGGAL MASALAH PARAF

DITEMUKAN TERATASI
D. RENCANA ASUHAN KEPERAWATAN

NO DIAGNOSA KEPERAWATAN NOC NIC RASIONAL PARAF

NO DIAGNOSA KEPERAWATAN NOC NIC RASIONAL PARAF
NO DIAGNOSA KEPERAWATAN NOC NIC RASIONAL PARAF
E. CATATAN PERKEMBANGAN DAN EVALUASI

NO. TANGGAL CATATAN KEPERAWATAN CATATAN PERKEMBANGAN DAN PARAF

DX EVALUASI