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

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DI RUANG............................................
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TANGGAL............s/d..........

A. PENGKAJIAN
1. IDENTITAS
PASIEN
Nama : …………………………
Umur : ………...…...…………..
Jenis kelamin : ........................................
Pendidikan : ........................................
Pekerjaan : ........................................
Status perkawinan : .......................................
Agama : .......................................
Suku : .......................................
Alamat : .......................................
Tanggal masuk : .......................................
Tanggal pengkajian : .......................................
Sumber informasi : .......................................

PENANGGUNG
Nama penanggung jawab : .......................................
Hub dgn pasien : .......................................

2. STATUS KESEHATAN
a. Status Kesehatan Saat Ini
 Keluhan utama
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 Alasan masuk Rumah Sakit dan perjalanan Penyakit saat ini
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 Upaya yang dilakukan untuk mengatasinya
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b. Status Kesehatan Masa Lalu

 Penyakit yang pernah dialami
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 Pernah dirawat
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 Alergi
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 Kebiasaan :(merokok/kopi/ alkohol/lain-lain yang merugikan
kesehatan)
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c. Riwayat Penyakit Keluarga :

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d. Diagnosa Medis dan therapy

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3. POLA FUNGSI KESEHATAN (11 Pola Fungsional Gordon)

a. Pemeliharaan dan persepsi terhadap kesehatan
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b. Pola Nutrisi/metabolic
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c. Pola eliminasi
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d. Pola aktivitas dan latihan

Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan
alat, 4: tergantung total.
Okigenasi:
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e. Pola tidur dan istirahat
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 f. Pola kognitif-perseptual
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g. Pola persepsi diri/konsep diri
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h. Pola seksual dan reproduksi
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i. Pola peran-hubungan
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j. Pola manajemen koping stress
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k. Pola keyakinan-nilai
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4. PEMERIKSAAN FISIK
a. Keadaan umum :..........................
Tingkat kesadaran : komposmentis/ apatis/ somnolen/ sopor/ koma
GCS : verbal :_______ psikomotor :______
mata:_______
b. Tanda-tanda vital : Nadi :_____Temp: _____ RR :______TD
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c. Keadaan fisik (IPPA)

1) Kepala dan leher
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2) Dada
 Paru
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 Jantung
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3) Payudara dan ketiak
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4) Abdomen
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5) Genetalia
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6) Integumen
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7) Ekremitas
 Atas
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 Bawah
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5. PEMERIKSAAN PENUNJANG
a. Data laboratorium yang berhubungan
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 A. ANALISA DATA

No Tanggal Data fokus Analisis Masalah

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 B. DIAGNOSA KEPERAWATAN
No Tanggal Dx Keperawatan Tanggal TTd
Dx Muncul teratasi

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 C. PERENCANAAN
Hari/Tanggal No Tujuan Intervensi Rasional
Dx (NOC) (NIC)

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 D. IMPLEMENTASI
No Evaluasi Formatif
Hari/Tgl Jam Tindakan Keperawata TTD
Dx

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 No
No Hari/Tgl Jam Evaluasi Ttd
Dx
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 E. EVALUASI
Lembar Pengesahan

Badung,..........................2016

Mengetahui,
Clinical Instructure/CI Mahasiswa,

(...................................................) (....................................................)
NIP. NIM.

Mengetahui,
Pembimbing Akademik

(..................................................................)
NIP

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