Pasuruan
Mengetahui,
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ASUHAN KEPERAWATAN
Nama Mahasiswa :
NIM :
I. PENGKAJIAN
A. DATA UMUM KLIEN
5. Riwayat KB
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6. Riwayat Kesehatan
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7. Riwayat Keluarga
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Genogram
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Keterangan:
: Laki-laki Meninggal
: Wanita Meninggal
: Laki-laki
: Wanita
: Klien
: Garis Keturunan
: Garis Keturunan
: Tinggal Serumah
c. Lingkungan rumah
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9. Kebutuhan Dasar
a. Cairan dan Nutrisi
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c. Personal Higiene
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f. Pola Eliminasi
BAB
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BAK
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b. Tanda-tanda Vital :
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c. Kepala-Leher
Inspeksi dan Palpasi
Kepala :
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Mata :
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Hidung :
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Mulut dan Tenggorok :
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Telinga :
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Leher :
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d. Dada
Thorak :
Inspeksi : _________________________________________________________
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Palpasi : _________________________________________________________
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Perkusi : __________________________________________________________
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Auskultasi :________________________________________________________
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Cordis :
Inspeksi :__________________________________________________________
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Palpasi : __________________________________________________________
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Perkusi :___________________________________________________________
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Auskultasi :________________________________________________________
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e. Abdomen:
Inspeksi : _________________________________________________________
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Palpasi : _________________________________________________________
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Perkusi : _________________________________________________________
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Auskultasi :_________________________________________________________
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f. Genetalia-Rektal
Genetalia
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Rektal
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g. Integumen
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h. Ektremitas
Ekstremitas atas :_________________________________________________
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Ekstremitas bawah : __________________________________________
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13. Terapi
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Ruang :
Nama Pasien :
No. Register :
Ruang :
Nama Pasien :
No. Register :
Ruang :
Nama Pasien :
No. Register :
V. IMPLEMENTASI KEPERAWATAN
Nama Klien :
No. Reg :
No Tgl Diagnosa Jam Implementasi Evaluasi Hasil
Keperawatan
V. IMPLEMENTASI KEPERAWATAN
Nama Klien :
No. Reg :
Diagnosa
No Tgl Jam Implementasi Evaluasi Hasil
Keperawatan
VI. CATATAN PERKEMBANGAN KLIEN
Nama Klien : Umur : Tempat Praktek :
No. Reg : Tgl Praktek : Dx Medis :
No. Tgl S O A P I E
Dx
VI. CATATAN PERKEMBANGAN KLIEN
Nama Klien : Umur : Tempat Praktek :
No. Reg : Tgl Praktek : Dx Medis :
No. Tgl S O A P I E
Dx