ASUHAN KEPERAWATAN PADA Tn / Ny./ Sdr …….

DENGAN………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
……………………………

I. Pengkajian (tgl……………, pukul: ………….WIB)

Identitas Klien

Nama :..........................................................................................................

Umur : .........................................................................................................

Jenis Kelamin : .........................................................................................................

Agama : .........................................................................................................

Suku/ Bangsa : .........................................................................................................

Pendidikan : .........................................................................................................

Pekerjaan : .........................................................................................................

Penghasilan : .........................................................................................................

Alamat : .........................................................................................................

MRS tgl/ jam : .........................................................................................................

Ruangan : .........................................................................................................

No. Reg : .........................................................................................................

Dx. Medis : .........................................................................................................

Identitas penanggung jawab

Nama : .........................................................................................................

Umur : .........................................................................................................

Jenis Kelamin : .........................................................................................................

Agama : .........................................................................................................

Suku/ Bangsa : .........................................................................................................

Pendidikan : .........................................................................................................

Pekerjaan : .........................................................................................................

Penghasilan : .........................................................................................................
Alamat : .........................................................................................................

Hub. Dengan klien : .........................................................................................................

Keluhan Utama : .........................................................................................................

..........................................................................................................

Riwayat Penyakit Sekarang : ............................................................................................

............................................................................................

............................................................................................

............................................................................................

............................................................................................

............................................................................................

............................................................................................

Riwayat Penyakit Dahulu : ............................................................................................

............................................................................................

............................................................................................

............................................................................................

Riwayat Penyakit Keluarga : ............................................................................................

............................................................................................

............................................................................................

............................................................................................

............................................................................................

Riwayat Psiko, Sosio, Spiritual:

Riwayat Psiko :.........................................................................................................

:.........................................................................................................

Riwayat Sosial : ........................................................................................................

.........................................................................................................

Riwayat Spiritual : .........................................................................................................

.........................................................................................................

ADL (Activity Daily of Life):

Pola Nutrisi

Sebelum sakit : ........................................................................................................

.........................................................................................................

.........................................................................................................

.........................................................................................................

Selama sakit :........................................................................................................

.........................................................................................................

.........................................................................................................

.........................................................................................................

Pola Eliminasi

Sebelum sakit : .........................................................................................................

:.........................................................................................................

:.........................................................................................................

:.........................................................................................................

Selama sakit : .....................................................................................................

:.........................................................................................................

:.........................................................................................................

:.........................................................................................................

Pola Istirahat

Sebelum sakit : ........................................................................................................

:.........................................................................................................

:.........................................................................................................
:.........................................................................................................

Selama sakit :.........................................................................................................

:.........................................................................................................

:.........................................................................................................

:.........................................................................................................

Pola Personal Higiene

Sebelum sakit : .........................................................................................................

:.........................................................................................................

:.........................................................................................................

:.........................................................................................................

Selama sakit :.....................................................................................................

:.........................................................................................................

:.........................................................................................................

:.........................................................................................................

Pola Aktivitas

Sebelum sakit : .........................................................................................................

:.........................................................................................................

:.........................................................................................................

:.........................................................................................................

Selama sakit :...................................................................................................

:.........................................................................................................

:.........................................................................................................

:.........................................................................................................
2. Pemeriksaan

2.1 Pemeriksaan Umum

Kesadaran:..................................., GCS: ................................................

Suhu :

Nadi :

RR :

BB :

TB :

Pemeriksaan Fisik:

Kepala : ....................................................................................................................

....................................................................................................................

....................................................................................................................

Mata : ....................................................................................................................

....................................................................................................................
....................................................................................................................

Hidung : ....................................................................................................................
....................................................................................................................

Mulut : ....................................................................................................................
....................................................................................................................

Telinga : ....................................................................................................................
....................................................................................................................

Leher : ....................................................................................................................
....................................................................................................................

Thorax :

I: ....................................................................................................................
....................................................................................................................

P: ....................................................................................................................
....................................................................................................................

P: ....................................................................................................................
....................................................................................................................

A: ....................................................................................................................

....................................................................................................................
Abdomen :

I: ....................................................................................................................
....................................................................................................................

A: ....................................................................................................................
....................................................................................................................

P: ....................................................................................................................
....................................................................................................................

P: ....................................................................................................................

....................................................................................................................

Genetalia : ..................................................................................................................

Ekstremitas :

Atas : Kanan: .......................................................................................................

.........................................................................................................

Kiri : .........................................................................................................

..........................................................................................................

Bawah : Kanan: .......................................................................................................

.........................................................................................................

Kiri : .........................................................................................................

..........................................................................................................

Pemeriksaan Penunjang: (tanggal:.............................)

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................
.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

.............................................................................................................................................
..............................................................................................................................................

.............................................................................................................................................

..............................................................................................................................................

Therapi (oleh dr tanggal )

..................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
......................................................................................

..................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
......................................................................................

..................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
......................................................................................

...............................................................................................................................................

Lamongan ,......................................

Mahasiswa

Yang mengkaji

----------------------------------------

NIM.