Aplikasi Proses Keperawatan Pada ..........

Di Ruang Perawatan Aisyah Dalam

RSUD Sekarwangi Kabupaten Sukabumi
Tanggal ........................................

A. PENGKAJIAN
1. Deskripsi Pasien
Nama : .......................................................................................................
Umur : .......................................................................................................
Jenis Kelamin : .......................................................................................................
Alamat : .......................................................................................................
No. CM : .......................................................................................................
Tanggal Masuk : .......................................................................................................
Dx. Medis : .......................................................................................................

2. Exception Summary Data

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3. Penampilan Umum
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4. Pengkajian Terfokus
a. Anamnesa
1) Keluhan Utama
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2) Riwayat Kesehatan Sekarang
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3) Riwayat Kesehatan Masa Lalu

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b. Pemeriksaan Fisik
1) Kesadaran : ................................................................................................
2) TTV : TD : Suhu :
Nadi : RR :
3) Terfokus
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5. Data Biologis
No Pola Kebiasaan Sebelum Sakit Saat Sakit Keluhan
1 Nutrisi
a. Makan
- Frekuensi
- Jenis

b. Minum
- Frekuensi
- Jenis

2 Eliminasi
a. BAK
- Frekuensi
- Warna
- Jumlah
b. BAB
- Frekuensi
- Warna
- Konsistensi

3 Personal Hygiene
a. Mandi
b. Gosok Gigi
c. Keramas

4 Istirahat dan Tidur

a. Siang

b. Malam

5 Pola Aktifitas

c. Pemeriksaan Penunjang
1) Terapi Obat
Waktu
Tanggal Nama Obat Rute Dosis
Pemberian
2) Pemeriksaan Laboratorium
Jenis
Tanggal Hasil Nilai Normal Interpestasi
Pemeriksaan

3) Ronstgen/USG/EKG
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6. Mind Maping
B. ANALISA DATA
Data Etiologi Masalah
Data Etiologi Masalah
C. DIAGNOSA KEPERAWATAN
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D. NURSING CARE PLAN

Rencana Asuhan Keperawatan ..... Di Ruang ........................................
Dibuat Tanggal .............................. Nama Perawat Primer: ..............................
Diagnosa Perencanaan
No
Keperawatan Tujuan Intervensi Rasional
 Diagnosa Perencanaan
No
Keperawatan Tujuan Intervensi Rasional
 Diagnosa Perencanaan
No
Keperawatan Tujuan Intervensi Rasional
E. IMPLEMENTASI
Shift : ....................................
Tanggal : ....................................

Data Action Respon

Evaluasi Sumatif Shiff

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Tanggal : ....................................

Data Action Respon

Evaluasi Sumatif Shiff

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Tanggal : ....................................

Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................

Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................

Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................

Data Action Respon

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Shift : ....................................
Tanggal : ....................................

Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................

Data Action Respon

Evaluasi Sumatif Shiff

Shift : ....................................
Tanggal : ....................................

Data Action Respon

Evaluasi Sumatif Shiff

F. EVALUASI
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