Lampiran 1

FORMAT ASUHAN KEPERAWATAN

I. Pengkajian
1.1 Identitas Klien
Nama : ..........................................................................................................
Umur : .........................................................................................................
Jenis Kelamin : .........................................................................................................
Agama : .........................................................................................................
Suku/ Bangsa : .........................................................................................................
Pendidikan : .........................................................................................................
Pekerjaan : .........................................................................................................
Penghasilan : .........................................................................................................
Alamat : .........................................................................................................
MRS tgl/ jam : .........................................................................................................
Ruangan : .........................................................................................................
No. Reg : .........................................................................................................
Dx. Medis : .........................................................................................................

1.2 Identitas penanggung jawab

Nama : .........................................................................................................
Umur : .........................................................................................................
Jenis Kelamin : .........................................................................................................
Agama : .........................................................................................................
Suku/ Bangsa : .........................................................................................................
Pendidikan : .........................................................................................................
Pekerjaan : .........................................................................................................
Penghasilan : .........................................................................................................
Alamat : .........................................................................................................
Hub.Dengan klien: .........................................................................................................

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

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

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1.5 Riwayat Penyakit Dahulu : ............................................................................................
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1.6 Riwayat Penyakit Keluarga : ............................................................................................
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1.7 Riwayat Psiko, Sosio, Spiritual:
Riwayat Psiko :

Riwayat Sosial :

Riwayat Spiritual:

1.8 ADL (Activity Daily of Life):

1. Pola Nutrisi
Sebelum sakit :

Selama sakit :

2. Pola Eliminasi
Sebelum sakit :

Selama sakit :

3. Pola Istirahat
Sebelum sakit :

Selama sakit :

4. Pola Personal Higiene

Sebelum sakit :

Selama sakit :
 5. Pola Aktivitas
Sebelum sakit :

Selama sakit :

2. Pemeriksaan
2.1 Pemeriksaan Umum
Kesadaran:..................................., GCS: ................................................
Suhu :
Nadi :
RR :
BB :
TB :

2.2 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 :
2.3 Pemeriksaan Penunjang Khusus Mata:
Pemeriksaan oftalmoskop :

Pemeriksaan lapang pandang perifer:

Pemeriksaan inflamasi:

Pengukuran tonografi:

Pengukuran genioskopi:

Tes provokatif:

Tes toleransi glukosa:

 ANALISA DATA

NAMA : RUANG :
UMUR : NO.REG :
NO ANALISIS DATA ETIOLOGI PROBLEM
 RUMUSAN DIAGNOSA

NAMA : RUANG :
UMUR : NO.REG :
NO RUMUSAN DIAGNOSA TANGGAL TANGGAL TTD
DITEMUKAN TERATASI
 RENCANA KEPERAWATAN

NAMA : RUANG :
UMUR : NO. REG :
TGL/ DX. KEP TUJUAN INTERVENSI RASIONAL TTD
JAM
 IMPLEMENTASI

NAMA : RUANG :
UMUR : NO.REG :
NO DX. KEP TGL/ IMPLEMENTASI TTD
JAM
 EVALUASI

NAMA : RUANG :
UMUR : NO.REG :
NO DX. KEP TGL/ CATATAN PERKEMBANGAN TTD
JAM