ASUHAN KEPERAWATAN PADA PASIEN .....

DENGAN DIAGNOSA
KEPERAWATAN ..... DI RUANG..... RS......

PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama : .........................................................................................
Umur : .........................................................................................
Agama : .........................................................................................
Jenis Kelamin : ...........................................................................................
Status : ...........................................................................................
Pendidikan :............................................................................................
Pekerjaan : ............................................................................................
Suku Bangsa :............................................................................................
Alamat : ..........................................................................................
Tanggal Masuk : ...........................................................................................
Tanggal Pengkajian : ...........................................................................................
No. Register : .............................................................................................
Diagnosa Medis : ............................................................................................

b. Identitas Penanggung Jawab

Nama : ............................................................................................
Umur : .............................................................................................
Hub. Dengan Pasien : ...........................................................................................
Pekerjaan : .............................................................................................
Alamat : ..............................................................................................

2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama
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2) Alasan masuk rumah sakit dan perjalanan penyakit saat ini

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3) Upaya yang dilakukan untuk mengatasinya

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 b. Status Kesehatan Masa Lalu
1) Penyakit yang pernah dialami
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2) Riwayat opname
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3) Alergi
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4) Kebiasaan (merokok/kopi/alkohol dll)

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c. Riwayat Penyakit Keluarga

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d. Diagnosa Medis dan terapi yang sudah diterima

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3. Pola kebutuhan dasar

a. Pola persepsi dan manajemen kesehatan
b. Pola nutrisi dan metabolik
Sebelum:
Saat sakit:
Terkait frekuensi makan ../sehari, rasa mual/muntah, penurunan nafsu makan, sensasi
rasa (lidah terasa pahit), dan sebagainya..
c. Pola eliminasi
1. BAB
Sebelum :
Saat sakit :
Terkait frekuensi BAB, konsistensi, warna, bau, keluhan nyeri, konstipasi, diare,
melena
2. BAK
Sebelum :
Setelah :
 Terkait frekuensi BAK, konsistensi, warna, bau, keluhan nyeri/disuria,
inkontinesia, anuria, poliuri, hematuri/tidak

d. Pola Latihan dan aktivitas

Indeks KARTZ (Sebelum dan saat sakit)

e. Pola istirahat tidur

Sebelum :
Saat sakit :
Terkait durasi tidur, waktu dimulai tidur dan bangun, kualitas tidur (puas/tidak,
insomnia ?), dsb

f. Pola Persepsi dan kognitif

g. Pola konsep diri dan persepsi diri

h. Pola peran hubungan

i. Pola toleransi terhadap stres (koping)

j. Pola reproduksi-seksualitas
Riwayat obstetri (wanita), menstruasi, dan sebagainya

k. Pola keyakinan dan nilai

4. Pengkajian Fisik
a. Keadaan umum : ……………………………………….
b. Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma
GCS : verbal:……….Psikomotor:……….Mata :……………..
c. Tanda-tanda Vital : Nadi =…… , Suhu =……. , TD =…………, RR =………
d. Keadaan fisik
1) Kepala dan leher :
2) Dada (Paru dan Jantung)
3) Abdomen
4) Genitalia
5) Ekstremitas (atas dan bawah)
e. Neurologis :
Status mental dan emosi :..........................................................................................
Pengkajian saraf kranial : .........................................................................................
Pemeriksaan refleks :.................................................................................................

5. Pemeriksaan Data Penunjang

a. Data laboratorium
b. Pemeriksaan radiologi
c. Hasil konsultasi
d. Pemeriksaan penunjang lainnya
Selanjutnya Tabel proses keperawatan:
1. Analisa data
2. Rumusan prioritas diagnosa keperawatan
3. Nursing Care Plan
4. Implementasi Keperawatan
5. Evaluasi (SOAP)