FORMAT PENGKAJIAN

DOKUMENTASI TINDAKAN ASISTENSI KEPERAWATAN

I. Biodata umum
1. Nama Pasien : …………………………………………………..
2. Alamat : …………………………………………………..
3. Jenis kelamin : …………………………………………………..
4. Umur : …………………………………………………..
5. Agama : …………………………………………………..
6. Tanggal MRS : …………………………………………………..
7. Tanggal pengkajian : …………………………………………………..
8. No Reg : …………………………………………………..
9. Diagnose medis : …………………………………………………..

II. ANAMNESE
1. KELUHAN SAAT MRS :
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2. KELUHAN SAAT INI :

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3. A. DATA OBJEKTIF :
a. Keadaan umum : ..................... ..........................................
b. Kesadaran : ..................... ..........................................
c. Tekanan darah : ..................... MmHg
d. Nadi : ..................... x/ menit
e. Nafas/RR : ..................... x/menit
f. Suhu : ..................... °C
g. BB : ..................... Kg
 B. PEMERIKSAAN PENUNJANG
1. LABORATORIUM :

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2. RADIOLOGI

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4. POLA KEBIASAAN SEHARI – HARI

NO POLA KEBIASAAN SEBELUM SAKIT SAAT SAKIT

Pola nutrisi
a. Makan
Frekuensi

1 Keluhan
b. Minum

Jenis
Jumlah
Keluhan
Pola eliminasai
2
A. BAK
Frekuensi
Jumlah
Warna
 Keluhan
B. BAB
Frekuensi
Konsistensi
Warna

Keluhan

Istirahat
a. Tidur siang
3
b. Tidur malam
c. Keluhan

Personal hygiene
a. Mandi
1. Frekuensi
2. Metode
3. Keluhan
b. Keramas
1. Frekuensi
4 2. Menggunakan
3. Keluhan
c. Gosok gigi
1. Frekuensi
2. Menggunakan
3. Keluhan
d. Gunting kuku
1. Frekuensi
2. Keluhan
5 Pola kebiasaan spiritual
 IV. TERAPI DOKTER / TINDAKAN
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V. LAIN – LAIN
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 RESPON PASIEN TERHADAP PELAKSANAAN TINDAKAN

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 RESPON PASIEN TERHADAP PELAKSANAAN TINDAKAN

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