Format Pengkajian Di-Ruang VK

ASUHAN KEPERAWATAN PADA PASIEN.......................
DENGAN.............................................................................................
DI RUANG.......................... RSU.....................................
TANGGAL.......................................................
A. PENGKAJIAN
Pengkajian pada pasien dilakukan pada tanggal……………...pukul…………di
Ruang…………RSU………………...................dengan metode observasi, wawancara,
pemeriksaan fisik dan dokumentasi (rekam medis)
1. PENGUMPULAN DATA
a. Identitas Pasien
Pasien Penanggung
(hubungan dg penanggung)
Nama : ………………………..... ……………………
Umur : ………………………..... ……………………
Jenis Kelamin : ………………………..... ……………………
Status Perkawinan: ………………………..... ……………………
Suku /Bangsa : ………………………..... ……………………
Agama : ………………………..... ……………………
Pendidikan : ………………………..... ……………………
Pekerjaan : ………………………..... ……………………
Alamat : ………………………..... ……………………
Alamat Terdekat : ………………………..... ……………………
Nomor Telepon : ………………………..... ……………………
Nomor Register : ………………………..... ……………………
Tanggal MRS : ………………………..... ……………………
b. Keluhan Utama
1) Keluhan utama masuk rumah sakit
…………………………………………………………………………………
…..
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………………………………………
2) Keluhan utama saat pengkajian
…………………………………………………………………………………
…..
…………………………………………………………………………………
…..
…………………………………………………………………………………
…………………………………………………………………………………
……………………………………………………………………………
c. Riwayat Obstetri
1) Riwayat menstruasi
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
2) Riwayat perkawinan
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
3) Riwayat kontrasepsi
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
4) Riwayat kehamilan, persalinan, dan nifas yang dulu
Anak ke- Kehamilan Persalinan Komplikasi Nifas Anak

No Thn Umur Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan JK BB PJ
kehamilan
5) Riwayat kehamilan, persalinan yang sekarang
a) Riwayat kehamilan
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
b) Riwayat persalinan
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
Diagnosa Medis:
..........................................................................................................................
Terapi saat pengkajian:
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
d. Riwayat Kesehatan Masa Lalu
1) Imunisasi
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
2) Riwayat alergi
........................................................................................................................
........................................................................................................................
........................................................................................................................
3) Riwayat kecelakaan
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
4) Riwayat dirawat di RS
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
5) Riwayat pemakaian obat
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
e. Riwayat penyakit keluarga
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
f. Pola Kebiasaan
1) Bernafas
Sebelum Pengkajian:……………………………………………………………
……………………………………………………………
……………………………………………………………
Saat Pengkajian : □ t.a.k (tidak ada keluhan), □ sesak saat menarik nafas,
□ sesak saat mengeluarkan nafas, □ nyeri waktu
bernafas,
□ batuk, □ dada berdebar
Data lain :
………………………………………………………….
…………………………………………………………..
2) Makan dan minum

……………………………………………………………
…………………………………………………………….
Saat Pengkajian : frekuensi makan (……..x/hari), jenis makanan
(………………), makanan pantangan (………………),
alergi makanan (………………..), porsi makan sehari
(…..porsi), minuman yg biasa diminum (……………….),
alcohol (……gelas/hari), merokok (…………..bgks/hari),
jumlah minum sehari (……..…..gelas/hari)
□ mual,
□ muntah (…...x/hari, volume……cc, konsistensi………),
□ nafsu makan menurun,
□ sulit mengunyah/menelan : ……………………………
□ sonde/NGT (……….x, kebutuhan………...kalori)
3) Eliminasi
……………………………………………………………
…………………………………………………………….
…………………………………………………………….
Saat Pengkajian : BAB frekuensi (…………x/hari), □ teratur, □ tidak
teratur
konsistensi (………………),Warna (………………),
Bau (………..)□ ada darah/lendir , □ konstipasi/obstipasi
BAK frekuensi (…………x/hari), warna (…………..),
Bau (……………), jumlah/volume (………..cc/kencing),
□ lancar, □ seret, □ darah, □ nyeri saat kencing,
□ terpasang dower kateter
4) Gerak dan aktivitas

Sebelum Pengkajian:……………………………………………………… ….
……………………………………………………………
……………………………………………………………
Saat Pengkajian : Jenis kegiatan utama……………, aktivitas yang biasa
dilakukan…………………, aktivitas yang tidak bisa
dilakukan…………………….., penyebab tidak bisa
beraktivitas……………………………………………...
Data lain :……………………………………………….
…………………………………………………………..
5) Istirahat dan tidur

……………………………………………………………
……………………………………………………………
……………………………………………………………
Saat Pengkajian : Jumlah jam tidur (….………………jam/hari),
□ sering terjaga
□ susah tidur
□ penggunaan obat tidur (obat ..…………..…………)
□ tidur siang (…….jam/hari)
Data lain :………………………………………………
…………………………………………………………
6) Kebersihan diri
……………………………………………………………
……………………………………………………………
Saat Pengkajian : Mandi, frekuensi (….x/hari), tempat (………………),
□ memakai sabun,
Cuci rambut, frekuensi (…..x/hari), □ memakai
shampoo, Pemeliharaan mulut dan gigi, frekuensi sikat
gigi (….x/hari, □ sebelum, □sesudah makan), □
memakai pasta gigi.
Berpakaian, frekuensi ganti baju (……x/hari)
Kebersihan kuku: □ bersih, □ kotor, keadaan kuku:
□ panjang, □ pendek,
Kemampuan membersihkan diri □ mandiri, □ dibantu
(oleh…………..)
Data lain :……………………………………………
………………………………………………………
7) Pengaturan suhu tubuh

……………………………………………………………
……………………………………………………………
Saat Pengkajian : □ perasaan panas, □ berkeringat, □ kemerahan

Data lain :………………………………………………
…………………………………………………………
8) Rasa nyaman
……………………………………………………………
……………………………………………………………
Saat Pengkajian : □Merasa tidak nyaman gatal, area gatal
(………………………………..…)
□Merasa tidak nyaman nyeri, skala nyeri(…….
……….), intensitas nyeri (…..……………), kualitas
nyeri(….…………….…..),
Lokasi nyeri (………………….), waktu (……….……),
penyebab nyeri ……………………………………...…
Data lain :……………………………………………….
…………………………………………………………..
9) Rasa aman
……………………………………………………………
……………………………………………………………
Saat Pengkajian : □ cemas, penyebab……………………………….……
□ takut, penyebab………………………………….…..
Data lain :………………………………………………
…………………………………………………………..
10) Data sosial
…………………………………………………………….
…………………………………………………………….
Saat Pengkajian : Jenis keluarga (…………………………), peran dalam
keluarga (………………………), pengambil keputusan
dalam keluarga……………………
Keharmonisan keluarga : □ harmonis, □ tidak
harmonis, penyebab……………………………….
Hubungan dengan tetangga □ baik, □ kurang baik,
Lingkungan rumah : kondisi lingkungan rumah ………
Kemampuan ekonomi keluarga…………………………
Hubungan dengan pasien lain………………………….
Hubungan dengan perawat……………………………
Data lain :………………………………………………
…………………………………………………………..
11) Prestasi dan produktivitas

……………………………………………………………
...........................................................................................
Saat Pengkajian : Prestasi yang pernah dicapai……………………………
Pengaruh pekerjaan terhadap penyakit…………………
Pengaruh penyakit terhadap produktivitas
…………………………………………………………
Data lain :………………………………………………
…………………………………………………………..
12) Rekreasi
……………………………………………………………
……………………………………………………………
Saat Pengkajian : Hobi pasien………………………………………….…
Kebiasaan rekreasi ………………………………….…
Data lain :………………………………………………
……………………………………………………….....
13) Belajar
……………………………………………………………
……………………………………………………………
Saat Pengkajian : Hal-hal yang perlu dipelajari berhubungan dengan
penyakitnya……………………………………………
Pemahaman pasien terhadap penyakitnya………………
…………………………………………………………..
14) Ibadah
……………………………………………………………
……………………………………………………………
Saat Pengkajian : Agama /kepercayaan yg dianut…………………………
Kebiasaan beribadah……………………………………
Data lain………………………………………………..
…………………………………………………………
g. Pemeriksaan Fisik
1) Keadaan Umum
a) Kesadaran : □ composmentis/sadar penuh, □ somnolen, □ koma
Data lainnya…………………………………………
b) Bangun Tubuh : □ kurus, □ sedang, □ gemuk
Data lainnya…………………………………………
c) Postur Tubuh : □ tegak, □ lordosis, □ kifosis, □ skoliosis,
Data lainnya…………………………………………
d) Cara Berjalan : □ lancar terkoordinir, □ terganggu,
Data lainnya……………….…………………………
e) Gerak Motorik : □ normal, □ tergangu,
Data lainnya…………………………………………
f) Keadaan Kulit
Warna : □ normal, □ ikterus, □ sianosis, □ pucat/anemis
Turgor : □ elastis, □ kurang elastis, □ jelek
Kebersihan: □ bersih, □ kurang bersih, □ kotor
Luka : □ tidak ada,
□ ada : □ terbuka, □ tertutup
Lokasi…………………………………………………
Luas luka………………………………………………
Warna…………………………………………………
Pus………………………………………………………
Hiperemi ………………………………………………
Jaringan…………………………………………………
Gejala Kardinal : TD :………....mmHg
N :…………..x/mnt
S :…………..oC
RR :…………x/mnt
g) Ukuran lain : BB sebelum hamil:………….kg
BB saat hamil:………………kg
TB :…………….cm
LILA :………….cm
2) Kepala
a) Kulit kepala □ bersih, □ kotor : □ ketombe, □ kutu
b) Rambut : □ rontok, □ jagung, □ merah
c) Nyeri tekan, lokasi………………………………………………………
d) Luka : …………………………………………………………………..
3) Mata
a) Konjungtiva : □ merah muda, □ anemis/pucat, □ ikterus/kuning
b) Sklera : □ putih, □ ikterus
c) Kelopak mata : □ oedema, □ benjolan, □ lingkaran hitam
d) Pupil : □ reflek pupil baik, □ pupil isokor, □ pupil midriasis
□ Bola mata menonjol
Data lainnya………………………………………………………………
4) Hidung
a) Keadaan : □ Bersih, □ Secret, □ Darah, □ Polip
b) Penciuman : □ Baik, □ Terganggu
c) Nyeri : □ nyeri tekan, □ Sinusitis, Lokasi………………………………...
d) Luka, □ Tidak ada, □ Ada :
5) Telinga
a) Keadaan : □ Bersih, □ Secret, □ Darah
b) Nyeri : □ tidak nyeri, □ nyeri tekan
c) Pendengaran, □ baik/normal, □ terganggu…………………………………
6) Mulut
a) Mukosa bibir : □ mukosa lembab, □ bibir sianosis, □ pucat, □ kering
b) Gusi : □ tidak berdarah, □ berdarah
c) Gigi : □ gigi lengkap, □ gigi bersih, □ caries/karang gigi, □ berlubang
d) Lidah : □ bersih, □ kotor,
e) Tonsil : □ normal, □ hyperemia pada tonsil, □tonsil membesar, □faring
radang
Data lainnya…………………………………………………………………
7) Leher
a) Inspeksi
Keadaan : □ baik/normal, □ Pembengkakan kelenjar tiroid, □ distensi
vena jugularis, □ kaku kuduk
b) Palpasi : □ kelenjar limfe membesar, □kelenjar parotis membesar,
□Pembengkakan kelenjar tiroid, □deviasi trakea, □teraba massa/tumor……
Data lainnya…………………………………………………………………
8) Thorax
a) Inspeksi
 Bentuk : □ simetris, □ asimetris
 Gerakan dada: □ bebas, □ terbatas, □ retraksi dada, □ palpitasi
 Payudara : □ simetris, □ asimetris
□ Nyeri………………………………………………………….
□ Bengkak………………………………………………………
□ Luka………………………………………………………..
………………………………………………………………….
b) Palpasi
 Pengembangan dada : □ simetris, □ asimetris
 Vibrasi tactile premitus : □ simetris, □ asimetris
 Nyeri tekan: ………………………………………………………….
…………………………………………………………………………
…………………………………………………………………………
c) Perkusi
 Suara paru : □ Sonor/resonan, □ dullnes, □ hypersonor
d) Auskultasi
 Suara paru : □ vesikuler/normal, □ ronchi, □ wheezing □ rales
 Suara jantung: □ Regular, □S1-S2 tunggal, □ Murmur, □ Gallop
Data lainnya………………………………………………………………
9) Abdomen
a) Inspeksi
 Pemeriksaan : □ distensi abdomen, □ ascites
 Luka, □ tidak ada, □ ada, Lokasi…………………………….………
Luas……………………………………………………
Warna………………………………………………….
Pus …………………………………………………….
Lain-lain……………………………………………….
b) Auskultasi
 Peristaltic usus:………x/mnt
c) Palpasi : □ hepatomegali, □ apendiksitis, □ distensi abdomen, □ ascites,
□massa, □ nyeri tekan, lokasi……………………………………………….
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
10) Genetalia & Perineum

a) Keadaan : □ Bersih, □ Keputihan, □ Darah
b) Letak Uretra : □ Normal, □ Epispadia, □ Hipospadia
c) Prosedur invasife : □ Tidak
□ Ya, Terpasang dower catheter,……………………….
Data lainnya………………………………………………………………….
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
11) Anus
Keadaan : □ Bersih, □ Hemoroid
Data lainnya………………………………………………………………….
………………………………………………………………………………
12) Ekstremitas
a) Ektremitas Atas
□pergerakan bebas, □ deformitas, □ Oedema, □ Sianosis pada
ujung kuku, □Clubbing finger, □ CRT ……..detik
□ Luka.........................................................................................
□ Terpasang infuse........................................................................
Data lainnya…………………………………………………………….
b) Ektremitas Bawah
□pergerakan bebas, □ deformitas, □ Oedema, □ Sianosis pada
ujung kuku, □Clubbing finger, □ CRT ……..detik
□ Luka..........................................................................................
□ Terpasang infuse,………………………………………………….....
Data lainnya…………………………………………………………….
c) Kekuatan Otot
Data lainnya………………………………………………………….............
h. Pemeriksaan Penunjang
1) Pemeriksaan Laboratorium
No Hari/Tanggal/Jam Jenis Pemeriksaan Lab Hasil Pemeriksaan Nilai Normal
. ………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… ……………………………………………… ………………………………… ……………………
………………… …………………………………………… ………………………………… ……………………
2) Pemeriksaan Radiologi
No. Hari/Tanggal/Jam Jenis Pemeriksaan Hasil Pemeriksaan
......................................... ............................................................. ............................................................................
......................................... ............................................................. ...........................................................................
......................................... .................................................................... ...........................................................................
......................................... ............................................................. ...........................................................................
......................................... ............................................................. ...........................................................................
......................................... ............................................................. ...........................................................................
......................................... ............................................................. ................................................................................
......................................... ............................................................. .............................................................................
........................................ ............................................................. ...........................................................................
........................................ ............................................................. ...........................................................................
........................................ ............................................................. ...........................................................................
......................................... ............................................................. ..........................................................................
........................................ ............................................................. ..........................................................................
........................................ ................................................................... ..........................................................................
........................................ ................................................................. ...........................................................................
........................................... ............................................................. ...........................................................................
......................................... ............................................................. ..........................................................................
........................................ ............................................................. ...........................................................................
........................................ ............................................................. ..............................................................................
......................................... ............................................................. ...........................................................................
......................................... ............................................................. .............................................................................
......................................... ............................................................. ...........................................................................
......................................... ............................................................. ...........................................................................
......................................... .............................................................. ............................................................................
KALA I
a. Data Fokus Kala I
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
.....................................................................................................................................................................................................................
b. Analisa data Kala I
Data Subyektif Etiologi Masalah
……………………………………………… ………………………………………………….. ......................................................

……………………………………………… ………………………………………………….. …………………………………..
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ……………………………………
…………………………………………………..
……………………………………………… ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ……………………………………
…………………………………………………..
……………………………………………… ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ……………………………………
…………………………………………………..
……………………………………………… ……………………………………
……………………………………………… …………………………………………………. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
………………………………………………. ………………………………………………….. ……………………………………
………………………………………………. ………………………………………………….. ……………………………………
………………………………………………. ……………………………………
…………………………………………………..
………………………………………………. ……………………………………
………………………………………………. ………………………………………………….. ……………………………………
………………………………………………. ………………………………………………….. ……………………………………
………………………………………………. ………………………………………………….. ……………………………………
………………………………………………. ………………………………………………….. ……………………………………
………………………………………………. ………………………………………………….. ……………………………………
………………………………………………. ………………………………………………….. ……………………………………
………………………………………………. ……………………………………
…………………………………………………..
………………………………………………. ……………………………………
………………………………………………. ………………………………………………….. ……………………………………
………………………………………………. ………………………………………………….. ……………………………………
……………………………………………… ………………………………………………….. ……………………………………
………………………………………………. ………………………………………………….. ……………………………………
…………………………………………………..
…………………………………………………..
…………………………………………………..
………………………………………………….
………………………………………………….
………………………………………………….
c. Diagnosa Keperawatan (berdasarkan prioritas)
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
RENCANA KEPERAWATAN KALA I
No Hari/Tgl/ Diagnosa Rencana Tujuan Rencana Tindakan Rasional

Jam Keperawatan
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
………………………… ………………………… ……………………………… ……………………………………
IMPLEMENTASI KALA I
No Hari/Tgl/Jam No. Diagnosa Tindakan Keperawatan Evaluasi Respon Paraf

Keperawatan
........................................................ ......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... .....................................................................
...................................................... ......................................................................
....................................................... ......................................................................
....................................................... .......................................................................
....................................................... .......................................................................
....................................................... .......................................................................
....................................................... .....................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... .......................................................................
........................................................ ......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... .......................................................................
....................................................... .......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... .......................................................................
....................................................... .......................................................................
........................................................ ......................................................................
....................................................... ......................................................................
....................................................... .....................................................................
....................................................... .........................................................................
....................................................... ........................................................................
....................................................... ......................................................................
....................................................... .......................................................................
........................................................ .......................................................................
....................................................... .......................................................................
....................................................... .......................................................................
....................................................... ........................................................................
....................................................... ........................................................................
........................................................ ......................................................................
....................................................... .........................................................................
....................................................... ...........................................................................
....................................................... ......................................................................
....................................................... ......................................................................
....................................................... .......................................................................
....................................................... ........................................................................
....................................................... ......................................................................
....................................................... ........................................................................
EVALUASI KALA I
No Hari/Tgl/Jam No. Diagnosa Evaluasi Paraf

Keperawatan
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………………………………………….
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………………………………………….
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………………………………………….

Format Pengkajian Di-Ruang VK

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Format Pengkajian Di-Ruang VK

Diunggah oleh

Hak Cipta:

Format Tersedia

ASUHAN KEPERAWATAN PADA PASIEN.......................

Anak ke- Kehamilan Persalinan Komplikasi Nifas Anak

2) Makan dan minum

4) Gerak dan aktivitas

5) Istirahat dan tidur

7) Pengaturan suhu tubuh

Saat Pengkajian : □ perasaan panas, □ berkeringat, □ kemerahan

11) Prestasi dan produktivitas

10) Genetalia & Perineum

Data Subyektif Etiologi Masalah

……………………………………………… ………………………………………………….. ......................................................

No Hari/Tgl/ Diagnosa Rencana Tujuan Rencana Tindakan Rasional

No Hari/Tgl/Jam No. Diagnosa Tindakan Keperawatan Evaluasi Respon Paraf

No Hari/Tgl/Jam No. Diagnosa Evaluasi Paraf

Anda mungkin juga menyukai