FORMAT LAPORAN ASUHAN KEPERAWATAN

ASUHAN KEPERAWATAN PADA………………………………

DENGAN………………………………
DI………………………………
A. PENGKAJIAN
1. DataUmum
Identitas Klien
Nama (Initial) : ................................................................................
Umur : ................................................................................
Agama : ................................................................................
Jenis Kelamin : ................................................................................
Status Marital : ................................................................................
Pendidikan : ................................................................................
Pekerjaan : ................................................................................
SukuBangsa : ................................................................................
Alamat : ................................................................................
Tanggal Masuk : ................................................................................
Tanggal Pengkajian : ................................................................................
No. Register : ................................................................................
DiagnosaMedis : ................................................................................

Identitas Penanggung Jawab

Nama (Initial) : .................................................................................
Umur : ................................................................................
Hub. Dengan Klien : .................................................................................
Pekerjaan : ................................................................................
Alamat : ................................................................................
2. Riwayat Kesehatan

Keluhan Utama
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Riwayat Penyakit Sekarang
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Riwayat Kesehatan Dahulu
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Riwayat Kesehatan Keluarga
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Genogram:

Riwayat Sosiokultural
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3. Pola Fungsi Kesehatan Gordon
a. Pola Persepsi dan Manajemen Kesehatan
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b. Pola Nutrisi-Metabolik
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c. Pola Eleminasi
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d. Pola Aktivitas dan Latihan
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e. Pola kognitif dan Persepsi
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f. Pola Persepsi-Konsep diri
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g. Pola Tidur dan Istirahat
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h. Pola Peran-Hubungan
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i. Pola Seksual-Reproduksi
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j. Pola Toleransi Stress-Koping
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k. Pola Nilai-Kepercayaan
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4. PEMERIKSAAN FISIK
a. KeadaanUmum
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b. Tanda Vital
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c. Sistem Panca Indra
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d. Sistem Pernafasan
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e. Sistem Kardiovaskuler
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f. Sistem Pencernaan
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g. Sistem Muskuloskeletal
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h. Sistem Perkemihan
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i. Sistem Reproduksi
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j. Sistem Syaraf
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k. Sistem Integumen
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l. Sistem Endokrin
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5. DATA PENUNJANG (Pemeriksaan Diagnostik) :

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6. DATATAMBAHAN
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7. THERAPI
Tanggal awal
No Nama Dosis Rute Indikasi
diberikan
B. ANALISADATA

Data Etiologi Masalah Kolaboratif/ Keperawatan

C. TABEL DAFTAR MASALAH KOLABORATIF/ DIAGNOSA KEPERAWATAN
No Tanggal dan Jam Diagnosa Tanggal dan Jam
ditemukan Keperawatan Teratasi

D. DIAGNOSAKEPERAWATANBERDASARKAN PRIORITAS
1. ........................................................................................................................
2. ........................................................................................................................
3. ........................................................................................................................
4. ........................................................................................................................
E. PERENCANAAN
Tujuan dan
No No. Diagnosa Intervensi Rasional
kriteria hasil
F. IMPLEMENTASI
Hari/ Nama
No
tgl/ Tindakan Keperawatan Evaluasi dan
Diagnosa
jam ttd
G. EVALUASI
Hari/ No Nama
No Evaluasi
tgl Diagnosa dan ttd