FORMAT ASUHAN KEPERAWATAN

JURUSAN KEPERAWATAN POLTEKKES KEMENKES PONTIANAK

A. PENGKAJIAN
1. Pengumpulan Data
a. Identitas pasien
Nama : …………………………………….............................................
No. RM : ………………………………………………………………….
Umur : …………………………………….............................................
Jenis kelamin : …………………………………….............................................
Agama : …………………………………….............................................
Suku : …………………………………….............................................
Pendidikan : …………………………………….............................................
Alamat : …………………………………….............................................
……………………………………...…………………………..
Pekerjaan : …………………………………….............................................
Tanggal masuk : …………………………………….............................................
Tanggal pengkajian : …………………………………….............................................
Diagnosa medis : …………………………………….............................................
Dokter penanggung jawab : …………………………………….............................................
b. Identitas penanggung jawab
Nama : …………………………………….............................................
Jenis kelamin : …………………………………….............................................
Hubungan dengan pasien : …………………………………….............................................

2. Riwayat Penyakit
a. Riwayat Penyakit Sekarang
1) Alasan masuk rumah sakit sakit
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2) Keluhan saat dikaji
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 b. Riwayat penyakit dahulu
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c. Riwayat kesehatan keluarga

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3. Genogram
(Gambarkan)

Keterangan :
 : Laki-laki : Pasien

 :Laki-laki meninggal

:Perempuan
: Tinggal Dalam Satu Rumah

 :Perempuanmeninggal


4. Data Biologis
a. Pola nutrisi
SMRS: ………………………………………………………………………………………..
MRS: ………………………………………………………………………………………..
b. Pola minum.
SMRS: ………………………………………………………………………………………..
MRS: ………………………………………………………………………………………...
c. Pola eliminasi
SMRS: …………………………………………………………………………………………
MRS: …………………………………………………………………………………………

d. Pola istirahat/tidur
SMRS: ……………………………………..............................................................................
MRS: ……………………………………..............................................................................

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 e. Pola hygiene
- Mandi
SMRS : ……………………………………..............................................................................
MRS : ……………………………………..............................................................................

- Cuci rambut
SMRS : ……………………………………..............................................................................
MRS : ……………………………………..............................................................................
- Gogok gigi
SMRS : ……………………………………...............................................................................
MRS : ……………………………………...............................................................................

5. Pola aktifitas
SMRS: ……………………………………..............................................................................
MRS: ……………………………………...............................................................................
……………………………………………………………………………………….....
.
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.
Aktifitas 0 1 2 3 4
Mandi
Berpakaian
Eliminasi
Mobilisasi ditempat tidur
Pindah
Makan dan minum

Keterangan : 0 = mandiri
1 = dibantu sebagian
2 = perlu bantuan orang lain
3 = perlu bantuan orang lain dan alat
4 = tergantung orang lain tidak mandiri

6. Data Sosial
a. Hubungan dengan keluarga
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b. Hubungan dengan tetangga
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c. Hubungan dengan pasien sekitar
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d. Hubungan dengan keluarga pasien lain

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 ……………………………………………………………………………………………………..
7. Data Psikologis
a. Status emosi

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b. Peran diri

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c. Gaya komunikasi

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.

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8. Pemeriksaan Fisik
a. Keadaan umum : …………………………..
Kesadaran : E…. M …… V….. (GCS = ……) = ………………..
TTV : TD = ………….. mmHg
N = …………... x/menit
RR = …………... x/menit
S = …………...ºC
b. Kepala
Inspeksi : …………..............................................................................................................
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Palpasi …………...............................................................................................................
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c. Mata
Inspeksi : …………............................................................................................................
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Palpasi : …………................................................................................................................
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d. Hidung
Inspeksi: …………..............................................................................................................
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Palpasi: …………..............................................................................................................
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e. Telinga
Inspeksi: …………..............................................................................................................

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Palpasi : …………...............................................................................................................
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f. Mulut
Inspeksi: …………................................................................................................................
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Palpasi: …………...............................................................................................................
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g. Leher
Inspeksi: …………..............................................................................................................
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Palpasi: …………..............................................................................................................
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h. Thoraks (paru-paru)
Inspeksi : ………………………………………………………...........................................
Palpasi : ………………………………………………………...........................................
Auskultasi : ………………………………………………………...........................................
Perkusi : ………………………………………………………...........................................
i. Thoraks (jantung)
Inspeksi: ………………………………………………………...........................................
Palpasi: ………………………………………………………...........................................
Auskultasi : ………………………………………………………...........................................
Perkusi : ………………………………………………………...........................................
j. Abdomen
Inspeksi: ………………………………………………………...........................................
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Palpasi: ………………………………………………………...........................................
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Perkusi: ………………………………………………………............................................

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 Auskultasi : ………………………………………………………............................................

k. Genetalia
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l. Ekstremitas

Kanan Kiri

Keterangan: …………………………………………..

9. Data Penunjang
LABORATORIUM
…………….. Hasil Nilai Normal

RONTGEN

b. Pengobatan
 ……………………………………………………………………............................................
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 ……………………………………………………………………............................................
 ……………………………………………………………………............................................
 ……………………………………………………………………............................................
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 ……………………………………………………………………............................................

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B. ANALISA DATA
NO. DATA ETIOLOGI MASALAH

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NO. DATA ETIOLOGI MASALAH

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C. DAFTAR MASALAH

NO. DIAGNOSA KEPERAWATAN TANGGAL MASALAH PARAF

DITEMUKAN TERATASI

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NO. DIAGNOSA KEPERAWATAN TANGGAL MASALAH PARAF

DITEMUKAN TERATASI

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NO. DIAGNOSA KEPERAWATAN TANGGAL MASALAH PARAF

DITEMUKAN TERATASI

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D. RENCANA ASUHAN KEPERAWATAN
NO DIAGNOSA KEPERAWATAN NOC NIC RASIONAL PARAF

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NO DIAGNOSA KEPERAWATAN NOC NIC RASIONAL PARAF

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NO DIAGNOSA KEPERAWATAN NOC NIC RASIONAL PARAF

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E. CATATAN PERKEMBANGAN DAN EVALUASI
NO. TANGGAL CATATAN KEPERAWATAN CATATAN PERKEMBANGAN DAN EVALUASI PARAF

DX

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