STIKES RS BAPTIS KEDIRI

PRODI KEPERAWATAN STRATA 1

FORMAT ASUHAN KEPERAWATAN DASAR

NAMA MAHASISWA : …………………………………………………………………

NIM : …………………………………………………………………
RUANG : …………………………………………………………………
TANGGAL : …………………………………………………………………

1.BIODATA :
Nama Pasien : ……………………………………………….............
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Nama Panggilan : ……………………………………………….............…………
Umur : ……………………………………………….............…………
Status : ……………………………………………….............…………
Agama : ……………………………………………….............…………
Pendidikan : ……………………………………………….............…………
Pekerjaan : ……………………………………………….............…………
Penghasilan : ……………………………………………….............…………
Alamat : ……………………………………………….............…………
Diagnosa Medis : ……………………………………………….............…………
Tanggal MRS : ……………………………………………….............…………
Tanggal Pengkajian : ……………………………………………….............…………
Golongan Darah : ……………………………………………….............…………

2. KELUHAN UTAMA
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3. RIWAYAT PENYAKIT SEKARANG

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4. RIWAYAT PENYAKIT MASA LALU
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5. RIWAYAT KESEHATAN KELUARGA

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GENOGRAM:
6. TANDA-TANDA VITAL
Suhu Tubuh : ……………………………ºC
Denyut Nadi : ……………………………x/menit
Tekanan Darah : ……………………………mmHg
Pernafasan :……………………………x/menit
TT / TB : ……………………………Kg, …………….cm

7. POLA AKTIVITAS SEHARI- HARI

a. Kebutuhan Kebersihan Diri/ Personal Hygiene

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b. Kebutuhan Nutrisi/ Pola Nutrisi

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c. Kebutuhan Eliminasi/ Pola Elimininasi BAK, BAB

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d. Kebutuhan Oksigenasi
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e . Kebutuhan Cairan dan Elektrolit

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f. kebutuhan aktivitas
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g. Kebutuhan Rasa Aman dan Nyaman

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h. kebutuhan Psikososial dan Spiritual

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7. POLA AKTIFITAS SEHARI – HARI

( Makan, istirahat, tidur, eliminasi, aktifitas, kebersihan dan seksual )
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8. KEADAAN/PENAMPILAN/KESAN UMUM PASIEN

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9. TANDA-TANDA VITAL
Suhu Tubuh : ……………………………ºC
Denyut Nadi : ……………………………x/menit
Tekanan Darah : ……………………………mmHg
Pernafasan :……………………………x/menit
TT / TB : ……………………………Kg, …………….cm

10.PEMERIKSAAN FISIK
A. Pemeriksaan Kepala dan Leher
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B. Pemeriksaan Integumen Kulit dan Kuku :
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C. Pemeriksaan Payudara dan Ketiak ( Bila diperlukan ):

D. Pemeriksaan Dada /Thorak

 Inspeksi Thorax :
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Paru :
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E. Pemeriksaan Jantung :

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F. Pemeriksaan Abdomen :
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G. Pemeriksaan Kelamin dan daerah sekitarnya ( bila diperlukan ):
Genetalis :
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Anus :
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H. Pemeriksaan Muskuloskeletal :
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 H. Pemeriksaan Neurologi :

J. Pemeriksaan Status Mental :

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11. Pemeriksaan Penunjang Medis :

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12. Pelaksanaan / Therapi :

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13. Harapan Klien / Keluarga sehubungan dengan penyakitnya :

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Kediri ,
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Mahasiswa,
 ANALISA DATA

NAMA PASIEN : ...............................................................

UMUR : ..............................................................
NO. REGISTER : ..............................................................

DATA GAYUT FAKTOR YANG MASALAH

DATA OBYEKTIF BERHUBUNGAN/RISIKO KEPERAWATAN
DATA SUBYEKTIF (E) (NANDA)
 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN : ..............................................................

UMUR : ..............................................................
NO.REGISTER : .............................................................

DIAGNOSA KEPERAWATAN : ..........................................................................................

1. NOC : ................................................................................................................................
a. ...........................................................Dipertahankan/ditingkatkan pada....................
 b. ...........................................................Dipertahankan/ditingkatkan pada....................
c. ...........................................................Dipertahankan/ditingkatkan pada....................
d. ...........................................................Dipertahankan/ditingkatkan pada....................
e. ...........................................................Dipertahankan/ditingkatkan pada....................
f............................................................Dipertahankan/ditingkatkan pada....................
g. ...........................................................Dipertahankan/ditingkatkan pada....................
h. ...........................................................Dipertahankan/ditingkatkan pada....................
i............................................................Dipertahankan/ditingkatkan pada....................
j............................................................Dipertahankan/ditingkatkan pada....................
k. ...........................................................Dipertahankan/ditingkatkan pada....................

2. NOC : ................................................................................................................................
a. ...........................................................Dipertahankan/ditingkatkan pada....................
b. ...........................................................Dipertahankan/ditingkatkan pada....................
c. ...........................................................Dipertahankan/ditingkatkan pada....................
d. ...........................................................Dipertahankan/ditingkatkan pada....................
e. ...........................................................Dipertahankan/ditingkatkan pada....................
f............................................................Dipertahankan/ditingkatkan pada....................
g. ...........................................................Dipertahankan/ditingkatkan pada....................
h. ...........................................................Dipertahankan/ditingkatkan pada....................
i............................................................Dipertahankan/ditingkatkan pada....................
j............................................................Dipertahankan/ditingkatkan pada....................
k. ...........................................................Dipertahankan/ditingkatkan pada....................

3. NOC : ................................................................................................................................
a. ...........................................................Dipertahankan/ditingkatkan pada....................
b. ...........................................................Dipertahankan/ditingkatkan pada....................
c. ...........................................................Dipertahankan/ditingkatkan pada....................
d. ...........................................................Dipertahankan/ditingkatkan pada....................
e. ...........................................................Dipertahankan/ditingkatkan pada....................
f............................................................Dipertahankan/ditingkatkan pada....................
g. ...........................................................Dipertahankan/ditingkatkan pada....................
h. ...........................................................Dipertahankan/ditingkatkan pada....................
i............................................................Dipertahankan/ditingkatkan pada....................
j............................................................Dipertahankan/ditingkatkan pada....................
k. ...........................................................Dipertahankan/ditingkatkan pada....................

Keterangan : ( dipertahankan/ditingkatkan ) coret salah satu

 DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN : ...............................................................

UMUR : ..............................................................
NO. REGISTER : ..............................................................

NO TANGGAL DIAGNOSA KEPERAWATAN TANGGAL TANDA

MUNCUL TERATASI TANGAN

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 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN : ...............................................................

NO.REGISTER : .............................................................

NO DIAGNOSA KEPERAWATAN INTERVENSI RASIONAL TTD

(NIC)

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 TINDAKAN KEPERAWATAN

NAMA PASIEN : ...............................................................

UMUR : ...............................................................
NO.REGISTER : .............................................................

NO NO.DX TGL/JAM TINDAKAN KEPERAWATAN TANDA

TANGAN

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 CATATAN PERKEMBANGAN

NAMA PASIEN : ...............................................................

UMUR : ...............................................................
TANGGAL : ...............................................................

NO NO.DX JAM EVALUASI (SOAP)

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