ASUHAN KEPERAWATAN PADA PASIEN DENGAN

….......................………………..(Dx Keperawatan Utama)

di Ruang Rawat……….. Rumah Sakit …………….

A. Pengkajian
1. Pengumpulan Data
a. Bio Data
1) Nama : ................................................................
2) Usia : ................................................................
3) Alamat : ................................................................
4) Jenis Kelamin : ................................................................
5) Pendidikan : ................................................................
6) Agama : ................................................................
7) Suku Bangsa : ................................................................
8) Tanggal Masuk Dirawat : ................................................................
9) Tanggal Dirawat Mahasiswa : ................................................................
10)Diagnosa Medis : ................................................................

b. Riwayat Kesehatan
1) Keluhan Utama :
a) Saat Masuk Rumah Sakit :
b) Saat Dikaji Mahasiswa :
2) Riwayat Kesehatan Sekarang (PQRST)
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3) Riwayat Kesehatan Dahulu
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4) Riwayat Kesehatan Keluarga

 c. Data Biologis
1) Pola Kehidupan Sehari-hari

Pemeriksaan Sebelum Sakit Setelah Sakit

Nutrisi
Frekuensi
Jenis
Pantangan
Keluhan
Cairan dan Elektrolit
Frekuensi
Jenis
Pantangan
Keluhan
Eliminasi
BAB
Frekuensi
Keluhan
BAK
Frekuensi
Keluhan
Istirahat dan Tidur
Kebiasaan
Frekuensi
Keluhan
Personal Hygiene
Mandi dan gosok
gigi
Berpakaian
Berhias
Keluhan

2) Pemeriksaan Fisik

a) Keadaan Umum
(1) Kesadaran :
(2) Orientasi :
b) Tanda-tanda vital
(1) Temperatur :
(2) Denyut Nadi :
(3) Respirasi :
(4) Tekanan Darah :
Keluhan :
c) Pemeriksaan menyeluruh
(1) Kepala dan Leher
(a) Bentuk :
(b) Ekspresi wajah :
(c) Mata :
(d) Telinga :
(e) Hidung :

(f) Mulut :

(g) Rongga mulut :

(h) Leher :
Keluhan :

(2) Dada
(a) Inspeksi :
(b) Palpasi :
(c) Perkusi :
(d) Auskultasi :
Keluhan :

(3) Perut
(a) Inspeksi :
(b) Auskultasi :
(c) Palpasi :
(d) Perkusi :
Keluhan :

(4) Ekstremitas
(a) Ekstremitas Atas
Pergerakan :
Kekuatan otot :
Massa otot :
Turgor :
Keluhan :

(b) Ekstremitas Bawah

Pergerakan :
Kekuatan otot :
Massa otot :
Turgor :
Refleks :
Keluhan :
d. Data Psikologis
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e. Data Sosial dan Spiritual
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f. Data Penunjang
1) Darah/urine/feses

Pemeriksaan Hasil Nilai Normal Interpretasi

2) Radiogram
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2. Analisa Data

Data Yang Menyimpang Etiologi Masalah

B. Diagnosa Keperawatan
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Bandung, ……………………200
Perawat Yang Mengkaji
 Rencana Asuhan Keperawatan
Nama Pasien : Diagnosa :
Tanggal :

No. Diagnosa Keperawatan Perencanaan Implementasi Evaluasi

Tujuan Intervensi Rasional

Keterangan : Tujuan berdasarkan P, Kriteria Berdasarkan S (Symptom), Intervensi Berdasar E

 Tindakan Keperawatan dan Evaluasi
Nama :
Diagnosa :
 Catatan Perkembangan
Nama :
Diagnosa :

Tanggal/
No Catatan
Jam No. DX Paraf
Perkembangan