FORMAT LAPORAN ASUHAN KEPERAWATAN

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

DENGAN DIAGNOSA MEDIS ...........................................................
DENGAN DIAGNOSA KEPERAWATAN..........................................
DI RUANG …………………..
TANGGAL…………………………………………………………………………

 PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama : ..................................................................................
Agama : ....................................................................................
Jenis Kelamin :......................................................................................
Status : ...........................................................................................
Pendidikan :............................................................................................
Pekerjaan : ............................................................................................
Suku Bangsa :............................................................................................
Alamat : ..........................................................................................
Tanggal Masuk : ...........................................................................................
Tanggal Pengkajian : ...........................................................................................
No. Register : .............................................................................................
Diagnosa Medis : ............................................................................................

b. Identitas Penanggung Jawab

Nama :
............................................................................................
Hub. Dengan Pasien : ...........................................................................................
Pekerjaan : .............................................................................................
Alamat : ..............................................................................................
2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
Saat MRS :..........................................................................................................
Saat ini : ..........................................................................................................
2) Upaya yang dilakukan untuk mengatasinya
...........................................................................................................................

b. Satus Kesehatan Masa Lalu

1) Penyakit yang pernah dialami
...........................................................................................................................
Pernah dirawat
...........................................................................................................................
Alergi
...........................................................................................................................
2) Kebiasaan (merokok/kopi/alkohol dll)
...........................................................................................................................
3) Riwayat Penyakit Keluarga
...........................................................................................................................
4) Diagnosa Medis dan therapy
...........................................................................................................................
3. Pengkajian Fisik
a. Keadaan umum :
Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma
GCS : verbal:……….Psikomotor:……….Mata :……………..
b. Tanda-tanda Vital : Nadi = ……, Suhu = ……., TD =………, RR =……
c. Keadaan fisik
1) Kepala dan leher :
....................................................................................................................................
2) Dada :
 Paru
....................................................................................................................................
 Jantung
....................................................................................................................................
3) Payudara dan ketiak :
....................................................................................................................................
4) Abdomen :
....................................................................................................................................
5) Genetalia :
....................................................................................................................................
6) Integumen :
....................................................................................................................................
7) Ekstremitas :
 Atas
................................................................................................................................
 Bawah
....................................................................................................................................
8) Neurologis :
 Status mental dan emosi :
....................................................................................................................................
 Pengkajian saraf kranial :
....................................................................................................................................
 Pemeriksaan refleks :
....................................................................................................................................
d. Pemeriksaan Penunjang
1) Data laboratorium yang berhubungan
....................................................................................................................................
2) Pemeriksaan radiologi
....................................................................................................................................
3) Hasil konsultasi
....................................................................................................................................
4) Pemeriksaan penunjang diagnostic lain
....................................................................................................................................
ANALISA DATA
DATA ETIOLOGI MASALAH
DAFTAR DIAGNOSA KEPERAWATAN /MASALAH KOLABORATIF BERDASARKAN PRIORITAS

TANGGAL / JAM TANGGAL

NO DIAGNOSA KEPERAWATAN Ttd
DITEMUKAN TERATASI
RENCANA TINDAKAN KEPERAWATAN

Hari/ Rencana Perawatan Ttd

No Dx
Tgl Tujuan dan Kriteria Hasil Intervensi
IMPLEMENTASI KEPERAWATAN

Ttd
Hari/ Tgl No Dx Jam Tindakan Keperawatan
EVALUASI KEPERAWATAN

Hari/Tgl
No No Dx Evaluasi TTd
Jam