LAPORAN DOKUMENTASI TINDAKAN ASISTENSI KEPERAWATAN

PADA …………….DENGAN ………………..

DI RUANG ………………………… RS …………………………

OLEH :

WIRO SABLENG

NIM : 0005758

SEKOLAH MENENGAH KEJURUAN ISLAM KEPANJEN

PROGRAM KEAHLIAN PERAWATAN KESEHATAN

Jl. Sultan Agung Kepanjen Malang 65163 Telp/Fax : 0341-396644

 LEMBAR PENGESAHAN

...........................................................................................................................................................................................

...........................................................................................................................................................................................

............................................................................................................................................................................................

...........................................................................................................................................................................................

...........................................................................................................................................................................................

...........................................................................................................................................................................................

...........................................................................................................................................................................................

...........................................................................................................................................................................................

...........................................................................................................................................................................................

Mengetahui,

PEMBIMBING INSTITUSI PEMBIMBING RS / C.I

(.………………………………………………………………………...) (.………………………………………………………………………...)
 TINJAUAN TEORI

............................................................................................................................................................................................

............................................................................................................................................................................................
.

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................
.

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................
..............................................................................................................................................................................................

..............................................................................................................................................................................................

..............................................................................................................................................................................................

..............................................................................................................................................................................................

..............................................................................................................................................................................................

..............................................................................................................................................................................................

..............................................................................................................................................................................................

..............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................

.............................................................................................................................................................................................
 FORMAT PENGKAJIAN
DOKUMENTASI TINDAKAN ASISTENSI KEPERAWATAN
I. Biodata umum
1. Nama Pasien : …………………………………………………..
2. Alamat : …………………………………………………..
3. Jenis kelamin : …………………………………………………..
4. Umur : …………………………………………………..
5. Agama : …………………………………………………..
6. Tanggal MRS : …………………………………………………..
7. Tanggal pengkajian : …………………………………………………..
8. No Reg : …………………………………………………..
9. Diagnose medis : …………………………………………………..

II. ANAMNESE
1. KELUHAN SAAT MRS :
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
..................................................................................................................................................................................

2. KELUHAN SAAT INI :

.................................................................................................................................................................................

.................................................................................................................................................................................

.................................................................................................................................................................................

.................................................................................................................................................................................
3. A. DATA OBJEKTIF :
a. Keadaan umum : ..................... ..........................................
b. Kesadaran : ..................... ..........................................
c. Tekanan darah : ..................... MmHg
d. Nadi : ..................... x/ menit
e. Nafas/RR : ..................... x/menit
f. Suhu : ..................... °C
g. BB : ..................... Kg

B. PEMERIKSAAN PENUNJANG
1. LABORATORIUM :

..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
..........................................................................................................................................................................
 2. RADIOLOGI

.........................................................................................................................................................................
..........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................

4. POLA KEBIASAAN SEHARI – HARI

NO POLA KEBIASAAN SEBELUM SAKIT SAAT SAKIT

Pola nutrisi

a. Makan

Frekuensi

1 Keluhan

b. Minum

Jenis

Jumlah

Keluhan

Pola eliminasai

A. BAK

Frekuensi

Jumlah
2
Warna

Keluhan

B. BAB

Frekuensi

Konsistensi

Warna

Keluhan

Istirahat

a. Tidur siang
3
b. Tidur malam
c. Keluhan
NO POLA KEBIASAAN SEBELUM SAKIT SAAT SAKIT

Personal hygiene

a. Mandi
1. Frekuensi
2. Metode

3. Keluhan

b. Keramas
1. Frekuensi
2. Menggunakan
4
3. Keluhan

c. Gosok gigi
1. Frekuensi
2. Menggunakan

3. Keluhan

d. Gunting kuku
1. Frekuensi
2. Keluhan
5 Pola kebiasaan spiritual

IV. TERAPI DOKTER / TINDAKAN

...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
V. LAIN – LAIN
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
.............................................................................................................................................................................
 STANDAR OPERASIONAL PROSEDUR

TINDAKAN ASISTENSI KEPERAWATAN : ………………………………………………….

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
..

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
..

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.

.........................................................................................................................................................................................
.