FORMAT DOKUMENTASI

ASUHAN KEPERAWATAN
PROGRAM STUDI ILMU KEPERAWATAN UNEJ

A. PENGKAJIAN
I. Identitas Klien:
No. Rekam Medis (RM) : Tanggal MRS :
Nama Klien : Tanggal pengkajian:
Nama panggilan : Sumber informasi :
Tempat/tanggal lahir :
Umur :
Agama :
Jenis kelamin :
Alamat :
Pendidikan :
Pekerjaan :
Suku :
Bahasa yang dimengerti :
Diagnosa medis SMRS :

II. Riwayat Penyakit

1. Keluhan Utama:
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2. Riwayat Penyakit Sekarang:
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3. Riwayat Penyakit Dahulu:
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4. Riwayat Penyakit Keluarga:
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Genogram:

III. Pengkajian Saat Ini (Pola Fungsional Kesehatan):

1. Persepsi dan pemeliharaan kesehatan.
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2. Pola nutrisi/metabolik
a.Program diit RS
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b. Intake makanan :
Sebelum masuk
RS:..........................................................................................................

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Saat di RS
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c. Intake cairan :
Sebelum masuk
RS:..........................................................................................................

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Saat di RS
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 d. Riwayat alergi
makanan:..................................................................................................

3. Pola eliminasi
a. Buang Air besar
(BAB):.................................................................................................

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b. Buang Air kecil
(BAK):.................................................................................................
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4. Pola aktivitas dan latihan

Kemampuan perawatan diri 0 1 2 3 4 Ket.
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah/berjalan
Ambulasi/ROM
0: mandiri; 1: dengan alat bantu; 2: dibantu orang lain; 3: dibantu orang lain dan
alat;
4: tergantung total
Oksigenasi:................................................................................................................
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5. Pola tidur dan istirahat
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6. Pola persepsi-kognisi
Penglihatan
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Pendengaran
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Pengecapan
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Penciuman
:.......................................................................................................................
Perasa
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Sensasi
:.......................................................................................................................
Orientasi
(OTW):..................................................................................................................
 7. Pola persepsi diri-konsep diri
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8. Pola seksualitas-reproduksi
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9. Pola peran hubungan

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10. Pola manajemen koping-stress

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11. Sistem nilai dan keyakinan

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IV. Pemeriksaan Fisik:

1. Keluhan saat
ini:.....................................................................................................................

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2. Keadaan
Umum:.....................................................................................................................
3. TTV : TD:......./..........mmHg N:............x/m S:...........0C
BB/TB:………..kg/……….cm (sebelum masuk
RS:……..kg/……….cm)
4. Pemeriksaan Cepalokaudal:
a. Kepala dan leher
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b. Thoraks :
I:………................................................................................................
Pe:.................................................................................................
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Pa:.................................................................................................
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A:..................................................................................................
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c. Abdomen :
I:............................................................................................................

A:...........................................................................................................

Pe:..........................................................................................................

Pa:..........................................................................................................

d. Inguinal
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Urinaria
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Genitalia
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e. Ekstremitas
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V. PROGRAM TERAPI
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VI. Pemeriksaan Diagnostik Penunjang (tuliskan jenis pemeriksaan dan hasilnya)

Laboratorium:
Jenis Pemeriksaan Tanggal Normal Satuan

Hematologi:
Darah Perifer
Lengkap
LED 0-20
Hb 12-14 g/dL
Ht 37-43 %
Eritrosit 4.5-5.5 Juta/μL
MCV/Ver 80-94 fL
MCH/Her 27-32 pg
MCHC/Her 32-36 %
Leukosit 5-10 ribu /μL
Trombosit 150-450 rb /μL
Albumin 3.5-5 g/dL
Hitung jenis:
Basofil
Eosinofil
Neutrofil
Limfosit
Monosit
Urinalisis
Urin Lengkap
Warna Kuning
Kejernihan jernih
Sedimen
Sel epitel
Leukosit /LPB
Eritrosit
Silinder
Kristal
Bakteri
BJ
pH
Protein
Glukosa
Keton
Darah/Hb
Bilirubin Umol/L
Urobilinogen
Nitrit
Esterase
Analisa Gas Darah
(AGD)
pH 7.35-7.45
pCO2 35-45 mmHg
pO2 85-100 mmHg
HCO3 22-26 mmol/L
Total CO2 23-27 mmol/L
BE ±2 mmol/L
SaO2 96-97 %
STD HCO3
STD BE
Elektrolit:
Na mmol/L
K mmol/L
Cl mmol/L

Ureum
Creatinin
B. ANALISA DATA
N DATA ETIOLOGI MASALAH
O
1. DS: ............................ .................................
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