FORMAT ASUHAN KEPERAWATAN

A. PENGKAJIAN
1. Pengumpulan Data
a. Biodata
1) Nama : . ......................................................................................
2) Jenis Kelamin :. ......................................................................................
3) Umur : .......................................................................................
4) Status Perkawinan : .......................................................................................
5) Pekerjaan : .......................................................................................
6) Agama : .......................................................................................
7) Pendidikan Terakhir : .......................................................................................
8) Alamat : .......................................................................................
9) Tanggal MRS : .......................................................................................

2. Diagnosa Medis :

3. Keluhan Utama (Saat Pengkajian)

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

4. Riwayat Penyakit Sekarang ......................................................................................

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

5. Riwayat Kesehatan / Penyakit Yang Lalu ...............................................................

6. Riwayat Kesehatan
Keluarga............................................................................................................................
7. Pola Aktifitas Sehari—hari
1) Makan dan Minum
DS :
DO :
...............................................................................................................................
2) Pola Eliminasi
1
 DS :. .......................................................................................................................
DO : .......................................................................................................................

3) Pola Istirahat dan Tidur

DS : ........................................................................................................................
DO : .......................................................................................................................

4) Kebersihan Diri
DS : ........................................................................................................................
DO : .......................................................................................................................
8. Riwayat Psikososial
...............................................................................................................................

9. Pemeriksaan Fisik
1) Keadaan Umum :
.............................................................................................................................
.............................................................................................................................
2) Tanda Vital :
..........................................................................................................................
.............................................................................................................................
.............................................................................................................................
B. Pemeriksaan kepala
o Kepala dan rambut :
..........................................................................................................................
.............................................................................................................................
.............................................................................................................................
o Mata :
.............................................................................................................................
.............................................................................................................................
o Hidung
..........................................................................................................................
.............................................................................................................................
.............................................................................................................................
2
 o Mulut dan Faring
..........................................................................................................................
.............................................................................................................................
.............................................................................................................................
o Telinga
..........................................................................................................................
.............................................................................................................................
.............................................................................................................................
o Wajah
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
C. Pemeriksaan Leher
.............................................................................................................................

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

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

D. Dada dan thorax (paru dan jantung)

 Dada Anterior : ........................................................................................
 Dada Posterior : ......................................................................................

E. Abdomen
Inspeksi :

perkusi : ...............................................................................................................

F. Genetalia.......................................................................................................................

G. Ekstremitas

o Ekstremitas atas........................................................................................

o Ekstremitas bawah : Inspeksi

o Palpasi :............................................

10. Pemeriksaan Penunjang

3
Jenis Hasil Normal Satuan Intervensi

Leukosit

Eritrosit

Hemoglobin

Malang, ..............................
Mahasiswa

(..........................................)

4
 H. ANALISA DATA
Nama Pasien :
Umur :
No. Register :

DATA FOKUS MASALAH KEMUNGKINAN PENYEBAB

1. DS :

DO :

TTV :

TD =

N=

S=

RR =

P=

Q=

S=

T=

2. DS

DO

5
3. DS :

DO :

4. DS :

DO

5. DS : -

DO :

6. DS : -

DO

6
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B. DIAGNOSIS KEPERAWATAN

Nama Pasien :
Umur :
No. Register :
NO Diagnosa Keperawatan

9
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C. PERENCANAAN

1. PRIORITAS MASALAH

DAFTAR MASALAH

Ruang :
Nama Pasien :
No. Register :
No. DX TANGGA TANDA
TANGGAL
L DIAGNOSIS KEPERAWATAN TANGAN
TERATASI
MUNCUL

11
 2. RENCANA ASUHAN KEPERAWATAN

RENCANA ASUHAN KEPERAWATAN

NAMA KLIEN :
NO. REG :
NO DIAGNOSA TUJUAN
TANGGAL INTERVENSI RASIONAL TT
DX KEPERAWATAN KRITERIA STANDART

12
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 D. PELAKSANAAN

IMPLEMENTASI KEPERAWATAN

Ruang :
Nama Pasien :
Umur :
No. Register :
TGL PUKUL NO. IMPLEMENTASI TT

DX. KEP

18
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 E. EVALUASI
CATATAN PERKEMBANGAN
Nama :
No. Reg :
TANGGAL/PUKUL Dx. Kep DATA (SOAPIER)

Hari 1 : S:
O: P:
Q :
R:
S :
T :
A:

Hari 2 : P :

S :
O :
A :
P :

21
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F. Evaluasi Sumatif

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