Lampiran 4: FORMAT PENGKAJIAN

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

DENGAN..............................................................
DI RUANG............................ BRSU TABANAN
TANGGAL..............................

I. PENGKAJIAN
A. Identitas Pasien
Nama :
No RM :
Umur :
Jenis Kelamin :
Pekerjaan :
Agama :
Status :
Tanggal MRS :
Tanggal Pengkajian :
B. Keluhan Utama
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
C. Riwayat Kesehatan
1. Riwayat Kesehatan Dahulu
.........................................................................................................................................
.........................................................................................................................................
............ ..........................................................................................................................
….
....................................................................................................................................…
....................................................................................................................................…

2. Riwayat Kesehatan Sekarang

 .........................................................................................................................................
.........................................................................................................................................
......................................................................................................................................
…
..................................................................................................................................….
....................................................................................................................................…
....................................................................................................................................…

3. Riwayat Kesehatan Keluarga

.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
....................................................................................................................................
…….
....................................................................................................................................
…..

c Nyeri Akut
Gejala dan Tanda Mayor Gejala dan Tanda Minor
Mengeluh nyeri Tekanan darah meningkat
Tampak meringis Pola napas berubah
Bersikap protektif (mis. Waspada, Nafsu makan berubah
posisi menghindari nyeri)
Gelisah Proses berfikir terganggu
Frekuensi nadi meningkat Menarik diri
Sulit tidur Berfokus pada diri sendiri
Diaforesis

Lampiran 4 : Analisa Data

Ruang :
Nama Pasien :
No. Register :
 No Data Fokus Masalah Kemungkinan Penyebab

Lampiran 5 : Masalah Keperawatan

Ruang :
Nama Pasien :
No. Register :
Lampiran 6 : Perencanaan
Ruang :
Nama Pasien :
No. Register :
 Hari, Diagnosa Tujuan Intervensi Rasional
Tanggal Keperawatan
Jam

Lampiran 7 : Pelaksanaan/Implementasi
Ruang :
Nama Pasien :
No. Register :
N Tanggal No Masalah Tindaan Evaluasi Tanda
o Keperawatan Tangan

Lampiran 8 : Evaluasi
Ruangan :
Nama Pasien :
No. Register :
Tanggal No Masalah Tanda Tangan
 Keperawatan

LEMBAR PENGESAHAN

Tabanan,

Mengetahui ,
Pembimbing Praktek Mahasiswa

NIP : NIM :

Mengetahui ,
Pembimbing Akademik

NIP :