YAYASAN PENDIDIKAN AL-AZHAR GEBANG TENGAH JEMBER

SMK ANALIS KESEHATAN

JEMBER
Jl. Kaca Piring No. 23 Jember Telp (0331) 412066,483718
e-mail : smkanalis.kesehatanjember@gmail.com

website : www.smkanalis.sch.id

ASUHAN KEPERAWATAN PADA .......

DI RUANG ................................. RS.....................

FORMAT ASUHAN KEPERAWATAN

A. PENGKAJIAN
Tanggal : ................................................
Jam : ................................................
a. Identitas Klien
Nama : .............................................................................................
Umur : .............................................................................................
Jenis Kelamin : .............................................................................................
Pekerjaan : .............................................................................................
Alamat : ............................................................................................
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Pendidikan : .............................................................................................
Agama : .............................................................................................
Suku Bangsa : .............................................................................................
Tanggal Masuk RS : .............................................................................................
NO CM : .............................................................................................
Diagnosa Medis : .............................................................................................
Tanggal Pengkajian : .............................................................................................

b. Identitas Penanggung Jawab

Nama : .............................................................................................
Umur : .............................................................................................
Jenis Kelamin : .............................................................................................
Pekerjaan : .............................................................................................
 Alamat : .............................................................................................
Pendidikan : .............................................................................................
Agama : .............................................................................................
Hubungan Dengan Klien : .............................................................................................

1. Riwayat Kesehatan
Keluhan utama
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Riwayat penyakit sekarang

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Riwayat penyakit dahulu

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Riwayat penyakit keluarga

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Genogram

Keterangan :

: Laki – Laki
: Perempuan\
: Suami
: Isteri
: Klien / Pasien
: Tinggal Serumah
: Garis Perkawinan
: Garis Keturunan

Pola Kesehatan Fungsional (Gordon)

a. Pemeliharaan Kesehatan
Hasil Kajian :
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b. Nutrisi Metabolik
No Jenis Sehat Sakit

1 Pola Makan ............................................ ............................................

Jenis ............................................ ............................................
Porsi ............................................ ............................................
Frekuensi ............................................ ............................................
Diet Khusus ............................................ ............................................
Makanan Disukai ............................................ .............................................
.
Kesulitan Menelan ............................................ .............................................
Gigi Palsu ............................................ .............................................
 Napsu Makan ............................................ .............................................

2 Pola Minum ............................................ ............................................

Jenis ............................................ ............................................
Frekuensi ............................................ ............................................
Jumlah ............................................ ............................................
Pantangan ............................................ ............................................
Minuman yang disukai ............................................ ............................................

c. Pola Eliminasi
No Jenis Sebelum dirawat Selama dirawat

1 BAB ........................................... ............................................

Frekuensi ........................................... ............................................
Warna ........................................... ............................................
Masalah ........................................... ............................................

2 BAK ............................................ ............................................

Frekuensi ............................................ ............................................
Jumlah ............................................ ............................................
Warna ............................................ ............................................
Masalah ............................................ ............................................

d. Pola Aktifitas Sehari-hari

No Jenis Sehat Selama dirawat
0 1 2 3 4 0 1 2 3 4
1. Mandi
2. Berpakaian
3. Eliminasi
4. Mobilisasi ditempat tidur
5. Berpindah
6. Berjalan
7. Berbelanja
8. Memasak
9. Naik tangga
10. Pemeliharaan rumah
Ket.: 0 = Mandiri
1 = Alat bantu
2 = Dibantu orang lain
3 = Dibantu orang lain – alat
4 = Tergantung/tidak mampu

No Jenis Selama Dirawat

1. Mandi
Frekuensi : ........................................................................
2. Berpakaian
 Frekuensi : .......................................................................

3. Mobilisasi Tempat Tidur

Frekuensi : .......................................................................

e. Pola Persepsi Kognitif

Berbicara : ..........................................................................................
..........................................................................................
Bahasa : ..........................................................................................
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Kemampuan membaca : ..........................................................................................
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Tingkat ansietas : ..........................................................................................
..........................................................................................
Kemampuan Berinteraksi : ..........................................................................................
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f. Pola Istirahat Tidur

No Jenis Sebelum Masuk RS Selama Dirawat

1. Tidur Siang ........................................... ............................................

Lama Tidur ........................................... ............................................
Keluhan ........................................... ............................................

2. Tidur Malam .......................................... ............................................

Lama Tidur .......................................... ............................................
Keluhan .......................................... ............................................

g. Pola Konsep Diri

Konsep Diri : .........................................................................................................
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Ideal Diri : .........................................................................................................
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Harga Diri : .........................................................................................................
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 Identitas Diri : .........................................................................................................
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Peran Diri : .........................................................................................................
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h. Pola Peran dan Hubungan

Hasil Kajian :
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i. Pola Reproduksi dan seksual

Hasil Kajian :
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j. Pola Pertahanan Diri atau Koping

Hasil Kajian :
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k. Pola Keyakinan dan Nilai

Hasil kajian :
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l. Pemeriksaan Status Mental dan spiritual
a. Kondisi emosi / perasaan klien
- Apa suasana hati yang menonjol pada klien ( sedih / gembira )
- Apakah emosinya sesuai dengan ekspresi wajahnya ( ya / tdk )
b. Kebutuhan Spiritual Klien :
- Kebutuhan untuk beribadah ( terpenuhi / tidak terpenuhi )
- Masalah - masalah dalam pemenuhan kebutuhan
spiritual ..............................................................................................
- Upaya untuk mengatasi masalah pemenuhan kebutuhan
spiritual : ............................................................................................
c. Tingkat Kecemasan Klien :

Komponen Yang Cemas Cemas Cemas Panik

No dikaji
Ringan Sedang Berat

1 Orintasi terhadap □ Baik □ Menurun □ Salah □ Tdk

Orang, ada reaksi

tempat,waktu

2 Lapang persepsi □ Baik □ Menurun □Menyempit □ Kacau

3 Kemampuan □ Mampu □ Mampu □Tidak □Tdk

menyelesaikan dengan mampu
masalah bantuan ada
tanggapan

4 Proses Berfikir □ Mampu □ Kurang □Tidak □Alur fikiran

berkon mampu mampu kacau
sentrasi mengingat mengingat
dan dan dan
mengin berkonsen berkonsent
gat trasi rasi
dengan
baik

5 Motivasi □ Baik □ Menurun □ Kurang □ Putus asa

Pemeriksaan fisik
Kesadaran
□ Compos Mentis □ Apatis □ Somnolen □ Coma
GCS : E......... M.......... V...............
Skala GCS
Mata (Eye) : □ 4 Spontan
□ 3 Terhadap perintah / suara
□ 2 Terhadap nyeri
□ 1 Tidak ada respon
Nilai, Eye :..................

Bicara (Verbal) : □ 5 Terorientasi

□ 4 Bingung
□ 3 Kata – kata yang tidak teratur
□ 2 Tidak dapat dimengerti
□ 1 Tidak ada
Nilai, Verbal : ................

Gerak (Motorik) : □ 6 Mematuhi perintah

□ 5 Melokalisasi nyeri
□ 4 Penarikan karena nyeri
□ 3 Fleksi abnormal
□ 2 Ekstensi abnormal
□ 1 Tidak ada respon
Nilai, Motorik : .............
Tanda vital
Tekanan darah : ..................mmHg
Suhu : ..................ºC
Nadi : ..................X/menit

Irama : Kualitas : □ Kuat / □ Lemah

Pernafasan : RR..............X/menit,

Keluhan yang dirasakan :

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

Head to toe
Kepala
Bentuk dan ukuran kepala : .............................
Warna rambut : □ Hitam, □ Beruban, □ Kuning, □ Coklat, □ Warna buatan
Kebersihan rambut : □ Bersih, □ Kotor (□ ketombe, □ kutu, □ berminyak, □ rontok)
Penglihatan : Visus : □ Jelas, □ Rabun, □ Buta
Sklera : □ Putih, □ Ikterik, □ Kemerahan
Konjungtiva : □ Anemis, □ Tidak
Pendengaran : □ Jelas, □ Tidak Jelas, □ Tidak mendengar
Kebersihan Telinga : □ Bersih, □ Kotor, □ Ada lesi, □ Serumen berlebihan
Hidung : □ Bersih, □ Kotor, □ Ada Lesi, □ Perdarahan
 Pernafasan cuping hidung ( + / - )
Penggunaan alat O2 : □ Ada (□ Nasal Canul, □ Binasal Canul, □ Simple Mask,
□ RM □ NRM)
Pemeberian O2 : ........................L/Menit

Mukosa bibir : □ Bersih, □ Kotor

Bibir : □ Sianosis sentral/kebiruan, □ Pucat, □ Kehitaman, □ Pecah2,
□ Normal
Mulut : □ Bersih, □ Kotor
Lidah : □ Putih, □ Berbintik – bintik, □ Bintik Berjamur, □ Ada lesi,
□ Perdarahan
Gigi : □ Bersih, □ Kotor, □ Gigi Palsu, □ Caries, □ Gigi tanggal
Keluhan yang dirasakan : ................................................................................................

Leher
Pembesaran kelenjar tiroid : □ ada, □ tidak
Keluhan yang dirasakan : ....................................................................................................

Pemeriksaan Dada
Paru – paru
Inspeksi : Pergerakan dada : □ simetris □ Tidak
Retraksi dinding dada : □ ada □ Tidak
Keadaan : □ ada lesi □ ada jaringan sikatrik
□ penyakit kulit penyerta.................
Bentuk dada : □ normal □ barel chest □ pigeon
Tindakan yang harus dilakukan :.......................................
Palpasi : Pergerakan dada : □ simetrsi □ tidak

Perkusi : □ sonor □ hipersonor □ resonan □ kurang resonan □ dullness

Tindakan yang harus dilakukan :................................................
Auskultasi : □ vesikuler □ bronkhial □ bronkhovesikuler
Suara tambahan : □ ronkhi basah □ ronkhi kering
□ krepitasi □ wheezing

Tindakan yang harus dilakukan :.........................................

Punggung
Inspeksi : Keadaan : □ ada lesi □ ada jaringan sikatrik
□ penyakit kulit penyerta.................
Bentuk punggung : □ normal □ skoliosis □ kifosis
□ lordosis
Tindakan yang harus dilakukan :..............................................
Palpasi : Pergerakan punggung : □ simetris □ tidak
Taktil/vocal fremitus : □ simetris □ tidak
(getaran rendah □ kiri □ kanan)
Tindakan yang harus dilakukan :...............................................
Perkusi : □ sonor □ hipersonor □ resonan □ kurang resonan □ dullness
Tindakan yang harus dilakukan :..............................................
Auskultasi : □ vesikuler □ bronkhial □ bronkhovesikuler
Suara tambahan : □ ronkhi basah □ ronkhi kering
 □ krepitasi □ wheezing

Tindakan yang harus dilakukan :..............................................

Jantung
Insepeksi : .................................................................................................
Palpasi : Palpasi dinding thoraks teraba (□ lemah, □ kuat, □ tidak
teraba)
Auskultasi : Bunyi jantung □ S1 = S2, □ S1 > S2, □ S1 < S3
Keluhan yang terkait : .................................................................................................

Abdomen
Keterangan klien : Flatus ( + / - ), Ket :...............................................................
Inspeksi : □ datar, □ cekung, □ cembung/membusung

Auskultasi : Bunyi peristaltic usus : .......................X/menit

Palpasi : Hepar : Pembesaran hepar : □ ada □ tidak ada,

Nyeri tekan □ ada □ tidak
Lien : Pembesaran limpa : □ ada □ tidak ada
Nyeri tekan □ ada □ tidak
Apendiks : Nyeri tekan □ ada □ tidak ( Batasnya.................)
Ginjal : □ teraba □ tidak

Perkusi : □ Timpani □ Pekak

Genetalia
Genetalia Pria
Inspeksi : Lesi ( + / - ), Benjolan ( + / -)
Palpasi : Penis : Nyeri tekan ( + / - ), Benjolan ( + ./ -) Cairan.................
Scrotum dan testis : Benjolan ( + / - ), nyeri tekan ( + / - )
Kelainan yang tampak pada scrotum.....................................

Genetalia Wanita
Inspeksi : lesi ( + / - ), eritema ( + / - ), Keputihan ( + / - ), Peradangan
( +/ - )

Anus
Inspeksi : Atresia ani ( + / - ), Tumor ( + / - ), Haemoroid ( + / - ), Perdarahan ( + /
- ), perineum : jahitan ( + / - ), benjolan ( + / - )
Palpasi : nyeri tekan pada daerah anus ( + / - )

Muskuloskeletal ( Ekstremitas )
Inspeksi : otot tangan kanan/kiri dan kaki kanan/kiri simetris
Palpasi : oedem tangan kanan ( + / - ) tangan kiri ( + / - )
Oedem kaki kanan ( + / - ) kaki kiri ( + / - )
Skala Kekuatan .......................................................................
Keterangan :
0 Kontraksi otot tidak terdeteksi
 1 Kejapan yang hampir tidak terdeteksi atau bekas kontraksi
dengan obeservasi atau palpasi
2 Pergerakan aktif bagian tubuh dengan mengeliminasi
gravitasi
3 Pergerakan aktif hanya melawan gravitasi dan sedikit
tahanan
4 Pergerakan aktif melawan gravitasi dan sedikit tahanan
5 Pergerakan aktif melawan tahanan penuh tanpan adanya
kelelahan otot ( Kekuatan otot normal ).
2. Pemeriksaan Penunjang
Laboratorium

No Jenis Pemeriksaan Hasil Pemeriksaan Nilai Pemeriksaan Normal Keterangan

Radiologi
Hasil Foto Rontgen :
 Hasil CT SCAN :
Hasil Foto Kontras :

3. Therapy

Jenis Frekuensi
Obat Yang Cara Dosis Keterangan /
No Golongan Pemberian
diberikan Pemberian Obat Riwayat Obat
Obat Waktu (jam)

1.

2.

3.

4.

5.

6.

7.

8.

B. ANALISA DATA

NO TANGGAL DATA ETIOLOGI PROBLEM

C. DIAGNOSA KEPERAWATAN

1. …………….
2. …………….
3. …………….
4. .....................
D. NURSING CARE PLANNING

TGL/JAM NO DP NOC NIC

E. IMPLEMENTASI

TGL/JAM NO. DP IMPLEMENTASI EVALUASI PARAF

F. CATATAN PERKEMBANGAN

TGL/JAM NO. DP EVALUASI PARAF