SEKOLAH TINGGI ILMU KESEHATAN PANTI RAPIH

Jl. Tantular 401 Pringwulung Condongcatur Depok Sleman Yogyakarta

Telp. (0274) 518977 Fax. (0274) 587143

LAPORAN ASKEP HARIAN

STIKES PANTI RAPIH YOGYAKARTA

Nama Mahasiswa : TTD PJ Ruangan/ CI RS

NPM :
Tanggal :
Bangsal :
Nama Pasien (Inisial) :
Diagnosa Medik :

A. PENGKAJIAN (DATA FOKUS)

1. Keluhan utama saat ini
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2. Keluhan penyerta
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3. Riwayat sakit
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4. Data psikologis
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5. Data spiritual (cara pandang pasien terhadap sakitnya dalam hubungannya dengan Tuhan)
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6. Data sosiologis, kultural, dan lingkungan (di RS dan di rumah yang berkaitan dengan sakitnya)
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7. Data pemenuhan kebutuhan dasar pasien (nutrisi, eliminasi, hygiene perseorangan, istirahat
tidur, aktivitas, oksigenasi, cairan dan elektrolit, keamanan dan keselamatan sesuai dengan
kondisi sakitnya)
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8. Pemeriksaan Fisik (inspeksi, palpasi, perkusi, auskultasi sesuai dengan keluhan dan penyakit
 pasien)
Kesadaran
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Tanda-tanda vital
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Sistemik
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Program Therapy
Nama Obat Dosis Indikasi Kontra Indikasi Alasan Pasien
Mendapat Obat

PEMERIKSAAN PENUNJANG
I. Pemeriksaan Laboratorium
Tanggal Jenis Komponen Hasil Nilai Satuan Interpretasi
Pemeriksaa yang Rujukan
n diperiksa
2. Pemeriksaan Radiologi

Tanggal Jenis Pemeriksaan Hasil

3. Pemeriksaan EKG/ MRI/ PEMERIKSAAN KHUSUS LAIN

Tanggal Jenis Pemeriksaan Hasil

PENGELOMPOKAN DATA

Data Subyektif

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Data Obyektif
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Penguji, Mahasiswa,

Tanggal……………………………. Tanggal...…………………

(…………………………………….) (…………………………….)

ANALISIS DATA

Nama :………………………….. Ruang :…………………..

No.RM :………………………….. Kamar:………………….

NO. DATA MASALAH KEMUNGKINAN

PENYEBAB/FAKTOR
RESIKO
 DIAGNOSIS KEPERAWATAN

Nama :………………………….. Ruang :…………………..

No.RM :………………………….. Kamar:………………….

NO. TANGGAL DIAGNOSIS KEPERAWATAN TANDA

MUNCUL TANGAN
 RENCANA KEPERAWATAN

Nama :………………………….. Ruang :…………………..

No.RM :………………………….. Kamar:………………….

No.D
TUJUAN DAN KRITERIA HASIL RENCANA TINDAKAN RASIONAL TTD
P