FORMAT ASUHAN KEPERAWATAN

Bangsal/ruangan : ....................... Tanggal Masuk : .......................

Nomor kamar : ....................... Tanggal Pengkajian : .......................

I. Pengkajian
A. Identitas
1. Klien
Nama Klien : ...................
Umur : .......... tahun

Jenis kelamin : Laki-laki Perempuan

Status marital : Belum menikah Menikah

Agama : .....................................

Suku/Bangsa : .....................................

Bahasa yang digunakan : Indonesia

Daerah : ................

Asing : ................

Pendidikan : .....................................
Pekerjaan : .....................................
Alamat Rumah : .................................................................................

2. Penanggung Jawab
Nama : ...................
Alamat Rumah : .................................................................................
Hubungan dengan klien : ...................

B. Data Medik
Diagnosa Medis
 Saat masuk : ...........................................................
 Saat pengkajian : ...........................................................
C. Alasan masuk rumah sakit
..................................................................................................................
Keluhan utama saat pengkajian : .......................................................................
D. Riwayat kesehatan saat ini : (PQRST)

Paliatif/penyebab....................................................................................................
Qualitas /..................................................................................................................
Region......................................................................................................................
Skala.........................................................................................................................
Timing.......................................................................................................................
E. Riwayat kesehatan masa lalu :
II. Penyakit yang pernah diderita : .....................................................................

III. Pernah dirawat : ya tidak

bila ya, kapan dan dimana dirawat : .................................................................

IV. Pernah dioperasi : ya tidak

bila ya, waktu operasi: : ...........................................................................
tempat operasi : ...........................................................................
Jenis tindakan operasi : ...........................................................................

V. Alergi terhadap obat, makan, dll : ya tidak

bila ya, sebutkan : .................................................................................
VI. Imunisasi : .................................................................................

VII. Kebiasaan merokok, alkohol dan obat-obatan : ya tidak

bila ya, sebutkan : .................................................................................

A. Riwayat kesehatan keluarga:

1. Susunan anggota keluarga
Genogram : ( 3 generasi)

2. Penyakit yang pernah diderita anggota keluarga : .............................................

3. Kesehatan orang tua (jika yang sakit anak) : .............................................
 4. Saudara kandung
: .............................................
5. Hubungan keluarga dengan klien
: .............................................
6. Anggota keluarga lain yang tinggal serumah : .............................................
7. Faktor risiko penyakit tertentu dalam keluarga, seperti :
Kanker Hipertensi Diabetes melitus

Penyakit jantung Epilepsi TBC

Penyakit lainnya, sebutkan ................................................................

B. Kebiasaan sehari-hari
1. Nutrisi - Cairan
a. Keadaan sejak sakit :
 Napsu makan : .............................................
 Frekuensi makan : .............................................
 Jumlah makan yang masuk
Kurang satu porsi

Satu porsi penuh

Lebih dari satu porsi

 Diet : .............................................
 Ketaatan terhadap diet tertentu : .............................................
 Mual/enek : .............................................
 Muntah : .............................................
 Nyeri ulu hati : .............................................
 Jumlah minum/24 jam : .............................................
 Jenis minum : .............................................
 Keluhan makan dan minum : .............................................

2. Eliminasi
a. Keadaan sejak sakit :
 Frekuensi BAB/24 jam : .............................................
 Waktu BAB : .............................................
 Warna feses : .............................................
 Konsistensi : .............................................
 Bentuk feses : .............................................
 Penggunaan pencahar : .............................................
  Keluhan BAB : .............................................
 Melena : .............................................
 Konstipasi : .............................................
 Frekuensi BAK/24 jam : .............................................
 Warna urine : .............................................
 Volume urine : .............................................
 Bau urine : .............................................
 Masalah pengontrolan buang air besar : .............................................
 Kolostomi : .............................................
 Sering menahan buang air kecil : .............................................
 Keluhan saat buang air kecil :

Disuria

Buang kecil tidak lancar

Harus mengejan saat buang air kecil

Urine menetes

Urine tidak bisa keluar sama sekali (retensi urine)

pengeluaran Urine tidak bisa dikontrol (inkontinensia)

Berkemih tidak terasa

Malam banyak berkemih (nokturia)

Hematuri

 Penggunaan kateter : .............................................

 Peningkatan perspirasi/keringat : .............................................

3. Aktivitas - latihan
a. Keadaan sejak sakit :
 Aktivitas perawatan diri

 Makan :

 Mandi :

 Berpakaian :

 Kerapian :
  Buang air besar :

 Buang air kecil :

 Mobilisasi ditempat tidur :

 Ambulasi :

Keterangan :
0 : mandiri
1 : bantuan dengan alat
2 : bantuan orang
3 : bantuan orang dan alat
4 : bantuan penuh

 Kesimpulan :.......................................................................................

 Rekreasi selama dirawat : .............................................

4. Tidur - istirahat
a. Keadaan sejak sakit
 Tidur siang
bila ya, berapa jam
 Tidur malam
 Kebiasaan sebelum tidur
 Keluhan tidur
 Ekspresi wajah mengantuk
:
: ya tidak
: ............ jam
: ............ jam
: .............................................
: .............................................
: Negatif Positif

 Banyak menguap : Negatif Positif

 Palpebrae inferior warna gelap : Negatif Positif

C. Data psikologis
1. Persepsi tentang penyakitnya : .............................................
2. Suasana hati/air muka : .............................................
3. Daya konsentrasi : .............................................
4. Koping : .............................................
5. Konsep diri : .............................................
6. Stressor : .............................................

D. Data sosial
1. Tempat tinggal : .............................................

2. Hubungan dengan keluarga/kerabat : .............................................

3. Hubungan dengan klien lain : .............................................

4. Hubungan dengan perawat : .............................................

 5. Adat istiadat yang dianut : .............................................

E. Data spritual
Agama yang dianut : .............................................
Apakah agama sangat penting bagi anda : .............................................
Jika ya, dalam hal apa : .............................................
Kegiatan keagamaan selama dirawat : .............................................
Apakah selalu berdoa untuk kesembuhan : .............................................

F. Pemeriksaan Fisik
1. Keadaan sakit : Klien tampak sakit ringan/ sedang/ berat/ tidak tampak sakit
Alasan : ...............................................................................................
...............................................................................................

2. Tanda-tanda vital
a. Kesadaran
1) Kualitatif : Kompos mentis (alert) Lethargi

Somnolent (obtunded) Stuporous

Semicoma Coma

2) Kuantitatif :
 Glasgow Coma Scale : Respon motorik (M) : .......
Respon bicara (V) : .......
Respon membuka mata (E) : .......
 Jumlah : ..........
 Kesimpulan : ...................................

b. Tekanan darah : ............. mmHg

MAP : ............. mmHg
Kesimpulan :...................................................................................

c. Nadi : frekuensi ......... kali/menit, volume................, ritme .................

d. Suhu : ...... oC Oral Axila Rectal

e. Pernapasan : frekuensi ........ kali/menit

Irama : teratur tidak teratur

Kusmaul Cheyness-stokes

jenis : dada perut

3. Antropometri
a. Lingkar lengan atas : ............ cm
b. Lipat kulit triceps : ............ cm
c. Tinggi badan : ............ cm
d. Berat badan : ............ cm
e. IMT (Indeks Massa Tubuh : .................. kg/m2
Kesimpulan : ...................................................

4. Kepala
a. Bentuk kepala : Simetris tidak simetris

Cephalo hematome : .............................................................................

Ukuran : .............................................................................

Fontanel : .............................................................................

b. Warna rambut : Hitam Coklat

Pirang Perak

c. Keadaan rambut : Rontok Pecah-pecah

Tumbuh subur

d. Kulit kepala : Kotor dan bau Lesi

Ketombe Bersih

e. Bengkak/benjolan : .............................................................................
f. Nyeri/pusing : .............................................................................
g. Keluhan lain : .............................................................................

5. Mata/Penglihatan
a. Ketajaman penglihatan : ...................................................................
b. Alis : ...................................................................
c. Bulu mata :
Warna : ...................................................................
Kondisi/distribusi : ...................................................................
Posisi : ...................................................................
Peradangan : ...................................................................

d. Simetris : ya tidak

e. Sclera : Putih dan jernih

 Kuning/ikterik

kebiruan

f. Pupil

 Bentuk : bulat tidak bulat

 Kesamaan ukuran : isocor anisocor

 Warna : gelap keruh & tidak berwarna

 Reaksi terhadap cahaya : miosis midriasis

 Refleks pupil (test N.III) :

sama besar, bulat dan bereaksi terhadap cahaya

mengecil

melebar

g. Palpebra :

edema

peradangan

Ptosis

lagopthalmus

baik/normal

h. Konjungtiva : .............................................................................
i. Bola mata : .............................................................................
j. Gerakan bola mata : .............................................................................
k. Lapang pandang : .............................................................................
l. Cornea & iris :
Abrasi : .............................................................................
Kejernihan : .............................................................................
Refleks kornea : .............................................................................
m. Peradangan : .............................................................................
n. TIO : .............................................................................
o. Keluhan penglihatan : .............................................................................
p. Alat bantu penglihatan: .............................................................................
 kaca mata

kontak lensal

tidak menggunakan alat bantu

6. Hidung/Penciuman
a. Struktur luar :
 Ukuran : ..............................................................................
 Bentuk : ..............................................................................
 Kesimetrisan : ..............................................................................

b. Struktur dalam :

 Warna : merah muda kemerahan keabu-abuan

c. Fungsi penciuman (test N.I) : ...................................................................

d. Perdarahan : ...................................................................
e. Lain-lain : ...................................................................

7. Telinga/pendengaran
a. Struktur luar :
Warna : ...................................................................
Lesi : ...................................................................
Cerumen : ...................................................................
Membran timpani : ...................................................................

b. Fungsi pendengaran :
Test Rinne : ...................................................................
Test Weber : ...................................................................

Test Swabach : ...................................................................

c. Nyeri : ...................................................................
d. Alat bantu : ...................................................................
e. Keseimbangan : ...................................................................
f. Lain-lain : ...................................................................

8. Mulut/Pengecapan
a. Bibir
Warna : ...................................................................
Kesimetrisan : ...................................................................
Kelembaban : ...................................................................
 Kondisi: Pecah-pecah, berdarah

Biru/sianosis

Pucat

Bengkak

b. Mukosa mulut
Warna : ...................................................................
Kelembaban : ...................................................................
Lesi : ...................................................................

c. Gigi :

Kebersihan : bersih tidak bersih

Caries : ada tidak ada

Kelengkapan : lengkap tidak lengkap

d. Gigi palsu : ..................................................................

e. Keadaan gusi : ..................................................................
f. Keadaan lidah : ...................................................................
g. Peradangan : ...................................................................
h. Fungsi mengunyah : ...................................................................
i. Fungsi mengecap : ...................................................................
j. Fungsi bicara : ...................................................................
k. Bau mulut : ...................................................................
l. Gag refleks : ...................................................................
m. Refleks menelan : ...................................................................
n. Lain-lain : ...................................................................

9. Leher
a. Kelenjar getah bening : ...................................................................
b. Kelenjar thyroid : ...................................................................
c. Kelenjar sub mandibulalis : ...................................................................
d. JVP : ...................................................................
e. Kaku kuduk : ...................................................................
f. Sulit menelan : ...................................................................
g. Lain-lain : ...................................................................
10. Dada
a. Bentuk : Simetris tidak simetris

Dada membusung (pectus carunatum)

Dada berbentuk corong (pectus excavatum)

Dada berbentuk tong (barrel chest)

b. Kwalitas napas ; cepat

lambat

dalam

dangkal

c. Suara napas :

Vesiculer

Broncho vesiculer

Bronchial/tracheal

Ronchi

Wheezing

d. Perkusi dada :

Pekak/datar

Redup/dullness

Resonan

Tympani

e. Ekspansi paru : ...................................................................

f. Batuk : ...................................................................
g. Sputum : ...................................................................
h. Nyeri dada : ...................................................................
i. Tactile fremitus : ...................................................................
j. Pergerakan rongga dada : ...................................................................
k. Penggunaan otot nafas tambahan : ......................................................
 l. Lain-lain : ...................................................................

11. Kardiovaskuler/SIrkulasi
a. Batas jantung : ...................................................................
b. Heart rate : ...................................................................
c. Bunyi jantung I : ...................................................................
d. Bunyi jantung II : ...................................................................
e. Bunyi jantung tambahan : ...................................................................
f. Nyeri dada : ...................................................................
g. Palpitasi : ...................................................................
h. Edema : ...................................................................
i. Cyanosis : ...................................................................
j. Jari-jari tabuh : ...................................................................
k. Lain-lain : ...................................................................

12. Abdomen/pencernaan

a. Keadaan kulit : ...................................................................

b. Bising usus : ...................................................................
c. hepar : ...................................................................
d. limfa : ...................................................................
e. Nyeri tekan : ...................................................................
f. Benjolan-benjolan : ...................................................................
g. Gembung : ...................................................................
h. Ascites : ...................................................................
i. Lain-lain : ...................................................................

13. Muskulo skeletal

a. Kekuatan otot ekstremitas atas: ...................................................................
b. Kekuatan otot ekstremitas bawah:.................................................................
c. Tonus otot : ...................................................................
d. Kaku sendi : ...................................................................
e. atropi : ...................................................................
f. ROM : ...................................................................
g. Trauma/lesi : ...................................................................
h. Nyeri : ...................................................................
i. Refleks : ...................................................................
j. Kecacatan/deformitas : ...................................................................
 k. Lain-lain : ...................................................................

14. Genitourinaria
Laki-laki :
a. Penis/skrotum : ...................................................................
b. Testis : ...................................................................
c. Fungsi seksual : ...................................................................
d. Pertumbuhan rambut : ...................................................................
e. Pembengkakan : ...................................................................
f. Nyeri daerah perineal : ...................................................................
g. Kebersihan genitalia : ...................................................................
h. Kebersihan anus : ...................................................................
i. Lain-lain : ...................................................................

Perempuan :

a. Menstruasi : ...................................................................
b. Kehamilan : ...................................................................
c. Konstrasepsi yang digunakan : ...................................................................
d. Pemeriksaan usap vagina : ...................................................................
e. Pertumbuhan rambut : ...................................................................
j. Fungsi seksual : ...................................................................
k. Nyeri daerah perineal : ...................................................................
f. Kebersihan genitalia : ...................................................................
g. Kebersihan anus : ...................................................................
h. Lain-lain : ...................................................................

15. Keadaan neurologi

a. Tingkat kesadaran : ...................................................................
b. Koordinasi : ...................................................................
c. Memori/daya ingat : ...................................................................
d. Orientasi (tempat,orang,waktu) : ...............................................................
e. Tremor : ...................................................................
f. Gangguan motorik/lumpuh : ...................................................................
g. Kejang : ...................................................................
h. Fungsi nervus I s/d XII :

N.I (Olfactorius) : ...................................................................

N.II (Optikus) : ...................................................................
N.III (Oculomotorius) : ...................................................................
 N.IV (Trochlearis) : ...................................................................
N.VI (Abducn) : ...................................................................
N.V (Trigeminus) : ...................................................................
N.VII (Facialis) : ...................................................................
N.VIII (Cochlea vestibularis) : ...................................................................
N.IX (Glosopharingeus) : ...................................................................
N.X (Vagus) : ...................................................................
N.XI (Accesoris) : ...................................................................
N.XII (Hypoglosus) : ...................................................................

i. Refleks tendon : ...................................................................

j. Refleks permukaan : ...................................................................
k. Refleks patologik : ...................................................................
i. Lain-lain : ...................................................................

16. Sensasi terhadap rangsangan

a. Rasa nyeri : ...................................................................

b. Rasa suhu : ...................................................................

c. Rasa raba : ...................................................................

17. Integumen/Kulit
a. Warna

flushing (kemerahan)/alamiah/sawo matang/putih

cyanosis

biru kemerahan

Joundice/ikterus

Pallor (pucat)

b. Tekstur

halus/licin

lunak

fleksibel

keriput

c. Turgor : ...................................................................

d. Kelembaban : ...................................................................
e. Suhu kulit :

Hangat

Dingin

Normal/alamiah

f. Lesi

macula, lokasi ……………………….

Papula, lokasi ………………………

Nodula, lokasi ……………………….

Tumor, lokasi ……………………….

Vesicula, lokasi ……………………….

pustula, lokasi ……………………….

Ulkus, lokasi ……………………….

g. Kelainan warna : ...................................................................

h. Pucat : ...................................................................
i. Pigmentasi : ...................................................................

hipo pigmentasi

hiperpigmentasi

normal/alamiah

j. Edema

+1

+2

+3

+4

k. Keadaan kuku : panjang pendek

Kebersihan kuku : ...................................................................

l. Lain-lain : ...................................................................
 18. Catatan tambahan
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................

G. Pemeriksaan diagnostik :
1. Laboratorium :
a. Darah : ..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................

b. Feses : ..............................................................................................
..............................................................................................
..............................................................................................

c. Urin : ..............................................................................................
..............................................................................................
..............................................................................................

d. Sputum : ..............................................................................................
..............................................................................................

e. Lain-lain : ..............................................................................................
..............................................................................................

2. Radiologi : ..................................................................................
..................................................................................
..................................................................................

3. EKG : ..................................................................................
..................................................................................

4. EEG : ..................................................................................
..................................................................................

5. USG : ..................................................................................
..................................................................................

6. Pemeriksaan lainnya : ..................................................................................

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

H. Program terapi :

1. Obat-obatan
................................................. .................................................
 ................................................. .................................................
................................................. .................................................
................................................. .................................................

2. Fisioterapi : ...........................................................................

Tanda tangan mahasiswa yang mengkaji

Jambi, 2016

( )
NPM.
 ANALISA DATA

NAMA PASIEN : ...............

UMUR : ...............
DATA KEMUNGKINAN PENYEBAB MASALAH
 NCP

NO DIAGNOSA INTERVENSI RASIONAL

KEPERAWATAN
 CATATAN PERKEMBANGAN
NAMA PASIEN : ...............
UMUR : ...............
NO TANGGAL DIAGNOSA CATATAN TANDA
MUNCUL KEPERAWATAN PERKEMBANGAN TANGAN
 CATATAN KEPERAWATAN

NAMA PASIEN : ...............

UMUR : ...............

TANGGAL DIAGNOSA CATATAN KEPERAWATAN TANDA

JAM KEPERAWATAN TANGAN
 CATATAN PERKEMBANGAN

NAMA PASIEN : ...............

UMUR : ...............

NO TANGGAL DIAGNOSA PERKEMBANGAN TANDA

JAM KEPERAWATA SOAP TANGAN
N