FORMAT ASUHAN KEPERAWATAN

 
A. PENGKAJIAN
1. PENGUMPULAN DATA
a. Biodata
1) Nama  :
2) Jenis Kelamin  :
3) Umur :
4) Agama :
5) Status Perkawinan :
6) Pendidikan Terakhir :
7) Pekerjaan :
8) Alamat :
9) Tanggal MRS  :
10) Tanggal Pengkajian/jam :

a. Diagnosa Medis :..................................................................................................................

b. Keluhan Utama :
Saat Pengkajian .....................................................................................................................
................................................................................................................................................
...........................
c. Riwayat Penyakit Sekarang
: .............................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
..
d. Riwayat Kesehatan / Penyakit Yang Lalu
: .............................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
...
e. Riwayat Kesehatan Keluarga
: .............................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
...
Daftar Pengobatan Sekarang (Diresepkan) Nama Obat Dosis Cara pemberian Frekw
pemberian

g. Pola Aktivitas Sehari :
 1) Pola Persepsi Pengelolaan Pemeliharaan Kesehatan 
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
2) Pola Aktivitas
Latihan KEMAMPUAN PERAWATAN DIRI :
0= Mandiri 1= Alat Bantu 2= Dibantu orang lain3= Dibantu orang dan peralatan 4= Ketergantun
gan/tidakmampu0 1 2 3 4Makan minum Mandi Berpakaian/dandanToileting Mobilitas ditempat
tidur Berpindah Berjalan Naik tangga
ALAT BANTU :__ Tidak __ Kruk __ Pispot disamping tempat tidur __ Walker __ Tongkat __
Kursi roda __ Lain- lain,sebutkan___________________ 
3)Pola Nutrisi dan Metabolik  
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
4)Pola Eliminasi 
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
5)Pola Tidur - Istirahat ......................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
......................................
6)Kebersihan Diri
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
7)Pola Kognitif – Perseptual
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
8)Pola Toleransi Koping Stres/Persepsi Diri/Konsep Diri
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
9)Pola Seksualitas/ Reproduksi
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
10)Pola Peran-Hubungan
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
11)Pola Nilai-Keyakinan
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................

h.Riwayat Psikososial :
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
i. Pemeriksaan Fisik
1.Keadaan Umum Dan Vital Sign
Keadaan Umum :
Kesadaran :
Suhu : 
Nadi :
Tekanan Darah
RR :
BB :
TB :
2.Pemeriksaan Kepala Leher
a.Kepala ............................................................................................................................................
............................................................................................................................................................
................
b.Mata ...............................................................................................................................................
............................................................................................................................................................
.............
c.Hidung
............................................................................................................................................................
............................................................................................................................................................
d.Telinga ...........................................................................................................................................
............................................................................................................................................................
.................
e.Mulut
............................................................................................................................................................
............................................................................................................................................................

f.Leher
............................................................................................................................................................
............................................................................................................................................................
3.Pemeriksaan Integumen
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
...........................................................................................................................................................
4.Pemeriksaan Thorax
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
...........................................................................................................................................................
 
5.Abdomen ........................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
....................
6.Genetalia ........................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
....................
7.Ekstremitas Atas : 
............................................................................................................................................................
............................................................................................................................................................
Bawah : .............................................................................................................................................
............................................................................................................................................................
Nilai kekuatan otot

 j.Pemeriksaan Neurologis
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
k.Pemeriksaan Penunjang
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
l.Terapi/Pengobatan/Penatalaksanaan
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................

Tanggal :

Tanda Tangan :

(…………………………………………………….)

 
 ANALISA DATA
Nama Pasien : No.Register : 
Umur : Ruang :
DATA PENUNJANG MASALAH KEMUNGKINAN
PENYEBAB
 DIAGNOSIS KEPERAWATAN

 Nama Pasien : No. Register : 

Umur : Ruang :
NO.DX TANGGAL DIAGNOSIS TANGGAL TANDA
MUNCUL KEPERAWATAN TERATASI TANGAN
 RENCANA ASUHAN KEPERAWATAN
 Nama Pasien :  No. Register :
Umur :  Ruang :

TGL NO.DX DIAGNOSA TUJUAN STANDAR RASIONAL TANDA

KEPERAWATAN KRITERIA INTERVENSI TANGAN

IMPLEMENTASI KEPERAWATAN
 Nama Pasien : No. Register :
Umur :  Ruang :

N TANGGAL NO.DX JAM TINDAKAN TTD

O

EVALUASI KEPERAWATAN
Nama Pasien : No. Register : 
Umur : Ruang :
NO.DX TANGGAL DIAGNOSA EVALUASI TANDA
TANGAN