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FORMATLAPORANASUHANKEPERAWATAN

ASUHANKEPERAWATAN
PADA Tn/Ny… DENGAN ……
DIRUANG…… RS……..

Tgl/JamMRS : ……………………………....
Tanggal/JamPengkajian : ……………………………....
Metodepengkajian :.................................................
DiagnosaMedis : ……………………………....
No.Registrasi : ................................................
I. BIODATA
1.IDENTITASKLIEN
NamaKlien : ………………………………..
Alamat : ………………………………..
Umur : ………………………………..
Agama : ………………………………..
StatusPerkawinan : ………………………………..
Pendidikan : ………………………………..
Pekerjaan : ………………………………..
2. IdentitasPenanggungjawab
Nama : ………………………………...
Umur :...................................................
Pendidikan : ...................................................
Pekerjaan:…………………………………
Alamat:………………………………...
HubungandenganKlien : .............................................

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II. RIWAYATKEPERAWATAN
1. KeluhanUtama
……………………………………………………………………………
2. RiwayatPenyakitSekarang
………………………………………………………………………………

3. RiwayatPenyakitDahulu
……………………………………………………………………………

4. RiwayatKesehatanKeluarga
……………………………………………………………………………

Genogram:

5. RiwayatKesehatanLingkungan:
............................................................................................................................

III. PENGKAJIANPOLAKESEHATANFUNGSIONAL
1. PolaPersepsidanPemeliharaan Kesehatan
…………………………………………………………………………………….

2. PolaNutrisi/Metabolik
SebelumSakit SelamaSakit
Frekuensi
Jenis
Porsi
Keluhan

3. PolaEliminasi
a. BAB
SebelumSakit SelamaSakit
Frekuensi
Konsistensi
Jumlah
Warna
Keluhan

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 b. BAK
SebelumSakit SelamaSakit
Frekuensi
JumlahUrine
Warna
Keluhan

AnalisaKeseimbanganCairanSelamaPerawatan
Intake Output Analisa
a. Minuman………cc c. Urine....................cc Intake:
b. Makanan..............cc d. Feses.......................cc ……………….ccOutp
e. IWL......................cc ut:………………
cc
Total............................cc Total...........................cc Balance........................cc

4. PolaAktifitasdan Latihan(SebelumdanSelama Sakit)

SebelumSakit Selama
Kemampuanperawatandiri Sakit
0 1 2 3 4 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitasditempat tidur
Berpindah
Ambulasi/ROM
Ket:
0: Mandiri, 1: dengan alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan
alat;4:tergantungtotal

5. PolaIstirahatTidur
a. SebelumSakit:
………………………………………………………........................
b.SelamaSakit: ..................................................................................................
6. PolaKognitif –Perseptual
a. SebelumSakit:………………………………………………………............
b.SelamaSakit: .................................................................................................
7. PolaPersepsiKonsep Diri
a.SebelumSakit:………………………………………………………............

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 b.SelamaSakit :..........................................................................................
8. PolaPeran danHubungan
a.SebelumSakit:……………………………………………………….............
b.SelamaSakit: ..............................................................................................
9. PolaSeksualitasReproduksi
a.SebelumSaki:………………………………………………………............
b.SelamaSakit : ..........................................................................................
10. PolaMekanismeKoping
a.SebelumSakit:………………………………………………………...........
b.SelamaSakit: .............................................................................................
11. PolaNilaidanKeyakinan
a.SebelumSakit:………………………………………………………..........
b.SelamaSakit: ................................................................................................

IV. PEMERIKSAANFISIK

1. Keadaan/PenampilanUmum
a.Kesadaran:…………………………………………………………………..
b. Tanda-TandaVital
• TekananDarah:...............................................................................
• Nadi
- Frekuensi:
- Irama:
- Kekuatan:
• Pernafasan
- Frekuensi:
- Irama:
• Suhu:
Analisa:.......................................

2. Kepala
• BentukKepala : ......................................................
• KulitKepala : ...................................................
• Rambut : .............................................
Analisa:.....................

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3. Muka
a. Mata
• Palpebra : ...........................................................................................
• Konjungtiva : ...........................................................................................
• Sclera : ...........................................................................................
• Pupil : ...........................................................................................
• Diameter ki/ka:...........................................................................................
• ReflekTerhadapCahaya ki/ka :.......................................................
• Penggunaanalatbantupenglihatan : .......................................................
b.Hidung : .......................................................................................................
c. Mulut : .......................................................................................................
d.Gigi : ……………………………………………………………….......
e. Telinga : ……………………………………………………………….......
Analisa :
.......................................................................................................

4.Leher:…………………………………………………………
Analisa:...............................................................................................
5. Dada(Thorax)
a. Paru-paru
Inspeksi : ………………………………….......................................
Palpasi : ………………………………….......................................
Perkusi :…………………………………......................................
Auskultasi :…………………………………......................................

Analisa:......................................................................................................
b. Jantung
Inspeksi :…………………………………......................................
Palpasi : …………………………………......................................
Perkusi : …………………………………......................................
Auskultasi :…………………………………......................................

Analisa:......................................................................................................

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 6. Abdomen
Inspeksi : ………………………………..........................................
Auskultasi : ..........................................................................................
Perkusi : ..........................................................................................
Palpasi : ..........................................................................................

Analisa:............................................................................................................
7.Genetalia : ......................................................................................................
Analisa:....................................................................................
8.Rektum : ......................................................................................................
Analisa:.........................................................................................
9. Ekstremitas
Atas
• Kekuatanototkanan dankiri :...................................................................
• ROMkanandankiri : ...................................................................
• Perubahanbentuktulang : ............................................
• PerabaanAkral : ..................................................
• Pittingedema : ...................................................................
Analisa:..................................................................................................

Bawah
• Kekuatanototkanan dankiri :...................................................................
• ROMkanandankiri : ...................................................................
• Perubahanbentuk tulang : ................................................
• PerabaanAkral : ..................................................................
• Pittingedema: ...............................................................................
Analisa:...................................................................................................

V. PEMERIKSAANPENUNJANG
1. HasilLaboratorium
Hari/ JenisPe Nilai Satuan Hasil KeteranganHasil
Tanggal/ meriksaan Normal
Jam

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 2. HasilCT-Scan
3. Hasilrontgen,dst..pemeriksaanpenunjanglain
VI. TERAPIMEDIS
Hari/ JenisTerapi Dosis Golongan Fungsi EfekS
Tanggal/ &Kandung &Farmakolo amping
jam gi
an
Cairan
IV:ObatPerora
l:
Obat
Parenteral:Obat
Topikal:

VII. ANALISADATA
Nama: No. CM :
Umur: DiagnosaMedis:
No. Hari/Tgl/ DataFokus Problem Etiologi Symptom
Jam
1. DS:
DO:
(observasi,pemeriksaanfisik,pemerik
saandiagnostik,pemeriksaanlab)

VIII. PRIORITAS DIAGNOSA

KEPERAWATAN1.

2.

3.

Dst...

IX. RENCANAKEPERAWATAN
Nama: No. CM :
Umur: DiagnosaMedis:

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 NoDx TujuandanKriteriaHasil Intervensi
1. SLKI_sertakanlabelnya SIKI_sertakanlabelnya
(SMART) (KalimatPasif)
2.

X. IMPLEMENTASI
Nama : No.CM :
Umur : DiagnosaMedis:
Hari/Tgl NoDx Implementasi Respon Ttd
/Jam
(Kalimataktif) S:
O:

XI. EVALUASIKEPERAWATAN
Nama : No.CM :
Umur : DiagnosaMedis:
NoDx Hari/Tgl/Jam Evaluasi Ttd

1 S:
O:
A:
P
2 S:
O:
A:
P:

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