PRODI S1 KEPERAWATAN

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN

Nama Mahasiswa : …………ANANTA ANUGRAINY NURIL

WIDODO…………………………………………...........
NIM : ……………………………………………………...........
Ruang : ……………………………………………………...........

2.1 PENGKAJIAN
2.1.1 Identitas
1. Identitas Pasien
Nama : MEYLIANA...............................................................
Umur : 20 tahun.......................................................................
Agama : Islam............................................................................
Jenis Kelamin : Perempuan...................................................................
Status Marital : .....................................................................................
Pendidikan : .....................................................................................
Pekerjaan : .....................................................................................
Asuransi : .....................................................................................
Suku Bangsa : .....................................................................................
Alamat : .....................................................................................
Tanggal Masuk : .....................................................................................
Tanggal Pengkajian : .....................................................................................
No.Register : .....................................................................................
Diagnosa Medis : .....................................................................................

2. Identitas Penanggung Jawab

Nama Penanggung : .....................................................................................
Hubungan dengan pasien : .....................................................................................
Alamat : .....................................................................................
Nomor Kartu Identitas : .....................................................................................
Jenis Kelamin : .....................................................................................
Pekerjaan : .....................................................................................
2.1.2 Riwayat Kesehatan
1. Keluhan Utama
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2. Riwayat Penyakit Sekarang

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3. Riwayat Kesehatan Dahulu
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4. Riwayat Kesehatan Keluarga
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Genogram :
 5. Riwayat Sosiokultural dan Spiritual
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6. Review Pola Sehat – Sakit

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7. Pola Aktifitas sehari hari
Pola Di Rumah Di Rumah Sakit
Nutrisi

Eliminasi

Istirahat

Aktivitas

Personal
Hygiene

Kebiasaan
2.1.3 Pemeriksaan Fisik
1. Keadaan Umum
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Tanda Vital
Suhu :......................... Nadi: ...................... Napas :..................... T.Darah ......................

2. Kepala
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3. Mata
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4. Hidung
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5. Telinga
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6. Mulut
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7. Leher
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8. Dada dan Punggung

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Paru-paru.........................................................................................................................
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Jantung............................................................................................................................
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9. Abdomen
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10. Muskuloskeletal dan Neurologis

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11. Pemeriksaan integumen/ kuku
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12. Anogenetalia
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2.1.4 Data Penunjang ( Pemeriksaan Diagnostik )

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2.1.5 Data Tambahan ( Penatalaksanaan )

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2.1.6 Harapan Klien/ Keluarga sehubungan dengan penyakitnya

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Mahasiswa
 2.2 ANALISA DATA
No. Data Etiologi Masalah Keperawatan

2.3 DIAGNOSA KEPERAWATAN

 Tanggal / Jam Diagnosa Keperawatan /Masalah Tanggal / Jam
No.
ditemukan kolaboratif Teratasi
 2.4 RENCANA SUHAN KEPERAWATAN ( NCP / NURSING CARE PLANS )
Diagnosa
No Keperawatan /Masalah Tujuan dan kriteria hasil Rencana Keperawatan Rasional
kolaboratif
 Diagnosa
No Keperawatan /Masalah Tujuan dan kriteria hasil Rencana Rasional
kolaboratif
2.5 IMPLEMENTASI
Tanggal,
Diagnosa Keperawatan Implementasi
Jam
2.6 EVALUASI
Tanggal, jam Diagnosa keperawatan Evaluasi