FORMAT ASUHAN KEPERAWATAN

Tanggal Pengkajian/Jam :

Ruang/RS :

A. BIODATA

1. Biodata Pasien

a. Nama :

b. Umur :

c. Alamat :

d. Pendidikan :

e. Pekerjaan :

f. Tanggal masuk :

g. Diagnosa medis :

h. Nomor register :

2. Biodata Penanggung jawab

a. Nama :

b. Umur :

c. Alamat :

d. Pendidikan :

e. Pekerjaan :

f. Hubungan dengan klien:

B. KELUHAN UTAMA
(Keluhan apakah yang paling dirasakan oleh pasien saat di kaji?)

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C. RIWAYAT KESEHATAN

1. Riwayat Kesehatan Sekarang

a. Terkait dengan keadaan sakit sekarang, tanyakan apa yang pertama kali dirasakan

oleh pasien...............................................................................................................

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b. Kapan keluhan pertama kali dirasakan....................................................................

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c. Apa yang dilakukan pasien/keluarga untuk mengatasi masalah tersebut?..............

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d. Bagaimana efek dari usaha yang dilakukan?..........................................................

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e. Setelah tidak ada perubahan dari usaha yang dilakukan, apa yang dilakukan

kemudian oleh pasien/keluarga ..............................................................................

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2. Riwayat Kesehatan Dahulu

a. Apakah pasien pernah mengalami keadaan sakit seperti ini sebelumnya. Jika ada,

kapan?......................................................................................................................

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b. Tindakan apa yang dilakukan untuk mengatasi masalah pada waktu itu? .............

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3. Riwayat Kesehatan Keluarga

a. Apakah ada anggota keluarga yang mengalami sakit seperti ini?...........................

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b. Adakah anggota keluarga yang mengalami penyakit kronis seperti : TBC, DM,

dan penyakit jantung...............................................................................................

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c. Jika pasien mengalami penyakit kronis seperti diatas, buatlah genogram untuk

mengetahui riwayat herediter dan resiko penularan (untuk penyakit menular)......

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D. PENGKAJIAN ( pemfis head to too ) Mengacu pada salah satu pendekatan ( pilih

salah satu) :

a. Pemeriksaan setiap system tubuh............................................................................

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b. Pemeriksaan dengan berdasar 6 B ( Brain, Breath, Blood, Bowell, Bone dan

Bladder)...................................................................................................................
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E. PEMERIKSAAN DIAGNOSTIK ( Disesuaikan dengan topic yg diambil...!)

 1. Laboratorium................................................................................................................

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2. Radiologi.......................................................................................................................

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F. PROGRAM TERAPI (Disesuaikandengan topic yg diambil...!)..................................

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ANALISA DATA
No Tanggal/ Data Objektif dan Etiologi Masalah Kep (Min

Jam Subjektif 3X DX)

1.

2.
3.
 RENCANA KEPERAWATAN

NO DIAGNOSA (SDKI) SLKI SIKI

1.

2.
3.
 IMPLEMENTASI

NO DIAGNOSA TINDAKAN KEPERAWATAN HARI/TGL TANDA

TANGAN
1.
2.
3.
 CATATAN PERKEMBANGAN

N KODE SOAP HARI/TGL TANDA

O DIAGNOSA TANGAN
1.
2.
3.