Format Rencana Asuhan Pasien

Klinik Global Farma

PENGKAJIAN
Dilaksanakan Tgl :
No. Ruang/kelas : :

1. Biodata
Nama :
Umur :
Jenis kelamin :
Agama :
Alamat :
Pendidikan :
Pekerjaan :
Status perkawinan :
Tanggal MRS :
Diagnosa Medis :
No. Reg :

Keluarga yang mudah dihubungi

Nama :
Pekerjaan :
Alamat :
Hubungan keluarga :

2. Keluhan
a. Alasan Masuk Rumah Sakit
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b. Keluhan saat pengkajian
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3. Riwayat penyakit sekarang

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4. Riwayat penyakit masa lalu

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5. Riwayat kesehatan keluarga

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6. Riwayat Psikososial Spiritual

a. Psikososial
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b. Sosial
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c. Spiritual
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7. Pola aktifitas sehari-hari (di rumah & di rumah sakit )

No. Kebiasaan Di Rumah Di Rumah Sakit
1. Makan

2. Minum

3. Eliminasi BAB

4. Eliminasi BAK

5. Istirahat/Tidur
 6. Personal hygiene

7. Aktifitas/Latihan
Olahraga
Lain-lain

Pemeriksaan Fisik :
a. Keadaan/Penampilan/Kesan Umum Pasien
Pasien tampak ...............................................................................................................................
Kulit dan keadaan tubuh...............................................................................................................
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b. Tanda-tanda vital
Tekanan Darah : Suhu :
Denyut Nadi : Respirasi/RR :

TB/BB :
Status Nutrisi :

c. Pemeriksaan Kepala dan Leher

Kepala : ...........................................................................................................................
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Rambut : ...........................................................................................................................
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 Wajah : ...........................................................................................................................
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Mata : ...........................................................................................................................
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Hidung : ...........................................................................................................................
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Telinga : ...........................................................................................................................
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Mulut &
Faring : ...........................................................................................................................
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Leher : ...........................................................................................................................
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d. Pemeriksaan Integumen/Kulit dan Kuku

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e. Pemeriksaan Payudara dan Ketiak
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f. Pemeriksaan Sistem Pernapasan

Inspeksi : ...........................................................................................................................
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Auskultasi : ...........................................................................................................................
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Perkusi : ...........................................................................................................................
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Palpasi : ...........................................................................................................................
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g. Pemeriksaan Sistem Kardivaskuler

Inspeksi : ...........................................................................................................................
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Auskultasi : ...........................................................................................................................
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Palpasi : ...........................................................................................................................
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Perkusi : ...........................................................................................................................
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h. Pemeriksaan Abdomen
Inspeksi : ...........................................................................................................................
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Auskultasi : ...........................................................................................................................
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Palpasi : ...........................................................................................................................
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Perkusi : ...........................................................................................................................
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i. Pemeriksaa Genetalia
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j. Pemeriksaan Muskuloskeletal/Ekstremitas
Kekuatan Otot : ...........................................................................................................................
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k. Pemeriksaan Neurologi
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l. Penatalaksanaan/Terapi
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m. Pemeriksaan Penunjang Medis

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ANALISA DATA
NAMA PASIEN :
UMUR :
NO. REGISTER :

DATA PENUNJANG ETIOLOGI MASALAH

ANALISA DATA
NAMA PASIEN :
UMUR :
NO. REGISTER :

DATA PENUNJANG ETIOLOGI MASALAH

DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN :
UMUR :
NO. REGISTER :

TGL TGL
NO. DIAGNOSA KEPERAWATAN TT
MUNCUL TERATASI
 RENCANA ASUHAN KEPERAWATAN / INTERVENSI

NAMA PASIEN :
UMUR :
NO. REGISTER :

DIAGNOSA
NO. TUJUAN INTERVENSI RASIONAL TT
KEPERAWATAN
 RENCANA ASUHAN KEPERAWATAN / INTERVENSI

NAMA PASIEN :
UMUR :
NO. REGISTER :

DIAGNOSA
NO. TUJUAN INTERVENSI RASIONAL TT
KEPERAWATAN
 CATATAN KEPERAWATAN / IMPLEMENTASI

NAMA PASIEN :
UMUR :
NO. REGISTER :

NO. DX
NO. TANGGAL JAM IMPLEMENTASI TT
KEP
 CATATAN KEPERAWATAN / IMPLEMENTASI

NAMA PASIEN :
UMUR :
NO. REGISTER :

NO. DX
NO. TANGGAL JAM IMPLEMENTASI TT
KEP
 CATATAN PERKEMBANGAN

NAMA PASIEN : NO. REGISTER :

UMUR : DX. MEDIS :

NO. NO. DX. TANGGAL/

CATATAN PERKEMBANGAN TT
KEP JAM
 CATATAN PERKEMBANGAN

NAMA PASIEN : NO. REGISTER :

UMUR : DX. MEDIS :

NO. NO. DX. TANGGAL/

CATATAN PERKEMBANGAN TT
KEP JAM