KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN JAMBI

JURUSN KEPERAWATAN
JL. Dr. Tazar No.05 Buluran Kenali Telanaipura Jambi Telp (0741)65816

FORMAT PENGKAJIAN KEPERAWATAN

Tanggal/Jam Masuk RS : ................................................... Tanggal Pengkajian : ........................................

A. BIODATA
1. Identitas Pasien
1. Nama : .................................... 5. Pekerjaan : ...............................
2. Umur : .................................... 6. Tanggal Masuk : ...............................
3. Alamat : .................................... 7. Diagnosis : ...............................
Medis
4. Pendidikan : .................................... 8. No. Register : ...............................
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2. Identitas P.Jawab
Nama : .................................... Pendidikan : ...............................
Umur : .................................... Pekerjaan : ...............................
Alamat : .................................... Hubungan dg Klien : ...............................
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B. RIWAYAT KEPERAWATAN
1. Keluhan Utama
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2. Riwayat penyakit sekarang

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 3. Riwayat penyakit masa lalu
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4. Riwayat Sosial
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5. Riwayat Kesehatan Keluarga

Genogram

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C. PENGKAJIAN BIOLOGIS
1. Rasa Aman dan Nyaman
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2. Aktivitas dan Istirahat

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3. Eliminasi
Eliminasi Urin
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Eliminasi Feses
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4. Personal Hygiene
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5. Istirahat
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6. Tidur
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7. Cairan
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8. Nutrisi
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9. Kebutuhan Oksigenasi dan Karbondioksida

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10. Kardiovaskuler
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 11. Seksualitas
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D. PENGKAJIAN PSIKOSOSIAL DAN SPIRITUAL

1. Psikologi
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2. Hubungan Sosial
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3. Spiritual
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E. PEMERIKSAAN FISIK
1. Keadaan Umum
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2. Pemeriksaan Cepalocaudal
Kepala
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Leher
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Dada
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Abdomen
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Genitalia
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Ekstremitas Atas
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Ekstremitas Bawah
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F. PEMERIKSAAN PENUNJANG
1. Radiologi (tuliskan tanggal pemeriksaan, hasil, dan rentang nilai normal)
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2. Laboratorium (tuliskan tanggal pemeriksaan, hasil, dan rentang nilai normal)

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3. EEG, ECG, EMG, USG, CT-SCAN (tuliskan tanggal pemeriksaan, hasil, dan rentang
nilai normal)
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G. TERAPI YANG DIBERIKAN

1. Oral
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2. Parenteral
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Jambi, .........................................................
Mahasiswa

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NIM. .............................................................
 ANALISA DATA

NO. DATA PENYEBAB MASALAH

 DIAGNOSA KEPERAWATAN

NO. TGL/ JAM DIAGNOSA KEPERAWATAN PARAF

 RENCANA KEPERAWATAN

TGL/ DIAGNOSA TUJUAN RENCANA TINDAKAN RASIONALISASI PARAF

JAM KEPERAWATAN
 PELAKSANAAN TINDAKAN KEPERAWATAN

NO. DK TGL/ JAM TINDAKAN KEPERAWATAN PARAF

 EVALUASI

MASALAH TGL/ CATATAN PERKEMBANGAN PARAF

KEPERAWATAN JAM