FORMAT PENGKAJIAN

KEPERAWATAN DASAR PROFESI

RPOGRAM STUDI S1 ILMU KEPERAWATAN STIKES BAITURRAHIM

HARI/TANGGAL
:
JAM :
PENGKAJIAN :
RUANG :

A. IDENTITAS
PASIEN
1. Nama :
2. Jenis Kelamin :
3. Umur :
4. Agama :
5. Status Perkawinan :
6. Pekerjaan :
7. Pendidikan terakhir :
8. Alamat :
9. No.RM :
10. Diagnostik Medis :

PENANGGUNG JAWAB
a. Nama :
b. Umur :
c. Pendidikan :
d. Pekerjaan :
e. Alamat :
B. RIWAYAT KEPERAWATAN
1. RIWAYAT KESEHATAN PASIEN
Riwayat Penyakit Sekarang
1) Keluhan utama
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2) Kronologi penyakit saat ini
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3) Pengaruh penyakit terhadap pasien
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4) Apa yang diharapkan pasien dari pelayanan kesehatan
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2. RIWAYAT PENYAKIT MASA LALU
1) Penyakit masa anak – anak.
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2) Alergi
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3) Pengalaman sakit / dirawat sebelumnya
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4) Pengobatan terakhir.
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3. RIWAYAT KESEHATAN KELUARGA
Genogram (minimal 3 generasi)

4. PENGKAJIAN BIOLOGIS ( Dikaji sebelum dan sesudah

sakit)

1. RASA AMAN DAN NYAMAN

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2. AKTIFITAS ISTIRAHAT – TIDUR

1) AKTIFITAS
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2) ISTIRAHAT
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3) TIDUR
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4) CAIRAN
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5) NUTRISI
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 6) ELIMINASI: URINE DAN FESES
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3. KEBUTUHAN OKSIGENASI DAN

KARBONDIOKSIDA

1) PERNAFASAN.
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2) KARDIVASKULER
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3) PERSONAL HYGIENE
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4) SEX
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4. PENGKAJIAN PSIKOSOSIAL DAN SPIRITUAL

1) Psikologi.
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2) Konsep diri:
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3) Hubungan sosial:
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 4) Spiritual.
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C. PEMERIKSAAN FISIK
1. KEADAAN UMUM

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2. PEMERIKSAAN
CEPALO KAUDAL
a. Kepala
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b. Leher
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c. Dada
 Inspeksi:
 Auskultasi:
 Perkusi:
 Palpasi:
d. Abdomen
 Inspeksi:
 Auskultasi:
 Perkusi:
 Palpasi:

e. Genetalia, Anus dan rektum

 Inspeksi:
 Palpasi:
 f. Ekstremitas
 Atas:
 Bawah:

D. Pemeriksaan Penunjang
1. Radiologi
2. Laboratorium
3. EEG, ECG, EMG, USG, CT Scan.
Tuliskan tanggal pemeriksaan, hasil dan rentang nilai normalnya
E. Teraphi yang Diberikan
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F. Format Proses Keperawatan

1. ANALISA DATA
DATA ETIOLOGI MASALAH
KEPERAWATAN

2. PRIORITAS MASALAH
1. .
2. .
3.

3. NCP dan IMPLEMENTASI

No Hari/tgl Diagnosa Tujuan Intervensi Aktivitas

Keperawatan Keperawatan Keperawatan
 4. IMPLEMENTASI KEPERAWATAN

No Hari/tgl Diagnosa Implementasi Evaluasi

Keperawatan Keperawatan