ASUHAN KEPERAWATAN PADA.................

DENGAM GANGGUAN PEMENUHAN KEBUTUHAN….................

A. PENGKAJIAN
Tanggal masuk : ..........................................................................................................................
Ruang : ..........................................................................................................................
No.Registrasi : ..........................................................................................................................
1. BIODATA
a. Identitas pasien
Nama : ...............................................................................................
Umur : ...............................................................................................
Jenis kelamin : ...............................................................................................
Suku/bangsa : ...............................................................................................
Agama : ...............................................................................................
Pendidikan : ...............................................................................................
Pekerjaan : ...............................................................................................
Alamat : ...............................................................................................
Tanggal pengkajian : ...............................................................................................
Jam pengkajian : ...............................................................................................
b. Identitas penanggung jawab
Nama : ...............................................................................................
Umur : ...............................................................................................
Jenis kelamin : ...............................................................................................
Suku/bangsa : ...............................................................................................
Agama : ...............................................................................................
Pendidikan : ...............................................................................................
Pekerjaan : ...............................................................................................
Alamat : ...............................................................................................
Hubungan dengan pesien : ...............................................................................................
2. KELUHAN UTAMA
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3. RIWAYAT KEPERAWATAN
a. Riwayat keperawatan sekarang :
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b. Riwayat keperawatan masa lalu :

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c. Riwayat keperawatan keluarga :
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d. Genogram ( terutama bagi pasien dengan penyakit keturunan ) :
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4. PENGKAJIAN POLA FUNGSIONAL
a. Pola persepsi dan manajement kesehatan :
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b. Pola nutrisi :
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c. Pola eliminasi :
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d. Pola aktifitas dan latihan :
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e. Pola istirahat dan tidur :
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f. Pola persepsi kognitif :
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g. Pola persepsi dan konsep diri :
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 h. Pola peran dan hubungan :
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i. Pola reproduksi dan seksual :
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j. Pola koping terhadap stress :
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k. Pola nilai dan kepercayaan :
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5. PEMERIKSAAN FISIK
a. Keadaan Umum :
b. Tingkat kesadaran :
c. Tanda-tanda vital :
Suhu: Nadi: Pernafasan: TD:
d. Kepala :
e. Mata :
f. Hidung :
g. Telinga :
h. Mulut :
i. Leher :
j. Dada :
k. Abdomen :
l. Ekstremitas :
m. Genitourinaria :
n. Kulit :

6.DATA PSIKOLOGIS
a. Stastus emosi
b. Gaya bicara/komunikasi
c. Interaksi social
d. Orientasi

7.DATA SPIRITUAL :
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8.PEMERIKSAAN PENUNJANG :
Hasil pemeriksaan laboratorium sesuai kasus :
Hb :
Lekosit :
Gol. Darah :
Dsb

9.PROGRAM TERAPI

Nama obat Dosis Fungsi

B. DATA FOKUS

No Reg : Nama/ Umur: Ruang

Hari, Tanggal Data Subjektif dan Ttd/nama
Objektif
C. ANALISA DATA
No Reg: Nama/Umur: Ruang
No Dx Tanggal Data Etiologi Problem Ttd, nama

D. PRIORITAS DIAGNOSA KEPERAWATAN

No Reg: Nama, Umur Ruang
No Dx Tanggal Ditemukan Masalah Keperawatan Tanggal teratasi Ttd/nama

E. INTERVENSI KEPERAWATAN
Diagnosa keperawatan:
Tujuan:
Kriteria Hasil

No Indikator Kondisi awal 1 2 3 4 5

SIKI:
1.
2
3.
4.dst

F. IMPLEMENTASI KEPERAWATAN
No reg: Nama,Umur: Ruang:
Hari, Tgl Jam, No Dx Tindakan Keperawatan, Respon, Ttd, nama

G. Evaluasi
No Reg : Nama, Umur: Ruang:
No Dx Catatan Perkembangan Ttd Nama
S:
O:
A:
P.