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

DENGAN ...........................................................
DI ................................................................

A. PENGKAJIAN
1. Data Umum
Identitas Klien
Nama : .................................................. ................................
Umur : .................................................. ................................
Agama : ................................................. .................................
Jenis Kelamin : .................................................. ................................
Status Marital : ................................................... ...............................
Pendidikan : .................................................. ................................
Pekerjaan : .................................................. ................................
Suku Bangsa : ................................................. .................................
Alamat : ................................................. .................................
Tanggal Masuk : .................................................. ................................
Tanggal Pengkajian : .................................................. ................................
No. Register : .................................................. ................................
Diagnosa Medis : ................................................. .................................
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Identitas Penanggung Jawab

Nama : .................................................. ................................
Umur : .................................................. ................................
Hub. Dengan Klien : .................................................. ................................
Pekerjaan : .................................................. ................................
Alamat : ................................................. .................................

2. Riwayat Kesehatan
Keluhan Utama
.....................................................................................................................
.....................................................................................................................
Riwayat Penyakit Sekarang
.....................................................................................................................
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Riwayat Kesehatan Dahulu
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Riwayat Kesehatan Keluarga
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Genogram :

Riwayat Sosiokultural
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3. PEMERIKSAAN FISIK

a. Keadaan Umum
...............................................................................................................
...............................................................................................................
.......................... ............................. ........................................................
b. Tanda Vital
...............................................................................................................
...............................................................................................................
................................................................................................................
c. Kepala
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................................................................................................................
. ...............................................................................................................
. ...............................................................................................................
d. Mata
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...............................................................................................................
................................................................................................................
e. Hidung
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.............................................................................................................. .
.........................................................................
f. Telinga
...............................................................................................................
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........... ................................................... .................................................
g. Mulut
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......... ................................................... ...................................................
h. Leher.........................................................................................................
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............................................................................................................ ...
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i. Dada dan Punggung
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j. Abdomen
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k. Ekstremitas
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...............................................................................................................
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l. Genetalia
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..............................................................................................................
m. Anus
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4. Kebutuhan Dasar Manusia (Virginia Henderson)

a. Bernafas
Sebelum sakit: ...........................................................................................
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Ketika sakit :..............................................................................................

b. Makan dan minum
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
c. Eliminasi
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
d. Mobilisasi
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
e. Istirahat dan tidur
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
f. Berpakaian
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
g. Suhu tubuh
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
h. Kebersihan tubuh
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
i. Menghindari bahaya
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
j. Berkomunikasi
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
k. Bekerja
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
l. Bermain
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
m.Spiritual
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
n. Belajar
Sebelum sakit: ...........................................................................................
Ketika sakit :..............................................................................................
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5. Pola Fungsi Kesehatan Gordon

a. Pola Persepsi dan Manajemen Kesehatan
................................................................................................................
................................................................................................................
b. Pola Nutrisi-Metabolik
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................................................................................................................
c. Pola Eliminasi
...............................................................................................................
...........................................................................
................................................................................................................
d. Pola Aktivitas dan Latihan
................................................................................................................
................................................................................................................
e. Pola koqnitif dan Persepsi sensori
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................ ............................. ..................................................................
f. Pola Persepsi-Konsep diri
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g. Pola Tidur dan Istirahat
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h. Pola Peran-Hubungan
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i. Pola Seksual-Reproduksi
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j. Pola Toleransi Stress-Koping
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k. Pola Nilai-Kepercayaan
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6. DATA PENUNJANG (Pemeriksaan Diagnostik) :

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7. DATA TAMBAHAN
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B. ANALISA DATA

Data Etiologi Masalah Keperawatan

Tabel Daftar Masalah Kolaboratif / Diagnosis Keperawatan

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NO TANGGAL / JAM DIAGNOSIS KEPERAWATAN TANGGAL, JAM

DITEMUKAN TERATASI
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C. PERENCANAAN KEPERAWATAN

NO. DIAGNOSIS TUJUAN INTERVENSI

KEPERAWATAN

D. IMPLEMENTASI KEPERAWATAN

Hari/
No Dx Tindakan Keperawatan Evaluasi TTD
Tgl/Jam
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E. EVALUASI KEPERAWATAN

No Hari/Tgl No Evaluasi TTD