ASUHAN KEPERAWATAN

KEBUTUHAN DASAR MANUSIA

Nama Mahasiswa : _______________________________________

Tempat Praktik : _______________________________________
Tanggal : _______________________________________

A. IDENTITAS DIRI
Nama : _________________________________
Umur : _________________________________
Jenis Kelamin : _________________________________
Alamat : _________________________________
Status : _________________________________
Agama : _________________________________
Suku : _________________________________
Pendidikan : _________________________________
Pekerjaan : _________________________________
Tanggal MRS : _________________________________
Tanggal Pengk. : _________________________________
Sumber Informasi: _________________________________

B. RIWAYAT PENYAKIT
1. Keluhan Utama
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2. Riwayat Penyakit Sekarang
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3. Riwayat Penyakit Dahulu
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 4. Riwayat Penyakit Keluarga
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5. Riwayat Alergi
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C. POLA FUNGSI KESEHATAN

1. Persepsi terhadap kesehatan
SEBELUM SAKIT SAKIT

2. Pola aktifitas dan latihan

SEBELUM SAKIT SAKIT

3. Pola istirahat dan tidur

SEBELUM SAKIT SAKIT

4. Pola nutrisi metabolik

SEBELUM SAKIT SAKIT

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5. Pola eliminasi
SEBELUM SAKIT SAKIT

6. Pola kognitif, perseptual

SEBELUM SAKIT SAKIT

7. Pola konsep diri

SEBELUM SAKIT SAKIT

8. Pola koping
SEBELUM SAKIT SAKIT

9. Pola seksual
SEBELUM SAKIT SAKIT

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 10. Pola peran berhubungan
SEBELUM SAKIT SAKIT

11. Pola nilai dan kepercayaan

SEBELUM SAKIT SAKIT

D. PEMERIKSAAN FISIK
1. Keadaan Umum
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____________________________________________________________________________
____________________________________________________________________________
2. Tanda-Tanda Vital
Tekanan darah : __________ mmHg Suhu : __________ 0C
Nadi : __________ x/menit Respirasi rate : __________ x/menit
3. Berat badan : __________ kg
Tinggi badan : __________ cm
4. Kepala
1) Rambut
Inspeksi :
_________________________________________________________________________
_________________________________________________________________________
Palpasi :
_________________________________________________________________________
_________________________________________________________________________
2) Mata
Inspeksi :
_________________________________________________________________________
_________________________________________________________________________
Palpasi :
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 3) Hidung
Inspeksi :
_________________________________________________________________________
_________________________________________________________________________
Palpasi :
_________________________________________________________________________
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4) Mulut dan faring
Inspeksi :
_________________________________________________________________________
_________________________________________________________________________
Palpasi :
_________________________________________________________________________
_________________________________________________________________________
5) Telinga
Inspeksi :
_________________________________________________________________________
_________________________________________________________________________
Palpasi :
_________________________________________________________________________
_________________________________________________________________________
5. Leher
Inspeksi :
____________________________________________________________________________
____________________________________________________________________________
Palpasi :
____________________________________________________________________________
____________________________________________________________________________
6. Thorax dan pernafasan
Inspeksi :
____________________________________________________________________________
____________________________________________________________________________
Palpasi :
____________________________________________________________________________
____________________________________________________________________________
Perkusi :
____________________________________________________________________________
____________________________________________________________________________

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 Auskultasi :
____________________________________________________________________________
____________________________________________________________________________
7. Jantung
Palpasi :
____________________________________________________________________________
____________________________________________________________________________
Perkusi :
____________________________________________________________________________
____________________________________________________________________________
Auskultasi :
____________________________________________________________________________
____________________________________________________________________________
8. Abdomen
Inspeksi :
____________________________________________________________________________
____________________________________________________________________________
Auskultasi :
____________________________________________________________________________
____________________________________________________________________________
Perkusi :
____________________________________________________________________________
____________________________________________________________________________
Palpasi :
____________________________________________________________________________
____________________________________________________________________________
9. Genetalia
Inspeksi :
____________________________________________________________________________
____________________________________________________________________________
Palpasi :
____________________________________________________________________________
____________________________________________________________________________
10. Ekstremitas
Inspeksi :
____________________________________________________________________________
____________________________________________________________________________
Palpasi :
____________________________________________________________________________
____________________________________________________________________________

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 11. Integumen
Inspeksi :
____________________________________________________________________________
____________________________________________________________________________
Palpasi :
____________________________________________________________________________
____________________________________________________________________________
12. Neuro
____________________________________________________________________________
____________________________________________________________________________

E. HASIL PEMERIKSAAN PENUNJANG DAN LABORATORIUM

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F. DIAGNOSA KEPERAWATAN
Analisa Data

Identitas Klien : .................................... Tanggal MRS : ......................................

No. Reg : .................................... Ruang : ......................................

DATA ETIOLOGI MASALAH

Diagnosa Keperawatan Prioritas

1. ____________________________________________________________________________
DS : ______________________________________________________________________
______________________________________________________________________
DO : ______________________________________________________________________
______________________________________________________________________
2. ____________________________________________________________________________
DS : ______________________________________________________________________
______________________________________________________________________
DO : ______________________________________________________________________

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 ______________________________________________________________________
G. RENCANA KEPERAWATAN
Identitas Klien : .......................................... No.Reg: ..............................................

No Diagnosa Keperawatan Tujuan Intervensi Rasional

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H. IMPLEMENTASI DAN EVALUASI
Catatan Perkembangan

Diagnosa Keperawatan :

Hari/ Tanggal :

Jam Implementasi Paraf Evaluasi

Jam :

DS :

DO :

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 Analisa :

Perencanaan :

( )

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