STIKES RS BAPTIS KEDIRI

PRODI KEPERAWATAN STRATA 1

FORMAT ASUHAN KEPERAWATAN KEBUTUHAN DASAR MANUSIA

NAMA MAHASISWA : ..................................................................................

NIM : ..................................................................................
RUANG : ..................................................................................
TANGGAL : ..................................................................................

1. BIODATA
Nama Pasien : ..............................................................................................
Nama Panggilan : ..............................................................................................
Umur : ..............................................................................................
Status : ..............................................................................................
Agama : ..............................................................................................
Pendidikan : ..............................................................................................
Pekerjaan : ..............................................................................................
Penghasilan : ..............................................................................................
Alamat : ..............................................................................................
Diagnosa Medis : ..............................................................................................
Tanggal MRS : ..............................................................................................
Tanggal Pengkajian: .............................................................................................
Golongan Darah : ..............................................................................................

2. KELUHAN UTAMA
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3. RIWAYAT PENYAKIT SEKARANG

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4. RIWAYAT PENYAKIT MASA LALU

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5. RIWAYAT KESEHATAN KELUARGA

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GENOGRAM :
6. TANDA – TANDA VITAL
Suhu Tubuh : ....................................... oC
Denyut Nadi : ....................................... x / mnt
Tekanan Darah : ....................................... mmHg
Pernafasan : ....................................... x / mnt
TT / TB : ....................................... Kg, ....................................... cm

7. POLA AKTIVITAS SEHARI – HARI

a. Kebutuhan Kebersihan Diri / Personal Hygiene

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b. Kebutuhan Nutrisi / Pola Nutrisi
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c. Kebutuhan Eliminasi / Pola Eliminasi BAK, BAB
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d. Kebutuhan Oksigenasi
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e. Kebutuhan Cairan dan Elektrolit
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f. Kebutuhan Aktivitas
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g. Kebutuhan Rasa Aman dan Nyaman
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h. Kebutuhan Psikososial dan Spiritual
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8. KEADAAN / PENAMPILAN UMUM PASIEN
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9. PEMERIKSAAN FISIK

a. Pemeriksaan Leher dan Kepala

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b. Pemeriksaan Integumen
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c. Pemeriksaan Payudara dan Ketiak
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d. Pemeriksaan Dada / Thorak
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e. Pemeriksaan Jantung
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f. Pemeriksaan Abdomen
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g. Pemeriksaan Genetalia dan sekitarnya
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h. Pemeriksaan Muskuloskeletal
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 i. Pemeriksaan Neurologi
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j. Pemeriksaan Status Mental

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10. PEMERIKSAAN PENUNJANG MEDIS

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11. PELAKSANAAN / TERAPI

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12. HARAPAN KLIEN / KELUARGA SEHUBUNGAN DENGAN PENYAKIT

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Kediri, ...........................................
Pembimbing Klinik Ruangan, Tanda Tangan Mahasiswa
 ANALISA DATA

NAMA PASIEN : ..............................................................

UMUR : ..............................................................
NO. REGISTER : ...............................................................
DATA OBYEKTIF (DO) FAKTOR YANG MASALAH
DATA SUBYEKTIF (DS) BERHUBUNGAN/RISIK KEPERAWATAN
O (E) (NANDA)

DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN : ...............................................................
UMUR : ..............................................................
NO. REGISTER : ..............................................................
NO TANGGAL DIAGNOSA KEPERAWATAN TANGGAL TANDA
MUNCUL (NANDA) TERATASI TANGAN

RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN :
UMUR :
NO REGISTER :

DIAGNOSA KEPERAWATAN:

1. SLKI :

a. Dipertahankan/ditingkatkan pada
b. Dipertahankan/ditingkatkan pada
c. Dipertahankan/ditingkatkan pada
d. Dipertahankan/ditingkatkan pada
e. Dipertahankan/ditingkatkan pada
f. Dipertahankan/ditingkatkan pada
g. Dipertahankan/ditingkatkan pada
h. Dipertahankan/ditingkatkan pada
i. Dipertahankan/ditingkatkan pada
j. Dipertahankan/ditingkatkan pada
k. Dipertahankan/ditingkatkan pada

2. SLKI :

a. Dipertahankan/ditingkatkan pada
b. Dipertahankan/ditingkatkan pada
c. Dipertahankan/ditingkatkan pada
d. Dipertahankan/ditingkatkan pada
e. Dipertahankan/ditingkatkan pada
f. Dipertahankan/ditingkatkan pada
g. Dipertahankan/ditingkatkan pada
h. Dipertahankan/ditingkatkan pada
i. Dipertahankan/ditingkatkan pada
j. Dipertahankan/ditingkatkan pada
k. Dipertahankan/ditingkatkan pada
l.
3. SLKI :

a. Dipertahankan/ditingkatkan pada
b. Dipertahankan/ditingkatkan pada
c. Dipertahankan/ditingkatkan pada
d. Dipertahankan/ditingkatkan pada
e. Dipertahankan/ditingkatkan pada
f. Dipertahankan/ditingkatkan pada
g. Dipertahankan/ditingkatkan pada
h. Dipertahankan/ditingkatkan pada
i. Dipertahankan/ditingkatkan pada
j. Dipertahankan/ditingkatkan pada
k. Dipertahankan/ditingkatkan pada

Keterangan : (dipertahankan/ditingkatkan) coret salah satu

 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN : ..............................................................

UMUR : ...............................................................
NO. REGISTER : ..............................................................
NO DIAGNOSA KEPERAWATAN INTERVENSI RASIONAL
SIKI
 TINDAKAN KEPERAWATAN

NAMA PASIEN : ...............................................................

UMUR : ...............................................................
NO.REGISTER : .............................................................
NO NO.DX TGL/JAM TINDAKAN KEPERAWATAN TANDA
TANGAN