FORMAT ASUHAN KEPERAWATAN PROGRAM STUDI PROFESI NERS

UNIVERSITAS BINA SEHAT PPNI KAB. MOJOKERTO

PENGKAJIAN
Taggal MRS : ........................................................................................
Ruang : ........................................................................................
No. Register : ........................................................................................
Diagnosa Medis : ........................................................................................
Tanggal Pengkajian : ........................................................................................

A. IDENTITAS PASIEN
Nama : ........................................................................................
Umur : ........................................................................................
Suku/bangsa : ........................................................................................
Bahasa : ........................................................................................
Pekerjaan : ........................................................................................
Agama : ........................................................................................
Status : ........................................................................................
Alamat : ........................................................................................
Nama Suami : ........................................................................................
Pekerjaan : ........................................................................................

B. STATUS KESEHATAN
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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C. Pemeriksaan Fisik
1) Kesadaran : ( ) Composmentis
( ) Samnolent
( ) Sopor
( ) Sopor Komatus
( ) Komatus
2) Tanda-tanda vital : TD : ................................................................
Nadi : ................................................................
RR : ................................................................
Suhu : ................................................................
BB : ................................................................
TB : ................................................................
3) B1
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4) B2
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5) B3
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6) B4
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7) B5
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8) B6
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D. Data Penunjang ( Laboratorium )

Pemeriksaan Hasil Satuan Nilai Rujukan

E. Terapi
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 F. Analisa Data
No Data Etiologi Masalah
G. Diagnosa Keperawatan

1. .....................................................................................................................................

2…...................................................................................................................................

H. Rencana Keperawatan
No. Tujuan & Kriteria Hasil Intervensi
Dx
I. Implementasi
No. Tanggal/Waktu Implementasi TTD
Dx
No. Tanggal/Waktu Implementasi TTD
Dx
No. Tanggal/Waktu Implementasi TTD
Dx
J. Evaluasi
No. Tanggal/ Evaluasi TTD
Dx Waktu S-O-A-P
No. Tanggal/ Evaluasi TTD
Dx Waktu S-O-A-P
No. Tanggal/ Evaluasi TTD
Dx Waktu S-O-A-P
No. Tanggal/ Evaluasi TTD
Dx Waktu S-O-A-P
No. Tanggal/ Evaluasi TTD
Dx Waktu S-O-A-P