ASUHAN KEPERAWATAN PADA..........................
DENGAN DIAGNOSA MEDIS.......................
DI.....................................................
TANGGAL..................................
I.
PENGKAJIAN
1. Identitas
a. Identitas
pasien
Nama :.........................................................
Umur :..........................................................
Agama :.........................................................
Jenis kelamin :........................................................
Status :........................................................
Pendidikan :........................................................
Pekerjaan :.......................................................
Suku bangsa :........................................................
Alamat :........................................................
Tanggal Masuk :........................................................
Tanggal Pengkajian :........................................................
No. Register :........................................................
Diagnose medis :........................................................
b. Identitas
Penanggung Jawab
Nama :........................................................
Umur :........................................................
Hub. Dengan pasien :........................................................
Pekerjaan :........................................................
Alamat :........................................................
2. Status
Kesehatan
a. Status
kesehatan saat ini
1) Keluhan
utama (saat MRS dan Saat ini)
........................................................
2) Alasan
masuk rumah sakit dan perjalanan saat ini
........................................................
3) Upaya
yang dilakukan untuk mengatasinya
........................................................
b. Status
kesehatan masa lalu
1) Penyakit
yang pernah dialami
........................................................
2) Pernah
dirawat
........................................................
3) Alergi
........................................................
4) Kebiasaan
(merokok/kopi/alcohol dll)
........................................................
c. Riwayat
penyakit keluarga
........................................................
d. Diagnose
medis dan therapy
........................................................
3. Pola
Kebutuhan Dasar (bio-psiko-sosio-kultural-spiritual)
a. Pola
persepsi dan manajemen kesehatan
........................................................
b. Pola
nutrisi metabolic
-
Sebelum sakit :........................................................
-
Saat sakit :........................................................
c. Pola
eliminasi
1) BAB
-
Sebelum sakit :........................................................
-
Saat sakit :........................................................
2) BAK
-
Sebelum sakit :........................................................
-
Saat sakit :........................................................
d. Pola
aktivitas dan latihan
1) Aktivitas
|
Kemampuan
perawatan diri
|
0
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1
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2
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3
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4
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Makan
dan minum
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Mandi
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Toileting
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Berpakaian
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Berpindah
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0: mandiri, 1: alat bantu, 2:
dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total
2) Latihan
-
Sebelum sakit........................................................
-
Saat sakit........................................................
e. Pola
kognitif dan persepsi
........................................................
f. Pola
persepsi-konsep diri
........................................................
g. Pola
tidur dan istirahat
-
Sebelum sakit :........................................................
-
Saat sakit :........................................................
h. Pola
peran-hubungan
........................................................
i.
Pola seksual-reproduksi
-
Sebelum sakit :........................................................
-
Saat sakit :........................................................
j.
Pola poleransi stress-koping
........................................................
k. Pola
nilai-kepercayaan
........................................................
4. Pengkajian
Fisik
a. Keadaan
umum :........................................................
Tingkat kesadaran :........................................................
GCS : mata : verbal
: psikomotor :
b. Tanda-tanda
vital
Nadi =........................................................
Suhu =........................................................
TD =........................................................
RR =........................................................
c. Keadaan
fisik
1) Kepala
dan leher :
........................................................
2) Dada
:
-
Paru :........................................................
-
Jantung :........................................................
3) Payudara
dan ketiak :
........................................................
4) Abdomen
:
........................................................
5) Genetalia
:
........................................................
6) Integument
:
........................................................
7) Ektremitas
:
-
Atas :........................................................
-
Bawah :........................................................
8) Neurologis
:
-
Status mental dan emosi :........................................................
-
Pengkajian saraf cranial :........................................................
-
Pemeriksaan reflek :........................................................
d. Pemeriksaan
penunjang
1) Data
laboratorium yang berhubungan........................................................
2) Pemeriksaan
radiologi........................................................
3) Hasil
konsultasi........................................................
4) Pemeriksaan
penunjang diagnostic lain........................................................
5. Analisa
Data
A. Tabel analisa data
|
Data
|
Interpretasi
|
Masalah
|
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DS :
DO :
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B. Tabel
daftar diagnosa keperawatan
|
No
|
Tanggal/
Jam ditemukan
|
Diagnosa keperawatan
|
Tanggal teratasi
|
Ttd
|
|
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C. Rencana
tindakan keperawatan
|
Hari/
tgl
|
No
|
Rencana
perawatan
|
Ttd
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Tujuan
dan kriteria hasil
|
Intervelsi
|
Rasional
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D. Implementasi
keperawatan
|
Hari/tgl/jam
|
No
Dx
|
Tindakan
keperawatan
|
Evaluasi
proses
|
Ttd
|
|
|
|
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E. Evaluasi
keperawatan
|
No
|
Hari/tgl/jam
|
No
Dx
|
Evaluasi
|
Ttd
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