ASUHAN KEPERAWATAN

Tanggal Pengkajian :......................... Ruang/RS :.........................................

A. BIODATA
1. Biodata Pasien
a. Nama :
b. Umur :
c. Alamat :
d. Pendidikan :
e. Pekerjaan :
f. Tanggal Masuk :
g. Diagnosa Medis :
h. Nomor Register :
2. Biodata Penanggung Jawab
a. Nama :
b. Umur :
c. Alamat :
d. Pendidikan :
e. Pekerjaan :
f. Hubungan Dengan Klien :

B. KELUHAN UTAMA
C. RIWAYAT KESEHATAN
1. Riwayat Kesehatan Sekarang
2. Riwayat Kesehatan Dahulu
3. Riwayat Kesehatan Keluarga
D. PENGKAJIAN MENGACU POLA FUNGSIONAL GORDON
1. Pola persepsi kesehatan
2. Pola nutrisi dan metabolisme
3. Pola eliminasi
4. Pola istirahat dan tidur
5. Pola aktivitas dan latihan
6. Pola peran dan hubungan
7. Pola persepsi sensori
8. Pola persepsi diri atau konsep diri
9. Pola seksual dan reproduksi
10. Pola mekanisme koping
11. Pola nilai dan kepercayaan
E. PEMERIKSAAN FISIK
F. PEMERIKSAAN DIAGNOSTIK
G. PROGRAM TERAPI
 DAFTAR MASALAH

Masalah Tanggal TTD

NO Tanggal/ Jam Data Fokus
Keperawatan Teratasi perawat
 RENCANA KEPERAWATAN

Tanggal Diagnosa TTD

No Tujuan Intervensi TTD
/ Jam Keperawatan Perawat
 TINDAKAN KEPERAWATAN

Tanggal / Masalah Keperawatan Respon TTD

Jam Perawat
 CATATAN PERKEMBANGAN

Tanggal / Subjektif, Obyektif, Assasment, TTD

DX Kep.
Jam Planning (SOAP) Perawat
 DESAIN INOVATIF

Jenis
No Alasan Tindakan Respon Pasien
Tindakan

PEMBAHASAN BERDASARKAN SUMBER REFERENSI

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