ASUHAN KEPERAWATAN

PADA PASIEN DENGAN DIAGNOSA PENYAKIT ..

DI RUANG RSUD DR. SOETOMO

Tanggal Pengkajian : Tgl MRS :

Jam Pengkajian :
Nama Mahasiswa :
Nim :
1. IDENTITAS PASIEN
Nama : ...............................................................................................................
Umur : ..............................................................................................................
Agama : ..............................................................................................................
Jenis Kelamin : ...............................................................................................................
Status : ..............................................................................................................
Pendidikan : ...............................................................................................................
Pekerjaan : ...............................................................................................................
Suku Bangsa : ...............................................................................................................
Alamat : ...............................................................................................................
No. Register : ................................................................................................................
Diagnosa : ................................................................................................................
Status Kesehatan
1) Keluhan Utama (Saat MRS dan saat ini)
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2) Riwayat Penyakit Sekarang
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3) Riwayat Kesehatan Keluarga





4) Riwayat Penyakit Dahulu
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5) Keadaan Kesehatan Lingkungan
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6) Upaya Yang Telah Dilakukan
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7) Terapi/Operasi Yang Pernah Dilakukan


8) Riwayat Kesehatan Lainnya (Pasien Ibu (keluarga Berencana) )



Genogram
 Alat bantu yang dipakai
Gigi palsu : ( ) Ya ( ) Tidak
Kacamata : ( ) Ya ( ) Tidak
Pendengaran : ( ) Ya ( ) Tidak
Lain lain :.

2. POLA FUNGSI KESEHATAN
1) Pola Persepsi Dan Tata Laksana Hidup
SMRS :..........................................................................................................................
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MRS : ..........................................................................................................................
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2) Pola Nutrisi Dan Metabolisme
SMRS :..........................................................................................................................
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MRS : ...........................................................................................................................
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3) Pola Eliminasi
SMRS :..........................................................................................................................
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MRS : ...........................................................................................................................
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4) Pola Istirahat Dan Tidur
SMRS :..........................................................................................................................
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MRS : ...........................................................................................................................
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5) Pola Aktifitas
SMRS :..........................................................................................................................
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MRS : ...........................................................................................................................
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6) Pola Hubungan Dan Peran
SMRS :..........................................................................................................................
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MRS : ...........................................................................................................................
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7) Pola Persepsi Dan Konsep Diri
SMRS :..........................................................................................................................
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 MRS : ...........................................................................................................................
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8) Pola Sensori Dan Kognitif
SMRS :..........................................................................................................................
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MRS : ...........................................................................................................................
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9) Pola Reproduksi Seksual
SMRS :..........................................................................................................................
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MRS : ...........................................................................................................................
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10) Pola Penanggulangan Stres
SMRS :..........................................................................................................................
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MRS : ...........................................................................................................................
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 11) Pola Tata Nilai Dan Kepercayaan
SMRS :..........................................................................................................................
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MRS : ...........................................................................................................................
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3. PENGKAJIAN FISIK
1) Keadaan Umum :
2) Tanda-tanda Vital
TD: mmHg
( ) Lengan Kiri ( ) Lengan Kanan ( ) Duduk ( ) Berbaring
N: x/m
( ) Teratur ( ) Tidak Teratur ( ) Kuat ( ) Lemah
RR: x/m
( ) Normal ( ) Cyanosis ( ) Chaynestoke ( ) Kusmaul
S: C
( ) Axilla ( ) Rectal ( ) Oral
BB: TB: CRT:

Review of System
1) B1 :
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2) B2 :
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3) B3 : .............................................................................................................................
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4) B4 : .............................................................................................................................
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5) B5 : .............................................................................................................................
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6) B6 : .............................................................................................................................
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Pemeriksaan Penunjang
1) Data laboratorium (Tgl: )
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2) Pemeriksaan Radiologi(Tgl: )
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3) Data Lain Lain(Tgl: )
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