FORMAT ASUHAN KEPERAWATAN

A. PENGKAJIAN
1. Pengumpulan Data
a. Biodata
1) Nama :
2) Jenis Kelamin :
3) Umur :
4) Status Perkawinan :
5) Pekerjaan :
6) Agama :
7) Pendidikan Terakhir :
8) Alamat :
9) Tanggal MRS :
10) Tanggal Pengkajian :

b. Diagnosa Medis :

c. Keluhan Utama (Saat Pengkajian)

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

d. Riwayat Penyakit Sekarang

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

e. Riwayat Kesehatan / Penyakit Yang Lalu

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

f. Riwayat Kesehatan Keluarga

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

g.Pola Aktifitas Sehari—hari

1) Makan dan Minum
 SMRS MRS

2) Pola Eliminasi

SMRS MRS

3) Pola Istirahat dan Tidur

SMRS MRS

4) Kebersihan Diri

SMRS MRS
 5) Aktivitas dan Latihan

SMRS MRS

h.Riwayat Psikososial
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

i. Pemeriksaan Fisik
1) Keadaan Umum :
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
2) Tanda Vital :
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

3) Pemeriksaan kepala dan leher :

.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
4) Pemeriksaan integumen
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

5) Dada dan thorax

.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

6) Payudara
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

7) Abdomen
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

8) Genetalia
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

9) Ekstrimitas
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
 .............................................................................................................................
.............................................................................................................................

j. Pemeriksaan Neurologis
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
k. Pemeriksaan Penujang
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
l. Terapi/Pengobatan/Penatalaksanaan
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

Malang, ..............................
Mahasiswa

(..........................................)
2. ANALISA DATA

Nama Pasien :
Umur :

DATA FOKUS MASALAH KEMUNGKINAN PENYEBAB

No. Register :
B. DIAGNOSIS KEPERAWATAN

Nama Pasien :
Umur :
No. Register :

1.

2.

3.

4.

5.
C. PERENCANAAN

1. PRIORITAS MASALAH

DAFTAR MASALAH

Ruang :
Nama Pasien :
No. Register :
No. TANGGAL TANGGAL TANDA
DIAGNOSIS KEPERAWATAN
DX MUNCUL TERATASI TANGAN
 2. RENCANA ASUHAN KEPERAWATAN

RENCANA ASUHAN KEPERAWATAN

NAMA KLIEN :
NO. REG :
NO DIAGNOSA TUJUAN
TANGGAL INTERVENSI RASIONAL TT
DX KEPERAWATAN KRITERIA STANDART
 D. PELAKSANAAN

IMPLEMENTASI KEPERAWATAN

Ruang :
Nama Pasien :
Umur :
No. Register :
TGL PUKUL NO. IMPLEMENTASI TT
DX. KEP
 E. EVALUASI
CATATAN PERKEMBANGAN

Nama :
No. Reg :
Dx Kep DATA (SOAPIER)
Tanggal : Tanggal : Tanggal :
Pukul : Pukul : Pukul :
DISCHARGE PLANNING