FORMAT PENGKAJIAN ASUHAN KEPERAWATAN LENGKAP

RUMAH  SAKIT TK II Dr. SOEPRAOEN

          POLITEKNIK KESEHATAN

    PROGRAM STUDI KEPERAWATAN

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN

                                                                                                      Nama mahasiswa  :

                                                                                                      NIM                      :

PENGKAJIAN

Dilaksanakan tgl                     : …………………………………………

Ruang                                      : ………………………………………….

No kamar/ TT                          : ………………………………………….

1. Biodata

Nama                           : …………………………………………………………..

Umur                           : ……………………………………………………………

Jenis kelamin               : …………………………………………………………….

Agama                         : …………………………………………………………….

Alamat                                    : …………………………………………………………….

Pendidikan                  : …………………………………………………………….

Pekerjaan                     : …………………………………………………………….

Status perkawinan       : …………………………………………………………….

Tgl. MRS                    : ……………………………………………………………

Diagnosa medis           : …………………………………………………………….

No. reg                                    : …………………………………………………………….

Keluarga yang mudah dihubungi

Nama                           : ……………………………………………………………

         Pekerjaan                     : ……………………………………………………………

Alamat                                    : ……………………………………………………………

Hubungan Keluarga    : ……………………………………………………………

2. Keluhan

a. Alasan masuk rumah sakit :

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b. Keluhan saat pengkajian :

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3. Riwayat penyakit sekarang :

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4. Riwayat penyakit masa lalu :

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5.  Riwayat kesehatan keluarga :

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6.   Riwayt Psikososial Spiritul :

      a. Psikologis

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b. Sosial

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c. Spiritual

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7. Pola Aktifitas Sehari-hari (di rumh & di RS ) :

No	KEBIASAAN	DIRUMAH	DIRUMAH SAKIT
1.	Makan
2.	Minum
3.	Eliminasi BA.B
4.	Eliminasi BAK
5.	Istirahat/tidur
6.	Aktifitas /latihan/ Olahraga Lain-lain

Pemeriksaan fisik :

a.        Keadaan /penampilan/Kesan Umum pasien :

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

  b.   Tanda-tanda vital :

              Suhu tubuh    :                                                           Respirasi          :

              Denyut nadi  :                                                           TB / BB           :                                           

              Tensi darah    :

c.      Pemeriksaan Kepala dan Leher :

  Kepala           : …………………………………………………………………..

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              Rambut         : ………………………………………………………………….

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Wajah           : ……………………………………………………………………

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Mata             : …………………………………………………………………..

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Hidung         : …………………………………………………………………

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Telinga         : ……………………………………………………………………

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Mulut &       : ………………………………………………………………….....

Faring             …………………………………………………………………….

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Leher            :  …………………………………………………………………..

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4. pemeriksaan Integumen/kulit dan kuku :

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5. Pemeriksaan Payudara dan Ketiak

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6. Pemeriksaan Thorak/Dada :

Thorax       : (Inspeksi)……………………………………………………………...

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Parui          : (Inspeksi,Perkusi,Palpasi,Auskultasi)…………………………………

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Jantung      : (Inspeksi, Perkusi, Palpasi, Auskultasi)……………………………..

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7. Pemeriksaan Abdomen(Inspeksi, Perkusi, Palpasi, Auskultasi)

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8. Pemeriksaan kelamin dan daerah sekitarnya (bila diperlukan)

Genetalia :………………………………...............................................................

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Anus       : ………………………………………………………………………..

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i      Pemeriksaan Muskulo (Ekstremitas) :…………………………………………..

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10. Pemeriksaan Neurologi :

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11. Pemeriksaan Status mental :

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12. Pemeriksaan Penunjang medis :

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13. Penatalaksanan / Therapi :

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                                                                                          Malang, ……………….

                                                                                                           Perawat

ANALISA DATA

NAMA PASIEN  :

UMUR                  :

NO. REGISTER   :

DATA PENUNJANG	MASALAH	KEMUNGKINAN PENYEBAB

     

ANALISA DATA

NAMA PASIEN  :

UMUR                  :

NO. REGISTER   :

DATA PENUNJANG	MASALAH	KEMUNGKINAN PENYEBAB

DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN  :

UMUR                  :

NO. REGISTER   :

NO.	TGL. MUNCUL	DIAGNOSA KEPERAWATAN	TGL. TERATASI	T.T

RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN  :

UMUR                  :

NO. REG              :

NO.	DIAGNOSA KEPERAWATAN	TUJUAN	RENCANA KEPERAWATAN	RASIONAL	T.T.

RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN  :

UMUR               :

NO. REG           :

NO.	DIAGNOSA KEPERAWATAN	TUJUAN	RENCANA KEPERAWATAN	RASIONAL	T.T.

CATATAN KEPERAWATAN

NAMA PASIEN  :

UMUR                  :

NO. REGISTER         :

NO.	TGL.	NO DX. KEP	JAM	TINDAKAN KEPERAWATAN	EVALUASI	T.T.

CATATAN KEPERAWATAN

NAMA PASIEN  :

UMUR                  :

NO. REGISTER         :

NO.	TGL.	NO DX. KEP.	JAM	TINDAKAN KEPERAWATAN	EVALUASI	T.T.

RUMAH SAKIT TK. II Dr. SOEPRAOEN

POLITEKNIK KESEHATAN

PROGRAM STUDI KEPERAWATAN

              FORMAT CATATAN PRKEMBANGAN

NAMA PASIEN  :

UMUR                  :

DX. MEDIS         :

NO. DX. KEP	TANGGAL/ JAM	CATATAN PERKEMBANGAN	TTD.
		S : O : A : P : I  : E : R :