YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN

Jl. Beliang No. 110 Telp / Fax (0536) 3227707

FORMAT ASUHAN KEPERAWATAN OK

Nama Mahasiswa : .
NIM : .
Ruang Praktek : .
Tanggal Praktek : .
Tanggal & Jam Pengkajian : .

I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama : ..
Umur : ..
Jenis Kelamin : ..
Suku/Bangsa : ..
Agama : ..
Pekerjaan : ..
Pendidikan : ..
Status Perkawinan : ..
Alamat : ..
Tgl MRS : ..
Diagnosa Medis : ..

B. RIWAYAT KESEHATAN /PERAWATAN

1. Keluhan Utama /Alasan di Operasi :
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2. Riwayat Penyakit Sekarang :
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3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi)
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4. Riwayat Penyakit Keluarga
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GENOGRAM KELUARGA :
C. PEMERIKASAAN FISIK
1. Keadaan Umum :
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2. Tanda-tanda Vital :
a. Suhu/T : .0C Axilla Rektal Oral
b. Nadi/HR : x/mt
c. Pernapasan/RR : ....x/tm
d. Tekanan Darah/BP : .....mm Hg

3. DATA PENUNJANG (RADIOLOGIS, LABORATURIUM, PENUNJANG LAINNYA)

4. PENATALAKSANAAN MEDIS (Preoperatif, Premedikasi, Post Operatif)

Palangka Raya,..
Mahasiswa

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 ANALISIS DATA

DATA SUBYEKTIF DAN KEMUNGKINAN

MASALAH
DATA OBYEKTIF PENYEBAB
PRIORITAS MASALAH
 RENCANA KEPERAWATAN

Nama Pasien : ..

Ruang Rawat : ..

Diagnosa Keperawatan Tujuan (Kriteria hasil) Intervensi Rasional

Diagnosa Keperawatan Tujuan (Kriteria hasil) Intervensi Rasional
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/Tanggal Tanda tangan dan

Implementasi Evaluasi (SOAP)
Jam Nama Perawat
Hari/Tanggal Tanda tangan dan
Implementasi Evaluasi (SOAP)
Jam Nama Perawat