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  • Format Askep Individu

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    Hezt Natalianto
    30 vues9 pages
    Dokumen tersebut merupakan contoh format asuhan keperawatan individu yang mencakup identifikasi pasien, diagnosa medis, anamnesa, dan hasil pemeriksaan fisik pasien. Dokumen tersebut memberikan informasi mengenai data demografi pasien, keluhan utama dan tambahan, riwayat penyakit, hasil pemeriksaan umum dan sistemik pasien seperti kesadaran, tanda-tanda vital, dan sistem organ tertentu.

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    Dokumen tersebut merupakan contoh format asuhan keperawatan individu yang mencakup identifikasi pasien, diagnosa medis, anamnesa, dan hasil pemeriksaan fisik pasien. Dokumen tersebut memberikan informasi mengenai data demografi pasien, keluhan utama dan tambahan, riwayat penyakit, hasil pemeriksaan umum dan sistemik pasien seperti kesadaran, tanda-tanda vital, dan sistem organ tertentu.

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    30 vues9 pages

    Format Askep Individu

    Transféré par

    Hezt Natalianto
    Dokumen tersebut merupakan contoh format asuhan keperawatan individu yang mencakup identifikasi pasien, diagnosa medis, anamnesa, dan hasil pemeriksaan fisik pasien. Dokumen tersebut memberikan informasi mengenai data demografi pasien, keluhan utama dan tambahan, riwayat penyakit, hasil pemeriksaan umum dan sistemik pasien seperti kesadaran, tanda-tanda vital, dan sistem organ tertentu.

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    sur 9

    ASUHAN KEPERAWATAN INDIVIDU

    NAMA PERAWAT : ..............................................................


    NIP : ..............................................................
    TANGGAL : ..............................................................

    A. Identifikasi
    Nama Pasien : .................................................. Nama Panggilan : ............................
    Umur : ..................................................
    Jenis Kelamin : ..................................................
    Agama : ..................................................
    Suku : ..................................................
    Pendidikan : ..................................................
    Alamat Pasien : ............................................................................................................
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    Nomor Register : ..................................................

    B. Diagnosa Medis : ............................................................................................................

    C. Anamnesa
    Keluhan Utama :
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    Keluhan Tambahan :
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    Riwayat Penyakit :
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    D. Pemeriksaan Fisik
    1. Keadaan Umum
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    2. Pemeriksaan Sistemik
    a. Kesadaran : ....................................................................................
    GCS : Nilai............................

    Refleks Mata (E) : Mata membuka spontan (4)


    Mata membuka dengan respon suara (3)
    Mata terbuka dengan rangsang nyeri (2)
    Mata tidak terbuka (1)
    Refleks Bicara (V) : Berbicara normal dan terorientasi (5)
    Berbicara tapi Bingung (4)
    Kata-kata tidak sesuai/tidak tepat (3)
    Suara tidak jelas/menggumam (2)
    Tidak ada respon (1)
    Refleks Motorik (M) : Mengikuti perintah (6)
    Melindungi daerah nyeri (5)
    Menghindar terhadap nyeri (4)
    Fleksi akibat nyeri (3)
    Ekstensi akibat nyeri (2)
    Tidak ada respon (1)

    Kesimpulan : ......................................................................................................................
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    b. Tanda-tanda Vital
    Tekanan Darah : ............../..............mmHg
    Nadi : ..............X/menit, tempat arteri...................................
    Suhu : ............0C, per Oral/ Axilla / Rectal
    Respirasi : ............X/menit, teratur/tidak, bunyi nafas.................................

    c. Pemeriksaan sistem
    a. Rambut : ........................................................................................................
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    b. Mata : ........................................................................................................
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    c. Hidung : ........................................................................................................
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    d. Mulut : ........................................................................................................
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    e. Telinga : ........................................................................................................
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    f. Ekstremitas atas : ........................................................................................................
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    g. Ekstremitas : ........................................................................................................
    bawah ........................................................................................................
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    h. Kondisi kulit : ........................................................................................................
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    Hal-hal mencolok yang ditemukan : .........................................................................................


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    3. Riwayat Aktivitas Sehari-hari


    Aktivitas SMRS MRS
    a. Pemenuhan nutris .................................................... ..................................................
    dan cairan .................................................... ..................................................
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    b. Pemenuhan eliminasi .................................................... ..................................................
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    c. Pemenuhan istirahat/ .................................................... ..................................................
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    d. Akitivitas fisik .................................................... ..................................................
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    E. Pemeriksaan Penunjang & Terapi


    ANALISA DATA

    No. Data Masalah Penyebab


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    DIAGNOSA KEPERAWATAN SESUAI PRIORITAS

    No. Diagnosa Keperawatan


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    RENCANA KEPERAWATAN
    Tanggal Dx. Keperawatan Tujuan/Kriteria Hasil Rencana Tindakan
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    IMPLEMENTASI DAN EVALUASI
    Tanggal
    No. Paraf
    & Impementasi Evaluasi
    Dx Perawat
    Waktu
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