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Asuhan Keperawatan Pada Tn/Ny/Nn/An … dengan … (Diagnosa

Medis)
di Ruang ... RS ...

Tanggal Masuk, Pukul :


Tanggal Pengkajian, Pukul :
No. Register :
Sumber Informasi :
Hubungan dengan pasien :

A. PENGKAJIAN
1. Biodata
Nama : ......................................................................................................
Umur : ......................................................................................................
Jenis Kelamin : ......................................................................................................
Suku Bangsa : ......................................................................................................
Status Perkawinan:.................................................................................................
Agama : ......................................................................................................
Alamat : ......................................................................................................
Pendidikan : ......................................................................................................
Pekerjaan : ......................................................................................................
Diagnosa Medis :.....................................................................................................
Penanggung Jawab
Nama : ......................................................................................................
Pekerjaan : ......................................................................................................
Hubungan dengan pasien: ..................................................................................
2. Keluhan Utama :
........................................................................................................................................
3. Riwayat Penyakit Sekarang :
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
4. Riwayat Penyakit Dahulu :
........................................................................................................................................
5. Riwayat Penyakit Keluarga (Genogram) :
........................................................................................................................................
Contoh genogram

6. Riwayat Alergi : ......................................................................................................


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

7. Data Psikososial
a. Konsep Diri
Gambaran Diri:.........................................................................................................
........................................................................................................................................
Harga Diri : ...........................................................................................................
........................................................................................................................................
Identitas Diri :..........................................................................................................
........................................................................................................................................
Peran Diri : ...........................................................................................................
........................................................................................................................................
Ideal Diri : ...........................................................................................................
........................................................................................................................................
b. Hubungan Sosial
........................................................................................................................................
c. Spiritual
........................................................................................................................................
d. Kecemasan
........................................................................................................................................
e. Kehilangan (Kubbler-Ross)
Denial : ...........................................................................................................
........................................................................................................................................
Anger : ...........................................................................................................
........................................................................................................................................
Bargaining : ...........................................................................................................
........................................................................................................................................
Depression : ...........................................................................................................
........................................................................................................................................
Acceptance : ...........................................................................................................
........................................................................................................................................
8. Pola Fungsi Kesehatan
a. Pola Nutrisi dan Metabolik
Di Rumah
Makan berapa kali dalam sehari:............................ x/hari
Jumlah cairan masuk dalam sehari:....................... cc/hari
Jenis makanan : ..............................................................................
Jenis minuman : ..............................................................................
Makanan kesukaan : ..............................................................................
Masalah yang mempengaruhi masukan makanan:...................................
Diet khusus, makanan pantang:........................................................................
Keterangan : ..............................................................................
........................................................................................................................................
Di RS
Makan berapa kali dalam sehari:............................ x/hari
Jumlah cairan masuk dalam sehari:....................... cc/hari
Jenis makanan : ..............................................................................
Jenis minuman : ..............................................................................
Makanan kesukaan : ..............................................................................
Masalah yang mempengaruhi masukan makanan:...................................
Diet khusus, makanan pantang:........................................................................
Status Gizi : BB=.......kg, TB=.......cm
Interpretasi status gizi : ............................................
Keterangan lain : ..............................................................................
........................................................................................................................................
b. Pola Eliminasi
Di Rumah
No Hal BAB BAK
1. Frekuensi

2. Konsistensi

3. Jumlah

4. Bau

5. Warna
Di RS
No Hal BAB BAK
1. Frekuensi

2. Konsistensi

3. Jumlah

4. Bau

5. Warna

c. Pola Kebersihan Diri


Di Rumah
Mandi : ......................................................................................................
Gosok Gigi : ......................................................................................................
Keramas : ......................................................................................................
Gunting Kuku : ......................................................................................................
Keterangan : ......................................................................................................
........................................................................................................................................
Di RS
Mandi : ......................................................................................................
Gosok Gigi : ......................................................................................................
Keramas : ......................................................................................................
Gunting Kuku : ......................................................................................................
Keterangan : ......................................................................................................
........................................................................................................................................
d. Pola Aktivitas dan Latihan
Di Rumah:
........................................................................................................................................
........................................................................................................................................
Di RS
........................................................................................................................................
........................................................................................................................................
e. Pola Istirahat/Tidur
Di Rumah
Tidur Siang : berapa jam................; jam berapa biasa tidur............................
Tidur Malam : berapa jam................; jam berapa biasa tidur............................
Masalah Tidur :.......................................................................................................
Keterangan : .........................................................................................................
Di RS
Tidur Siang : berapa jam................; jam berapa biasa tidur............................
Tidur Malam : berapa jam................; jam berapa biasa tidur............................
Masalah Tidur :.......................................................................................................
Keterangan :.......................................................................................................

9. Pemeriksaan Fisik
a. Keadaan Umum: .....................................................................................................
Kesadaran : .........................................................................................................
GCS : .........................................................................................................
Tanda-tanda vital:
TD : ................../................. mmHg Nadi : ............... x/menit
Suhu: ..............°C Respirasi: ................ x/menit
b. Pemeriksaan Kulit dan Kuku
Inspeksi
Warna Kulit :............................................................................................................
Keterangan : .............................................................................................................
Palpasi
Kondisi Kulit:............................................................................................................
Turgor Kulit :............................................................................................................
CRT : .............................................................................................................
Keterangan : .............................................................................................................
c. Pemeriksaan Kepala
Inspeksi
Bentuk Kepala:.........................................................................................................
Rambut : .............................................................................................................
Massa : .............................................................................................................
Keterangan : .............................................................................................................
Palpasi
Kepala: .......................................................................................................................
Keterangan: .............................................................................................................
d. Pemeriksaan Mata
Inspeksi
Alis : ................................................................................................................
Mata : ................................................................................................................
Bola Mata : ................................................................................................................
Sklera : ................................................................................................................
Pupil : ................................................................................................................
Konjungtiva:..............................................................................................................
Keterangan :...............................................................................................................
Palpasi
Mata : ................................................................................................................
Keterangan :...............................................................................................................
e. Pemeriksaan Hidung
Inspeksi
Lubang hidung :.......................................................................................................
Hidung : .........................................................................................................
Keterangan : .........................................................................................................
Palpasi
Sinus Hidung : .........................................................................................................
Keterangan : .........................................................................................................
f. Pemeriksaan Telinga
Inspeksi
Daun Telinga : .........................................................................................................
Kondisi lubang Telinga: .......................................................................................
Keterangan : .........................................................................................................
Palpasi
Telinga : .........................................................................................................
Keterangan : .........................................................................................................
g. Pemeriksaan Mulut
Inspeksi
Bibir : .........................................................................................................
Gigi : .........................................................................................................
Gusi : .........................................................................................................
Lidah : .........................................................................................................
Uvula : .........................................................................................................
Tonsil : .........................................................................................................
Keterangan : .........................................................................................................
Palpasi
Keterangan : .........................................................................................................
h. Pemeriksaan Leher
Inspeksi
Kondisi Kulit : .........................................................................................................
Keterangan : .........................................................................................................
Palpasi
Kelenjar Tiroid :.......................................................................................................
Vena jugularis: .........................................................................................................
Trakea : .........................................................................................................
Kelenjar Limfe :.......................................................................................................
Keterangan : .........................................................................................................
i. Pemeriksaan Paru
Inspeksi
Dada : .........................................................................................................
Kondisi kulit : .........................................................................................................
Keterangan : .........................................................................................................
Palpasi
Pada Dada : .........................................................................................................
Perkusi : .........................................................................................................
Auskultasi : .........................................................................................................

Suara Nafas :

j. Pemeriksaan Jantung
Inspeksi
Ictus Cordis : .........................................................................................................
Kondisi kulit : .........................................................................................................
Keterangan : .........................................................................................................
Palpasi
Ictus Cordis : .........................................................................................................
Perkusi : .........................................................................................................
Auskultasi : .........................................................................................................
BJ I : .........................................................................................................
BJ II : .........................................................................................................
BJ III : .........................................................................................................
BJ tambahan : .........................................................................................................
Keterangan : .........................................................................................................

k. Pemeriksaan Abdomen
Inspeksi : .........................................................................................................
Auskultasi : .........................................................................................................
Palpasi : .........................................................................................................
Perkusi : .........................................................................................................
Keterangan : .........................................................................................................
l. Pemeriksaan Muskuloskeletal
Inspeksi : .........................................................................................................
Palpasi : .........................................................................................................

Kekuatan Otot

Keterangan : .........................................................................................................
m. Pemeriksaan Genetalia
Inspeksi : .........................................................................................................
Palpasi : .........................................................................................................
Keterangan : .........................................................................................................
10. Pemeriksaan Penunjang
Pemeriksaan Tanggal:
Pemeriksaan Hasil Nilai Normal Interpretasi
11. Terapi
Nama & Dosis Rute Pemberian Fungsi Obat
Obat
B. Analisa Data
Nama : No Register :
Umur : Diagnosa Medis :
Tgl. Data Masalah Etiologi
C. PRIORITAS DIAGNOSA KEPERAWATAN
Nama : No Register :
Umur : Diagnosa Medis:
No Tanggal Diagnosa Keperawatan
D. RENCANA KEPERAWATAN
Nama : No Register :
Umur : Diagnosa Medis:
No. Tujuan Kriteria Hasil Intervensi
Dx
E. IMPLEMENTASI KEPERAWATAN
Nama : No Register :
Umur : Diagnosa Medis:
Tanggal Waktu No. Implementasi Tanda
(Jam) Dx Tangan
F. EVALUASI
Nama : No Register :
Umur : Diagnosa Medis:
Tanggal Waktu No. Evaluasi Tanda
(Jam) Dx Tangan