FORMAT PENGKAJIAN KEPERAWATAN

Pengkajian tgl.

: ...............................................................................

Jam

: ...................

MRS tanggal

: ...............................................................................

No. RM

: ...................

Hari Rawat Ke

: ...................

Diagnosa Masuk : ...............................................................................

Ruangan/kelas

: ...............................................................................

A. IDENTITAS PASIEN
Nama

: ............................................................... Penanggung jawab biaya

Usia

: ............................................................... Nama

: .........................

: ......................................

Jenis kelamin : ............................................................... Alamat

: ......................................

Suku /Bangsa : ............................................................... Hub. Keluarga

: ......................................

Agama

: ............................................................... Telepon

: ......................................

Pendidikan

: ...............................................................

Status perkawinan ........................................................

Pekerjaan

: ...............................................................

Alamat

: ...............................................................

B. RIWAYAT PENYAKIT SEKARANG

1. Keluhan Utama : .......................................................................................................................
2. Alasan masuk rumah sakit : ......................................................................................................
3. Riwayat Penyakit Sekarang : ....................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
C. RIWAYAT PENYAKIT DAHULU
1. Pernah di rawat

ya, jenis : .......................

tidak

2. Riwayat Penyakit Kronik dan Menular

ya, jenis : .......................

tidak

3. Riwayat Penyakit Alergi

ya, jenis : .......................

tidak

4. Riwayat Operasi

ya, jenis : .......................

tidak

5.

Kapan

: ...............................

Jenis Operasi

: ...............................

Lain-lain :
.................................................................................................................................................

D. RIWAYAT PENYAKIT KELUARGA

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
GENOGRAM

E. PENGKAJIAN PSIKOSOSIAL
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
F. PENGKAJIAN SPIRITUAL
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
G.

KEBUTUHAN DASAR / POLA KEBIASAAN SEHARI HARI

1. Makan
Sebelum MRS : .....................................................................................................
Sesudah MRS : .....................................................................................................
2. Minum
Sebelum MRS : .....................................................................................................
Sesudah MRS : .....................................................................................................
3. Tidur
Sebelum MRS : .....................................................................................................
Sesudah MRS : .....................................................................................................
4. Eliminasi fekal / BAB
Sebelum MRS : .....................................................................................................
Sesudah MRS : .....................................................................................................
5. Eliminasi urine / BAK
Sebelum MRS : .....................................................................................................

Sesudah MRS : .....................................................................................................

6. Aktifitas
Sebelum MRS : .....................................................................................................
Sesudah MRS : .....................................................................................................
7. Personal hygiene
Sebelum MRS : .....................................................................................................
Sesudah MRS : .....................................................................................................
H. PEMERIKSAAN FISIK
Hari : ..................................................................................................... .
1.

Keadaan umum : .....................................................................................................

Kehilangan BB : .....................................................................................................
Kelemahan

: .................................................................................................................

Perubahan mood : ...............................................................................................................

Vital sign

TD

: .............................................................................................

: .............................................................................................

: .............................................................................................

: .............................................................................................

Tingkat kesadaran : .............................................................................................................

2. Head to toe
Kepala
Inspeksi

: .........................................................................................................

palpasi

: .........................................................................................................

Mata
Inspeksi

: .........................................................................................................

palpasi

: .........................................................................................................

Hidung
Inspeksi

: .........................................................................................................

palpasi

: .........................................................................................................

Telinga
inspeksi

: .........................................................................................................

Palpasi

: .........................................................................................................

Mulut
inspeksi

: .........................................................................................................

Leher
inspeksi

: .........................................................................................................

Palpasi

: .........................................................................................................

Dada
inspeksi

: .........................................................................................................

palpasi

: .........................................................................................................

auskultasi

: .........................................................................................................

perkusi

: .........................................................................................................

Abdomen
inspeksi

: .........................................................................................................

auskultasi

: .........................................................................................................

perkusi

: .........................................................................................................

palpasi

: .........................................................................................................

Ekstremitas
atas

: .........................................................................................................

bawah

: .........................................................................................................

.....................................................................................................................................
Genetalia
inspeksi

: .........................................................................................................

palpasi

: .........................................................................................................

I. PEMERIKSAAN NEUROLOGIS
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

J. PEMERIKSAAN PENUNJANG
...............................................................................................................................................
...............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
K. TERAPI/PENGOBATAB/PENATALAKSANAAN
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
..............................................................................................................................................
ANALISA DATA
Nama :
Umur :
No Register :

No

Data Penunjang

Etiologi

Masalah

DIAGNOSA
Nama :
Umur :

No Register :

No

Diagnoasa Keparawatan

Tanggal
Dtemukan

Paraf

Tanggal
teratasi

Paraf

INTERVENSI, IMPLEMENTASI
Nama :
Umur :
No Register :

No
Dx

Kriteria Hasil/ Tujuan

Tgl
jam

Intervensi

Rasional

Implementasi

Tgl
jam

TTD

EVALUASI
Nama :
Umur :
No Register :

No

Diagnosa

Tgl/jam

SOAP

TTD