ASUHAN KEPERAWATAN PADA Tn/Ny/Nn/An.........

DENGAN......................................................
I.

II.

III.

Identitas Klien
Nama
Usia
Jenis Kelamin
Alamat
No. Registrasi
Diagnosa Medis
Tanggal MRS
Jam MRS
Tanggal Pengkajian
Jam Pengkajian

:
:
:
:
:
:
:
:
:
:

Data Subyektif
KeluhanUtama

Mekanisme Trauma

SAMPLE
Sign and Symptom

Allergy

Medication

Past Medical History

Last Oral Intake

Event Preceding

Data Obyektif
Airway

Breathing

Circulation

Disability

Exposure

Full Vital Sign

Head to Toe
KeadaanUmum

Kepala, LeherdanWajah
- Dada

- Respirasi
Cardiovaskuler

Abdomen

Pelvis danGenetalia

Ekstremitas

Punggung (Manuver Log Roll)

IV.

Pemeriksaan Penunjang
ECG

Ro. Toraks

BGA
Pa CO2 :
Pa O2 :
Sa O2 :
pH
:
HCO3 :

V.

Therapi

VI.

Tindakan Resusitasi
N
o
1
2
3
4
5
6
7

Tgl/Jam

Tindakan Resusitasi

Keterangan

VII.

Analisa Data
No
1

Tanda

Etiologi

Problem

VIII.

Prioritas Diagnosa Keperawatan

No
1
2
3
4
5

Prioritas Diagnosa Keperawatan

IX.

Intervensi Keperawatan

X.
XII.
Tg
Dx.
l/Jam
XI.
Kep
XVI.
XXXIV.
1
XVII.
XVIII.
XIX.
XX.
XXI.
XXII.
XXIII.
XXIV.
XXV.
XXVI.
XXVII.
XXVIII.
XXIX.
XXX.
XXXI.
XXXII.
XXXIII.
XXXVIII. LII.
2
XXXIX.
XL.
XLI.
XLII.
XLIII.
XLIV.
XLV.
XLVI.

XIII.

Tujuan

XIV.

Intervensi Keperawatan

XV.
Ttd

XXXV.

XXXVI.

XXXVII.

LIII.

LIV.

LV.

XLVII.
XLVIII.
XLIX.
L.
LI.
LVI.
LXXIV.
3
LVII.
LVIII.
LIX.
LX.
LXI.
LXII.
LXIII.
LXIV.
LXV.
LXVI.
LXVII.
LXVIII.
LXIX.
LXX.
LXXI.
LXXII.
LXXIII.
LXXVIII.
LXXIX.

LXXV.

LXXVI.

LXXVII.

LXXX. Implementasi
LXXXI.LXXXIII.
Dx.
Tgl/Jam
LXXXII.
Kep
LXXXVII.C.
LXXXVIII.
LXXXIX.
XC.
XCI.
XCII.
XCIII.
XCIV.
XCV.
XCVI.
XCVII.
XCVIII.
XCIX.
CIV.
CXVIII.
CV.
CVI.
CVII.
CVIII.
CIX.
CX.
CXI.
CXII.
CXIII.
CXIV.
CXV.
CXVI.
CXVII.
CXXII. CXXXVI.
CXXIII.

LXXXIV.

Implementasi

LXXXV.

Respon Pasien

LXXXVI.
TTD

CI.

CII.

CIII.

CXIX.

CXX.

CXXI.

CXXXVII.

CXXXVIII.

CXXXIX.

CXXIV.
CXXV.
CXXVI.
CXXVII.
CXXVIII.
CXXIX.
CXXX.
CXXXI.
CXXXII.
CXXXIII.
CXXXIV.
CXXXV.

CXL.

Evaluasi
CXLI. CXLIII. T
Dx.
gl/Jam
CXLII.
Kep
CXLVI.CXLVII. CXLVIII.
CXLIX.
CL.
CLI.
CLII. O :
CLIII.
CLIV.
CLV.
CLVI.
CLVII. A:
CLVIII.
CLIX. P:
CLX.
CLXI.
CLXII.
CLXIII.
CLXV. CLXVI. CLXVII.
CLXVIII.
CLXIX.
CLXX.
CLXXI. O :
CLXXII.
CLXXIII.
CLXXIV.
CLXXV.
CLXXVI.
CLXXVII.
CLXXVIII.
CLXXIX.
CLXXX.
CLXXXI.
CLXXXII.
CLXXXIV.
CLXXXV. CLXXXVI.
CLXXXVII.
CLXXXVIII.
CLXXXIX.
CXC. O :
CXCI.
CXCII.
CXCIII.
CXCIV.
CXCV. A :
CXCVI.
CXCVII.
CXCVIII.
CXCIX.
CC.
CCI.

CXLIV.Evaluasi

CXLV. T
TD

S:

CLXIV.

S:

CLXXXIII.

A:
P:

S:

P:

CCII.

CCIII.
CCIV.
CCV.
CCVI. Discharge Palning
CCVII. Format Discharge Planning (Pulang/Pindah Ruangan)
CCVIII.CCX.
S
CCIX.
CCXI. CCXX.
O
CCXII.
CCXIII.
CCXIV.
CCXV.
CCXVI.
CCXVII.
CCXVIII.
CCXIX.
CCXXI.CCXXIII.
A
CCXXII.
CCXXIV.
CCXXVI.
P
CCXXV.
CCXXVII.
CCXXXIV.
I
CCXXVIII.
CCXXIX.
CCXXX.
CCXXXI.
CCXXXII.
CCXXXIII.
CCXXXV.
CCXL.
E
CCXXXVI.
CCXXXVII.
CCXXXVIII.
CCXXXIX.
CCXLI.
CCXLII.
Nama pasien: Tn/Ny/Nn/An_______________(P/L) masuk rumah sakit
pada tanggal_____________ jam______WIB dengan diagnosa
medis_________________ telah diberikan tindakan diatas. Untuk itu perlu perawatan
lanjutan di____________ kunjungan rutin ke___mulai tanggal____________
CCXLIII.
CCXLIV.
Terapi obat yang diberikan :
CCXLV.
CCXLVI.
CCXLVII.
CCXLVIII.
CCXLIX.
Anjuran
CCL.
CCLI.

CCLII.
CCLIII.
CCLIV.
CCLV. Malang,_____________________
CCLVI. Ttd
CCLVII.
CCLVIII.
CCLIX.(____________________)