Lampiran 3

FORMAT ASUHAN KEPERAWATAN

PENGKAJIAN
1. PENGUMPULAN DATA
a. Biodata
1) Nama :
……………………………………………………
2) Jenis Kelamin :
……………………………………………………
3) Umur :
……………………………………………………
4) Status Perkawinan :
……………………………………………………
5) Pekerjaan :
……………………………………………………
6) Agama :
……………………………………………………
7) Pendidikan Terakhir :
……………………………………………………
8) Alamat :
……………………………………………………
9) Tanggal MRS :
……………………………………………………

b. Diagnosa Medis
...................................................................................................................................
c. Keluhan Utama
...................................................................................................................................
...................................................................................................................................
d. Riwayat Penyakit Sekarang
...................................................................................................................................
...................................................................................................................................
e. Riwayat Kesehatan/Penyakit Yang Lalu
...................................................................................................................................
...................................................................................................................................
f. Riwayat Kesehatan Keluarga
...................................................................................................................................
...................................................................................................................................
g. Pola Aktivitas Sehari-hari
1) Makan dan Minum
..............................................................................................................................
..............................................................................................................................
2) Pola Eliminasi
..............................................................................................................................
..............................................................................................................................

3) Pola Istirahat dan Tidur

 ..............................................................................................................................
..............................................................................................................................
4) Kebersihan Diri
..............................................................................................................................
..............................................................................................................................
h. Riwayat Psikososial
...............................................................................................................................
...............................................................................................................................
i. Pemeriksaan Fisik
1) Keadaan Umum
.............................................................................................................................
2) Tanda Vital
.............................................................................................................................
3) Pemeriksaan Kepala dan Leher
.............................................................................................................................
.............................................................................................................................
4) Pemeriksaan Integumen
.............................................................................................................................
.............................................................................................................................
5) Pemeriksaan Dada dan Thorax
.............................................................................................................................
.............................................................................................................................
6) Pemeriksaan Payudara
.............................................................................................................................
.............................................................................................................................
7) Pemeriksaan Abdomen
.............................................................................................................................
.............................................................................................................................
8) Pemeriksaan Genetalia
.............................................................................................................................
.............................................................................................................................
9) Pemeriksaan Ektrimitas
.............................................................................................................................
.............................................................................................................................
j. Pemeriksaan Neurologis
....................................................................................................................................
....................................................................................................................................
k. Pemeriksaan Penunjang
....................................................................................................................................
....................................................................................................................................
l. Terapi/Pengobatan/Penatalaksaan
....................................................................................................................................
....................................................................................................................................

Malang,

Mahasiswa
2. ANALISA DATA
 Nama Pasien : ……………………………………………….
Ruang : ……………………………………………….
No. Register : ……………………………………………….

DATA FOKUS MASALAH ETIOLOGI

3. DIAGNOSA KEPERAWATAN

No. DIAGNOSA KEPERAWATAN

PERENCANAAN
 1. PRIORITAS MASALAH
Nama Pasien : …………………………………………….
Ruang : …………………………………………….
No. Register : …………………………………………….

No. TANGGAL TANGGAL

DIAGNOSA KEPERAWATAN TTD
Dx MUNCUL TERATASI

2. RENCANA ASUHAN KEPERAWATAN

 Nama Pasien : ……………………………………………….
Ruang : ……………………………………………….
No. Register : ……………………………………………….

TUJUAN &
TGL DX KRITERIA INTERVENSI RASIONAL
HASIL

PELAKSANAAN
 Nama Pasien : ………………………………………………….
Ruang : ………………………………………………….
No. Register : ………………………………………………….

No.
TANGGAL PUKUL TINDAKAN TTD
Dx

EVALUASI
 Nama Pasien : …………………………………………………………………….
Ruang : …………………………………………………………………….
No. Register : …………………………………………………………………….

No.
TANGGAL: TANGGAL: TANGGAL: TTD
Dx