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

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

II.

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

:
:
:
:
:
:
:
:
:
:

Data Subyektif
1. Kasus Non-Trauma
Keluhan Utama

Provocative

Quality

Radiasi

Skala

Time

Riwayat Penyakit Dahulu

2. Kasus Trauma
Keluhan Utama

Mekanisme Trauma

III.

SAMPLE
Sign and Symptom

Allergy

Medication

Past Medical History

Last Oral Intake

Event Preceding

Data Obyektif
1. Kasus Non-Trauma
Airway

Breathing

Circulation

Disability
Kesadaran Kualitatif :
Kesadaran Kwalitatif :

Head to Toe
Keadaan Umum
Kepala dan Wajah
- Kepala

Mata

Telinga

Hidung

Mulut

Leher

Dada

Perut dan Pinggang

Pelvis dan Perineum

Ekstremitas

2. Kasus Trauma
Airway

Breathing

Circulation

Disability

Exposure

Full Vital Sign

Head to Toe
Keadaan Umum

Kepala, Leher dan Wajah

- Dada

- Respirasi
Cardiovaskuler

Abdomen

Pelvis dan Genetalia

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

Tgl/Jam

Tindakan Resusitasi

Keterangan

2
3
4
5
6
7

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
XVII.
XXXV.
1
XVIII.
XIX.
XX.
XXI.
XXII.
XXIII.
XXIV.
XXV.
XXVI.
XXVII.
XXVIII.
XXIX.
XXX.
XXXI.
XXXII.
XXXIII.
XXXIV.
XL.
LIV.
2
XLI.
XLII.
XLIII.
XLIV.
XLV.
XLVI.
XLVII.
XLVIII.

XIII.

Tujuan

XIV.

XXXVI.

XXXVII.

LV.

LVI.

Intervensi Keperawatan

XV.

Rasional

XXXVIII.

LVII.

XVI.
Ttd

XXXIX.

LVIII.

XLIX.
L.
LI.
LII.
LIII.
LIX. LXXVII.
3
LX.
LXI.
LXII.
LXIII.
LXIV.
LXV.
LXVI.
LXVII.
LXVIII.
LXIX.
LXX.
LXXI.
LXXII.
LXXIII.
LXXIV.
LXXV.
LXXVI.
LXXXII. XCIX.
4
LXXXIII.
LXXXIV.
LXXXV.
LXXXVI.
LXXXVII.
LXXXVIII.
LXXXIX.
XC.
XCI.

LXXVIII.

LXXIX.

LXXX.

LXXXI.

C.

CI.

CII.

CIII.

XCII.
XCIII.
XCIV.
XCV.
XCVI.
XCVII.
XCVIII.
CIV.
CXXII.
5
CV.
CVI.
CVII.
CVIII.
CIX.
CX.
CXI.
CXII.
CXIII.
CXIV.
CXV.
CXVI.
CXVII.
CXVIII.
CXIX.
CXX.
CXXI.
CXXVII.
CXXVIII.

CXXIII.

CXXIV.

CXXV.

CXXVI.

CXXIX.Implementasi
CXXX. CXXXII.
Dx.
Tgl/Jam
CXXXI.
Kep
CXXXVI.CXLIX.
CXXXVII.
CXXXVIII.
CXXXIX.
CXL.
CXLI.
CXLII.
CXLIII.
CXLIV.
CXLV.
CXLVI.
CXLVII.
CXLVIII.
CLIII. CLXVII.
CLIV.
CLV.
CLVI.
CLVII.
CLVIII.
CLIX.
CLX.
CLXI.
CLXII.
CLXIII.
CLXIV.
CLXV.
CLXVI.
CLXXI.CLXXXV.

CXXXIII.

Implementasi

CXXXIV.

Respon Pasien

CXXXV.
TTD

CL.

CLI.

CLII.

CLXVIII.

CLXIX.

CLXX.

CLXXXVI.

CLXXXVII.

CLXXXVIII.

CLXXII.
CLXXIII.
CLXXIV.
CLXXV.
CLXXVI.
CLXXVII.
CLXXVIII.
CLXXIX.
CLXXX.
CLXXXI.
CLXXXII.
CLXXXIII.
CLXXXIV.
CLXXXIX.
CCIII.
CXC.
CXCI.
CXCII.
CXCIII.
CXCIV.
CXCV.
CXCVI.
CXCVII.
CXCVIII.
CXCIX.
CC.
CCI.
CCII.
CCVII. CCXIX.
CCVIII.
CCIX.
CCX.
CCXI.
CCXII.
CCXIII.
CCXIV.

CCIV.

CCV.

CCXX.

CCXXI.

CCVI.

CCXXII.

CCXV.
CCXVI.
CCXVII.
CCXVIII.

CCXXIII.

Evaluasi

CCXXIV.
CCXXVI.
Dx.
Tgl/Ja
CCXXV. m
Kep
CCXXIX.
CCXXX. CCXXXI.
CCXXXII.
CCXXXIII.
CCXXXIV.
CCXXXV.
CCXXXVI.
CCXXXVII.
CCXXXVIII.
CCXXXIX.
CCXL. A:
CCXLI.
CCXLII.
CCXLIII.
CCXLIV.
CCXLV.
CCXLVI.
CCXLVIII.
CCXLIX. CCL. S :
CCLI.
CCLII.
CCLIII.
CCLIV.O :
CCLV.
CCLVI.
CCLVII.
CCLVIII.
CCLIX.A :
CCLX.
CCLXI.P :
CCLXII.
CCLXIII.
CCLXIV.
CCLXV.
CCLXVII.
CCLXVIII. CCLXIX.
CCLXX.
CCLXXI.
CCLXXII.
CCLXXIII.
CCLXXIV.
CCLXXV.
CCLXXVI.
CCLXXVII.
CCLXXVIII.
CCLXXIX.
CCLXXX.
CCLXXXI.
CCLXXXII.
CCLXXXIII.
CCLXXXIV.

CCXXVII.

S:

Evaluasi

CCXXVIII.
TTD

CCXLVII.

O:

P:

CCLXVI.

S:

O:

A:
P:

CCLXXXV.

CCLXXXVI.
CCLXXXVII.
CCLXXXVIII. S :
CCCIII.
CCLXXXIX.
CCXC.
CCXCI.
O:
CCXCII.
CCXCIII.
CCXCIV.
CCXCV.
CCXCVI.
A:
CCXCVII.
CCXCVIII.
P:
CCXCIX.
CCC.
CCCI.
CCCII.
CCCIV.CCCV. CCCVI.
S:
CCCXXIII.
CCCVII.
CCCVIII.
CCCIX.
CCCX. O :
CCCXI.
CCCXII.
CCCXIII.
CCCXIV.
CCCXV.
A:
CCCXVI.
CCCXVII.
P:
CCCXVIII.
CCCXIX.
CCCXX.
CCCXXI.
CCCXXII.
CCCXXIV.
CCCXXV.
Discharge Palning
CCCXXVI.
Format Discharge Planning (Pulang/Pindah Ruangan)
CCCXXVII.
CCCXXIX.
S
CCCXXVIII.
CCCXXX.
CCCXXXIX.
O
CCCXXXI.
CCCXXXII.
CCCXXXIII.
CCCXXXIV.
CCCXXXV.
CCCXXXVI.
CCCXXXVII.
CCCXXXVIII.
CCCXL.
CCCXLII.
A
CCCXLI.
CCCXLIII.
CCCXLV.
P

CCCXLIV.
CCCXLVI.
CCCLIII.
I
CCCXLVII.
CCCXLVIII.
CCCXLIX.
CCCL.
CCCLI.
CCCLII.
CCCLIV.
CCCLIX.
E
CCCLV.
CCCLVI.
CCCLVII.
CCCLVIII.
CCCLX.
CCCLXI.
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____________
CCCLXII.
CCCLXIII.
Terapi obat yang diberikan :
CCCLXIV.
CCCLXV.
CCCLXVI.
CCCLXVII.
CCCLXVIII.
CCCLXIX.
CCCLXX.
CCCLXXI.
Anjuran
CCCLXXII.
CCCLXXIII.
CCCLXXIV.
CCCLXXV.
CCCLXXVI.
CCCLXXVII.
CCCLXXVIII.
CCCLXXIX. Malang,_____________________
CCCLXXX.
Ttd
CCCLXXXI.
CCCLXXXII.
CCCLXXXIII. (____________________)