RUMAH SAKIT TK II Dr.

SOEPRAOEN
POLITEKNIK KESEHATAN
PROGRAM STUDI KEPERAWATAN

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN

Nama mahasiswa :
NIM :

PENGKAJIAN
Dilaksanakan tgl : …………………………………………

Ruang : ………………………………………….

No kamar/ TT : ………………………………………….

1. Biodata

Nama : …………………………………………………………..

Umur : ……………………………………………………………

Jenis kelamin : …………………………………………………………….

Agama : …………………………………………………………….

Alamat : …………………………………………………………….

Pendidikan : …………………………………………………………….

Pekerjaan : …………………………………………………………….

Status perkawinan : …………………………………………………………….

Tgl. MRS : ……………………………………………………………

Diagnosa medis : …………………………………………………………….

No. reg :
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Keluarga yang mudah dihubungi

Nama : ……………………………………………………………

Pekerjaan : ……………………………………………………………

Alamat : ……………………………………………………………
 Hubungan Keluarga : ……………………………………………………………

2. Keluhan

a.Alasan masuk rumah sakit :

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b. Keluhan saat pengkajian :
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3. Riwayat penyakit sekarang :

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4. Riwayat penyakit masa lalu :
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5. Riwayat kesehatan keluarga :
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6. Riwayt Psikososial Spiritul :
a. Psikologis
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b. Sosial
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c. Spiritual
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7. Pola Aktifitas Sehari-hari (Di Rumah & di Rumah Sakit ) :

No KEBIASAAN DI RUMAH DI RUMAH SAKIT

1. Makan

2. Minum

3. Eliminasi BA.B

4. Eliminasi BAK

5. Istirahat/tidur

6. Aktifitas /latihan/

Olahraga

Lain-lain
Pemeriksaan fisik :
a. Keadaan /penampilan/Kesan Umum pasien :

b. Tanda-tanda vital :

c. Pemeriksaan Kepala dan Leher :

Kepala :

Rambut :

Wajah :

Mata :

Hidung :

Telinga:

Mulut :

Faring :

Leher :

c. Pemeriksaan Integumen/kulit dan kuku :

d. Pemeriksaan Payudara dan Ketiak :

e. Pemeriksaan Thorak/Dada :
Paru : (Inspeksi,Perkusi,Palpasi,Auskultasi)

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Jantung : (Inspeksi, Perkusi, Palpasi, Auskultasi)
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f. Pemeriksaan Abdomen(Inspeksi, Perkusi, Palpasi, Auskultasi)
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g. Pemeriksaan kelamin dan daerah sekitarnya (bila diperlukan)

Genetalia :
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Anus

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i Pemeriksaan Muskulo (Ekstremitas)

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j. Pemeriksaan Neurologi :
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k. Pemeriksaan Penunjang medis :
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l. Penatalaksanan / Therapi :
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Malang, ……………….

Perawat
 ANALISA DATA

NAMA PASIEN :
UMUR :
NO. REGISTER :

DATA PENUNJANG PENYEBAB MASALAH

 ANALISA DATA

NAMA PASIEN :
UMUR :
NO. REGISTER :

DATA PENUNJANG PENYEBAB MASALAH

 DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN :
UMUR :
NO. REGISTER :
NO DIAGNOSA KEPERAWATAN TTD
 DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN :
UMUR :
NO. REGISTER :
NO DIAGNOSA KEPERAWATAN TTD
 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN:
UMUR :
NO. REG :
NO. DIAGNOSA TUJUAN INTERVENSI RASIONAL TTD
KEPERAWATAN
 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN:
UMUR :
NO. REG :
NO. DIAGNOSA TUJUAN INTERVENSI RASIONAL TTD
KEPERAWATAN
 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN:
UMUR :
NO. REG :
NO. DIAGNOSA TUJUAN INTERVENSI RASIONAL TTD
KEPERAWATAN
CATATAN KEPERAWATAN

NAMA PASIEN:
UMUR :
NO. REGISTER :

NO. TGL. NO DX. JAM TINDAKAN KEPERAWATAN EVALUASI TTD

KEP
 CATATAN KEPERAWATAN

NAMA PASIEN:
UMUR :
NO. REGISTER :

NO. TGL. NO DX. JAM TINDAKAN KEPERAWATAN EVALUASI TTD

KEP.
 CATATAN KEPERAWATAN

NAMA PASIEN:
UMUR :
NO. REGISTER :

NO. TGL. NO DX. JAM TINDAKAN KEPERAWATAN EVALUASI TTD

KEP.
RUMAH SAKIT TK. II Dr. SOEPRAOEN
POLITEKNIK KESEHATAN
PROGRAM STUDI KEPERAWATAN

FORMAT CATATAN PRKEMBANGAN

NAMA PASIEN:
UMUR :
DX. MEDIS :

NO. TGL/ CATATAN PERKEMBANGAN TTD.

DX. JAM
KEP
RUMAH SAKIT TK. II Dr. SOEPRAOEN
POLITEKNIK KESEHATAN
PROGRAM STUDI KEPERAWATAN

FORMAT CATATAN PRKEMBANGAN

NAMA PASIEN:
UMUR :
DX. MEDIS :
 NO. TGL/ CATATAN PERKEMBANGAN TTD.
DX. JAM
KEP

RUMAH SAKIT TK. II Dr. SOEPRAOEN

POLITEKNIK KESEHATAN
PROGRAM STUDI KEPERAWATAN

FORMAT CATATAN PRKEMBANGAN

NAMA PASIEN:
UMUR :
DX. MEDIS :
NO. TGL/ CATATAN PERKEMBANGAN TTD.
DX. JAM
KEP