FORMAT LAPORAN ASUHAN KEPERAWATAN

BERDASARKAN FORMAT HENDERSON

ASUHAN KEPERAWATAN PADA ........................................

DENGAN DIAGNOSA MEDIS...........................................................................
DENGAN GANGGUAN.............................................DI RUANG
......................................................................................
TANGGAL

PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama :

Umur :

Agama :

Jenis Kelamin :

Status :

Pendidikan :

Pekerjaan :

Suku Bangsa :

Alamat :

Tanggal Masuk :

Tanggal Pengkajian :

No. Register :
 Diagnosa Medis :

b. Identitas Penanggung Jawab

Nama :

Umur :

Hub. dengan Pasien :

Pekerjaan :

Alamat :

2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
Saat MRS :

Saat ini :

2) Upaya yang dilakukan untuk mengatasinya

...............................................................................................................................
b. Status Kesehatan Masa Lalu
1) Penyakit yang pernah dialami
...............................................................................................................................
Pernah dirawat
...............................................................................................................................
Alergi
...............................................................................................................................
2) Kebiasaan (merokok/kopi/alkohol dll)
...............................................................................................................................
3) Riwayat Penyakit Keluarga
...............................................................................................................................
4) Diagnosa Medis dan therapy
...............................................................................................................................
3. Pola Kebutuhan Dasar (Data Bio-psiko-sosio-kultural-spiritual)
a. Pola bernapas
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
...............................................................................................................................
b. Pola makan-minum
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
c. Pola eliminasi
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
...............................................................................................................................
d. Pola aktivitas dan latihan
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
e. Pola istirahat dan tidur
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
...............................................................................................................................
f. Pola berpakaian
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
g. Pola rasa nyaman
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
...............................................................................................................................
h. Pola aman
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................

i. Pola kebersihan diri

Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
...............................................................................................................................
j. Pola komunikasi
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
k. Pola beribadah
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
...............................................................................................................................
l. Pola produktifitas
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
m. Pola rekreasi
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
...............................................................................................................................
n. Pola kebutuhan belajar
Sebelum sakit
...............................................................................................................................
Saat sakit
...............................................................................................................................
4. Pengkajian Fisik
a. Keadaan umum :
Tingkat kesadaran : komposmetis / apatis / somnolen / spoor / koma
GCS : Verbal:.......... Psikomotor:............Mata :..................
b. Tanda-tanda vital :
Nadi :............. Suhu : ................TD :.................... RR :...................
c. Keadaan fisik
1) Kepala dan leher :
...............................................................................................................................
2) Dada :
Paru
...............................................................................................................................
Jantung
...............................................................................................................................
3) Payudara dan ketiak :
...............................................................................................................................
4) Abdomen :
...............................................................................................................................
5) Genetalia :
...............................................................................................................................
6) Integumen :
...............................................................................................................................
7) Ekstremitas :
Atas
...............................................................................................................................
Bawah
...............................................................................................................................
8) Neurologis :
Status mental dan emosi :
...............................................................................................................................
Pengkajian saraf kranial :
...............................................................................................................................
Pemeriksaan refleks :
...............................................................................................................................
d. Pemeriksaan Penunjang
1) Data laboratorium yang berhubungan
...............................................................................................................................
2) Pemeriksaan radiologi
...............................................................................................................................
3) Hasil konsultasi
...............................................................................................................................
4) Pemeriksaan penunjang diagnostic lain
...............................................................................................................................
5. ANALISA DATA
INTERPRETASI
MASALAH
DATA (Sesuai dengan
KEPERAWATAN
patofisiologi)
DAFTAR DIAGNOSA KEPERAWATAN /MASALAH KOLABORATIF BERDASARKAN PRIORITAS
TANGGAL / JAM TANGGAL
NO DIAGNOSA KEPERAWATAN (NANDA) Ttd
DITEMUKAN TERATASI

RENCANA TINDAKAN KEPERAWATAN

 Rencana Perawatan
Hari/
No Dx Ttd
Tgl NOC NIC

IMPLEMENTASI KEPERAWATAN
Hari/
No Dx Tindakan Keperawatan Evaluasi proses Ttd
Tgl/Jam
Evaluasi Keperawatan

Hari/Tgl
No No Dx Evaluasi TTd
Jam