PEMERINTAH KABUPATEN KOTAWARINGIN TIMUR

AKADEMI KEPERAWATAN
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FORMAT ASUHAN KEPERAWATAN

(Pasien Dewasa-Medical Surgical)
Tanggal Pengkajian : …………………………….. Jam : ……………WIB

I. IDENTITAS
Nama : ……………………………… Tgl.MRS : ………………….
Umur : ……………………………… No. Reg : ...........................
Jenis Kelamin : ……………………………… Diagnosa : ...........................
Suku/Bangsa : ………………………………
Agama : ………………………………
Pekerjaan : ………………………………
Pendidikan : ............................................
Alamat : ………………………………
Ditanggung oleh : Askes/Jamkesmas/Jamsostek/Sendiri/lainnya
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II. KELUHAN UTAMA (Alasan utama yang membuat pasien berobat)

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III. RIWAYAT KESEHATAN

A. Riwayat Penyakit Sebelumnya (penyakit berat yang pernah diderita, obat-obat yang biasa
dikonsumsi, kebiasaan berobat, alergi, kebiasaan merokok atau alkohol, operasi yang pernah
dilakukan yang tidak berkaitan dengan penyakit sekarang)
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B. Riwayat Penyakit Sekarang (mulai kapan sakitnya, upaya apa yang telah dilakukan, bagaimana
hasilnya) :
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C. Riwayat Kesehatan Keluarga (penyakit yang pernah dan sedang diderita oleh anggota keluarga)
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Akademi Keperawatan Pemerintah Kabupaten Kotawarigin Timur 2014

GENOGRAM (3 Generasi dan sebutkan penyakit yang diderita setiap anggota keluarga)
Keterangan Genogram

IV. WAWANCARA, OBSERVASI DAN PEMERIKSAAN FISIK

Keadaan Umum :( tingkat kesadaran, kelemahan, cara berjalan, dll)
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Tanda-tanda vital : TD : mmHg; N : x/menit

RR : x/menit T : °C

Sistem tubuh (B6)

1. Pernapasan (breathing/B1)
Data objektif : (frekuensi nafas, irama nafas, suara nafas, upaya bernafas (apakah otot
Bantu pernafasan), bentuk dada, retraksi dada, nafas cuping hidung, dan
Lain-lain)
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Data subjektif : (keluhan pasien yang terkait dengan pernafasan)
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Masalah keperawatan : ………………………………………………………………………………..
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2. Kardiovaskuler (bleeding / B2)

Data objektif : (suara jantung, apakah ada edema sebutkan lokasinya, dan lain-lain)
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Akademi Keperawatan Pemerintah Kabupaten Kotawarigin Timur 2014

Data subjektif : (keluhan pasien yang terkait dengan sistem kariovaskuler)

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Masalah keperawatan : ………………………………………………………………………………..
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3. Persayarafan (brain / B3)
Data objektif lain : (kesadaran, GCS dan sebutkan nilai totalnya, mata (sclera, conjungtiva, dan
pupilnya bagaimana), apakah ada kekakuan pada leher, refleks, pendengaran
kiri dan kanan, penciuman, pengecapan, penglihatan, perabaan dan lain-lain)
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Data subjektif :(keluhan pasien yang terkait sistem persyarafan)

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Masalah keperawatan : ………………………………………………………………………………..

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4. Eliminasi urin (bladder/B4)

 Karakteristik urin :
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Data objektif lain :(poduksi urine (ml), frekuensi BAK/hari,warna dan bau urine, apakah
terpasang kateter, dan lainnya sebutkan)
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 Data subjektif : (keluhan pasien yang terkait dengan sistem eliminasi urin)
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Masalah keperawatan : ………………………………………………………………………………..
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Akademi Keperawatan Pemerintah Kabupaten Kotawarigin Timur 2014

5. Eliminasi alvi (bowel/B5)

Data objektif :(abdomen (inspeksi, palpasi, auskultasi, perkusi), BAB /hari (konsistensi feces,
warna, bau) diet, dan lain-lain)

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Data subjektif : (keluhan pasien yang terkait dengan sistem eliminasi alvi)
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Masalah keperawatan : ………………………………………………………………………………..
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6. Tulang-otot-integument (bone/B6)
Data objektif : (kemampuan pergerakan sendi, kemampuan pergerakan sendi, extremitas atas dan
extremitas bawah, warna kulit, Akral, turgor kulit)
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Data subjektif : (keluhan pasien yang terkait dengan sistem tulang-otot-integumen)
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Masalah keperawata:………………………………………………………………………………...............
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V. POLA FUNGSI KESEHATAN
1. Aktivitas dan Istirahat
Data objektif :(Tidur siang ada/tidak(berapa lama),tidur malam(jam berapa)ada
penurunan aktivitas/tidak,merasa cepat lelah/tidak,suka terbangun tengah malam/susah
tidur/tidak, apakah tampak lingkar hitam pada mata, apakah tampak sering
menguap/tidak).
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Data Subjektif :(keluhan pasien yang terkait dengan pola aktivitas dan istirahat)
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Masalah keperawata:………………………………………………………………………………..
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Akademi Keperawatan Pemerintah Kabupaten Kotawarigin Timur 2014

2. Keadaan nutrisi dan pencernaan

Data objektif lain : (Nafsu makan menurun/tidak(berapa kali sehari,porsi),suka makan
makanan tambahan/tidak(kue,buah-buahan),suka makan sayur/tidak,suka minum
susu/tidak,sering minum air putih/tidak, terpasang infus/tidak, terpasang NGT/tidak)
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Data subjektif :(keluhan pasien yang terkait dengan keadaan nutrisi dan pencernaan)
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Masalah keperawatan : ..................................

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3. Cairan tubuh
Data objektif :

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Data subjektif :( keluhan pasien yang terkait dengan cairan tubuh)
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Masalah keperawatan :
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Akademi Keperawatan Pemerintah Kabupaten Kotawarigin Timur 2014

4. Psikososial-Spiritual
Data objektif :( Hubungan dengan keluarga baik/tidak,suka berinteraksi dengan
lingkungan sekitar/tidak,sering ikut acara-acara di lingkungan tempat tinggal/tidak, Ketaatan
dalam menjalankan ibadah berkurang/tetap,menjalankan shalat terhambat/tidak,suka baca-
baca buku keagamaan/tidak)
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Data subjektif :(keluhan pasien yang terkait dengan psikososial-spritual)
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Masalah keperawatan : …………………………………………………………………………….....
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VI. DATA PENUNJANG (Laboratorium, USG, Rontgen, dll)
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Therapy yang diberikan :
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Sampit, …………………………..
Tanda tangan mahasiswa

( …………………………………. )
NIM :

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Akademi Keperawatan Pemerintah Kabupaten Kotawarigin Timur 2014