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

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DI RUANG..............................................................
TANGGAL...................................................

Identitas Pasien
Nama : ....................................................................................................
No. RM : ....................................................................................................
Umur : ....................................................................................................
Jenis Kelamin : ....................................................................................................
Pekerjaan : ....................................................................................................
Agama : ....................................................................................................
Status : ....................................................................................................
Tanggal MRS : ....................................................................................................
Tanggal Pengkajian : ....................................................................................................

A. ALASAN DIRAWAT
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B. RIWAYAT KESEHATAN
1. Riwayat Kesehatan Dahulu (RKD) :
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2. Riwayat Kesehatan Sekarang (RKS) :
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3. Riwayat Kesehatan Keluarga (RKK) :
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C. POLA FUNGSI KESEHATAN (11 Pola Fungsional Gordon)

a. Pemeliharaan dan persepsi terhadap kesehatan

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b. Pola nutrisi/ metabolic

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c. Pola eliminasi
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d. Pola aktivitas dan latihan

Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulansi ROM
0 : mandiri, 1 : alat bantu, 2 : dibantu orang lain, 3 : dibantu orang lain dan alat, 4 :
tergantung total
 Oksigenasi :
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e. Pola tidur dan istirahat

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f. Pola kognitif-perseptual
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g. Pola persepsi diri/ konsep diri

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h. Pola seksual dan reproduksi

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i. Pola peran-hubungan
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j. Pola manajemen koping stress
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k. Pola keyakinan-nilai
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D. PEMERIKSAAN FISIK
a. Keadaan umum : ..........................
Tingkat kesadaran : komposmentis/ apatis/ somnolen/ sopor/ koma
GCS : mata:.............. verbal :............ psikomotor :............

b. Tanda-tanda vital :
Tekanan darah : ..............
Nadi : .................
Respirasi : ......................
Suhu : ............

c. Keadaan fisik (IPPA)

1) Kepala dan leher
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2) Dada
 Paru
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 Jantung
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3) Payudara dan ketiak

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4) Abdomen
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5) Genetalia
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6) Integumen
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7) Ekstremitas
 Atas
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 Bawah
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 E. PEMERIKSAAN PENUNJANG
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F. FISIOLOGI SDKI
G. ANALISA DATA
No. Hari,tanggal,
Jam Data Fokus Etiologi Masalah Keperawatan
 H. DIAGNOSA KEPERAWATAN

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I. PERENCANAAN/INTERVENSI
Hari,tanggal, DX.
jam Keperawatan TujuanNOC Intervensi NIC Rasional
J. PELAKSANAAN/ IMPLEMENTASI
No. Hari, tanggal, No.
Implementasi Evaluasi TTD
jam Dx
K. EVALUASI
No. Hari,tanggal, No.
jam Dx EvaluasiSumatif TTD
LEMBAR PENGESAHAN

Mengetahui, Denpasar,..................
Pembimbing Praktik Mahasiswa

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NIP............................................. NIM.............................................

Mengetahui,
PembimbingAkademik

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NIP....................................................