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ASUHAN KEPERAWATAN PADA …………… DENGAN DIAGNOSA MEDIS …………………………………………… DI ……………………………………………… TANGGAL………………………………. A. PENGKAJI AN 1. Data Umum Identitas Kien Nama : …………………………………………………………………… Umur : …………………………………………………………………… Agama : …………………………………………………………………… Jenis kelamin : …………………………………………………………………… Sta tus Mari tal : …………………………………………………………………… Pendidikan : …………………………………………………………………… Pekerjaan : …………………………………………………………………… Suk u Ban gsa : …………………………………………………………………… Alamat : …………………………………………………………………… Tangga l MRS : …………………………………………………………………… Ta nggal Pengkajian : …………………………………………………………………… No. Register : …………………………………………………………………… Diagnosa Medis : …………………………………………………………………… Identitas Penan!!un! Ja"a# Nama : …………………………………………………………………… Umur : …………………………………………………………………… Hu. Dengan !lien : …………………………………………………………………… Pekerjaan : …………………………………………………………………… Alamat : …………………………………………………………………… $. Ri "a %at Kese &a ta n Keu&an Utama ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………
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Transcript of Format Askep KMB
ASUHAN KEPERAWATAN PADA DENGAN DIAGNOSA MEDIS DI TANGGAL.
A. PENGKAJIAN1. Data UmumIdentitas KlienNama : Umur : Agama : Jenis kelamin : Status Marital : Pendidikan : Pekerjaan : Suku Bangsa : Alamat : Tanggal MRS : Tanggal Pengkajian : No. Register : Diagnosa Medis :
Identitas Penanggung JawabNama : Umur : Hub. Dengan Klien : Pekerjaan : Alamat :
2. Riwayat KesehatanKeluhan UtamaRiwayat Penyakit SekarangRiwayat Kesehatan Dahulu
Genogram
Riwayat Sosiokultural
3. Pola Fungsi Kesehatan Gordona. Pola Persepsi dan Manajemen Kesehatanb. Pola Nutrisi-MetabolikSebelum sakit :Saat sakit :
c. Pola EliminasiSebelum sakit:Saat Sakit :d. Pola Aktivitas dan Latihan1) AktivitasKemampuan Perawatan diri01234
Makan dan Minum
Mandi
Toileting
Berpakian
Berpindah
0: Mandiri, 1: Alat Bantu, 2: Dibantu orang lain, 3: Dibantu orang lain dan alat, 4: tergantung total
2) LatihanSebelum Sakit:Saat Sakit :.e. Pola Kognitif dan Persepsif. Pola Persepsi-Konsep Diri.
g. Pola Tidur dan IstirahatSebelum Sakit :Saat Sakit :h. Pola Peran-HubunganSebelum Sakit:Saat Sakit :i. Pola Seksual-ReproduksiPola Toleransi Stress-KopingSebelum Sakit:Saat sakit:j. Pola Nilai Kepercayaan4. Pemeriksaan Fisika. Keadaan umum : .Tingkat Kesadaran : .GCS (Glassalow Coma Scale ) : b. Tanda-Tanda VitalTD : mm/Hg RR : x/mnt, N : x/mnt, S : Cc. Kepala :d. MataHidungTelingae. Mulutf. LeherDada dan Punggungg. Abdomen
EkstremitasGenetaliah. Anus
5. Data Penunjang
6. Data Tambahan............................7. Therapy............................B. ANALISA DATANo.DataEtiologiMasalah Kolaboratif/ Keperawatan
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No.DataEtiologiMasalah Kolaboratif/ Keperawatan
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DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS:
C. PERENCANAANNO.DIAGNOSATUJUANINTERVENSIRASIONAL
NO.DIAGNOSATUJUANINTERVENSIRASIONAL
NO.DIAGNOSATUJUANINTERVENSIRASIONAL
D. IMPLEMENTASIHari/Tgl/JamNo. DxTindakan KeperawatanEvaluasiTtd
Hari/Tgl/JamNo. DxTindakan KeperawatanEvaluasiTtd
Hari/Tgl/JamNo. DxTindakan KeperawatanEvaluasiTtd
E. EVALUASINoHari/TglNo.DxEvaluasiTtd
