ASUHAN KEPERAWATANA. PENGKAJIAN1. Biodata Pasien
Nama : …………………………………No. Reg : …………………………………Tgl. MRS : …………………………………Usia : …………………………………Jenis Kelamin : …………………………………Bangsa/Suku : …………………………………Agama : …………………………………Alamat : …………………………………Golongan Darah : …………………………………Diagnosa Medis : …………………………………
Nama Ibu : …………………………………Usia : …………………………………Agama : …………………………………Pendidikan : …………………………………Pekerjaan : …………………………………Alamat : …………………………………
Nama Ayah : …………………………………Usia : …………………………………Agama : …………………………………Pendidikan : …………………………………Pekerjaan : …………………………………Alamat : …………………………………
2. Keluhan Utama………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3. Riwayat Sekarang…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………4. Riwayat penyakit dahulu………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………5. Riwayat kesehatan keluarga
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
6. Riwayat Persalinan………………………………………………………………………………………………………………………………………………………………………………………………………………
Format askep kep. Anak unitri
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
7. POLA FUNGSI KESEHATANa. Pola Nutrisi
Dirumah: Dirumah sakit:
b. Pola EliminasiDirumah: Dirumah sakit:
c. Pola AktivitasDirumah: Dirumah sakit:
d. Pola Higiene (Kebersihan diri)Dirumah: Dirumah sakit:
e. Pola Istirahat dan tidurDirumah: Dirumah sakit:
8. Pemeriksaan Fisika. Keadaan Umum : ………………………………………………………..
………………………………………………………..Kesadaran : ………………………………………………………..
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TTV : Tensi ……………. Nadi ………….../mnt Suhu ………….oC RR ……………../mnt
BB : …………
b. Kepala – Leher :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
c. Dada :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
d. Abdomen :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
e. Ekstremitas :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
f. Genetelia – Anus :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
g. Px Neurologis :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
9. PEMERIKSAAN DIAGNOSTIK
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10. Penatalaksanaan / Therapi Medis
B. DIAGNOSA KEPERAWATAN1. Analisa Data
Nama : ………………………….Usia : ………………………….No. Reg : ………………………….
No Kelompok Data Masalah Penyebab
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2. Diagnosa Keperawatan berdasar PrioritasNama : ………………………….Usia : ………………………….No. Reg : ………………………….
No Tgl/Jam DiagnosaTgl/Jam Teratasi
TT
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Format askep kep. Anak unitri
C. INTERVENSI (RENCANA TINDAKAN)Nama : ………………………….Usia : ………………………….No. Reg : ………………………….
Tgl/Jam Dx.Kep Krit. Standart Rencana Tind Rasional TT
Veebe FILE`s FORM/ASKEP 7
Tgl/Jam Dx.Kep Krit. Standart Rencana Tind Rasional TT
Veebe FILE`s FORM/ASKEP 8
Tgl/Jam Dx.Kep Krit. Standart Rencana Tind Rasional TT
Veebe FILE`s FORM/ASKEP 9
D. IMPLEMENTASI (PELAKSANAAN)Nama : ………………………….Usia : ………………………….No. Reg : ………………………….Tgl/Jam Dx.Kep Tindakan TT
Veebe FILE`s FORM/ASKEP 10
E. EVALUASI
Nama : ………………………….Usia : ………………………….No. Reg : ………………………….Tgl/Jam Dx.Kep Evaluasi TT
Veebe FILE`s FORM/ASKEP 11
Tgl/Jam Dx.Kep Evaluasi TT
Veebe FILE`s FORM/ASKEP 12
Tgl/Jam Dx.Kep Evaluasi TT
Veebe FILE`s FORM/ASKEP 13
F. CATATAN PERKEMBANGANNama : ………………………….Usia : ………………………….No. Reg : ………………………….Tgl/Jam Dx.Kep CATATAN PERKEMBANGN TT
Veebe FILE`s FORM/ASKEP 14
Tgl/Jam Dx.Kep CATATAN PERKEMBANGN TT
Veebe FILE`s FORM/ASKEP 15
Tgl/Jam Dx.Kep CATATAN PERKEMBANGN TT
Veebe FILE`s FORM/ASKEP 16
Tgl/Jam Dx.Kep CATATAN PERKEMBANGN TT
Veebe FILE`s FORM/ASKEP 17
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