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STIKES RS. BAPTIS KEDIRI PROGRAM PENDIDIKAN PROFESI NERS PROGRAM PROFESI FORMAT ASUHAN KEPERAWATAN NAMA MAHASISWA



: …………………………………………



NIM



: …………………………………………



RUANG



: ………………………………………...



TANGGAL



: ………………………………………....



1.



BIODATA : Nama Umur Jenis Kelamin Agama Alamat Pendidikan Pekerjaan Tanggal MRS Tanggal Pengkajian Golongan Darah



: ……………………………………………….No.Reg…………… : …………………………………………………………………… : …………………………………………………………………… : …………………………………………………………………… : …………………………………………………………………… : …………………………………………………………………… : …………………………………………………………………… ……………………………………………………………………… : …………………………………………………………………… : ……………………………………………………………………



2.



KELUHAN UTAMA ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... .......................................................................................................................................................



3.



RIWAYAT PENYAKIT SEKARANG ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... .......................................................................................................................................................



4.



RIWAYAT PENYAKIT MASA LALU ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... .........................................................................................................................................................



5.



RIWAYAT KESEHATAN KELUARGA ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... .........................................................................................................................................................



6.



RIWAYAT PSIKO SOSIAL DAN SPIRITUAL ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................



7. POLA AKTIFITAS SEHARI – HARI ( Makan, istirahat, tidur, eliminasi, aktifitas, kebersihan dan seksual ) ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ 8. KEADAAN/PENAMPILAN/KESAN UMUM PASIEN ............................................................................................................................................................ …........................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ ............................................................................................................................................................ 9. TANDA-TANDA VITAL Suhu Tubuh : ……………………………ºC Denyut Nadi : ……………………………x/menit Tekanan Darah : ……………………………mmHg Pernafasan :……………………………x/menit TT / TB : ……………………………Kg, …………….cm 10.PEMERIKSAAN FISIK A. Pemeriksaan Kepala dan Leher ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... B. Pemeriksaan Integumen Kulit dan Kuku : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... C. Pemeriksaan Payudara dan Ketiak ( Bila diperlukan ): ............................................................................................................................................... ............................................................................................................................................... D. Pemeriksaan Dada /Thorak Inspeksi Thorax :.................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. Paru :..................................................................................................................................... .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. E. Pemeriksaan Jantung : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................



F. Pemeriksaan Abdomen : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... G. Pemeriksaan Kelamin dan daerah sekitarnya ( bila diperlukan ): Genetalis :.............................................................................................................................. ............................................................................................................................................... ............................................................................................................................................... Anus :................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... H. Pemeriksaan Muskuloskeletal : ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ H. Pemeriksaan Neurologi : ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ J. Pemeriksaan Status Mental : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... 11. Pemeriksaan Penunjang Medis : ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... 12. Pelaksanaan / Therapi : ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... 13. Harapan Klien / Keluarga sehubungan dengan penyakitnya : ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... Kediri , ………………………. Tanda Tangan Mahasiswa,



ANALISA DATA NAMA PASIEN



: ..............................................................



UMUR



: ..............................................................



NO. REGISTER



: ...............................................................



DATA OBYEKTIF (DO) DATA SUBYEKTIF (DS) (S)



FAKTOR YANG BERHUBUNGAN/RISIKO (E)



MASALAH KEPERAWATAN (P)



DAFTAR DIAGNOSA KEPERAWATAN NAMA PASIEN : ............................................................... UMUR : .............................................................. NO. REGISTER : .............................................................. NO



TANGGAL MUNCUL



DIAGNOSA KEPERAWATAN (SDKI)



TANGGAL TERATASI



TANDA TANGAN



RENCANA ASUHAN KEPERAWATAN NAMA PASIEN



:



UMUR



:



NO REGISTER



:



DIAGNOSA KEPERAWATAN : 1. SLKI a. b. c. d. e. f. g. h. i. j. k.



Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada



2. SLKI : a. b. c. d. e. f. g. h. i. j. k. l. 3. SLKI :



Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada



a. b. c. d. e. f. g. h. i. j. k.



Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada Dipertahankan/ditingkatkan pada



Keterangan : (dipertahankan/ditingkatkan) coret salah satu



RENCANA ASUHAN KEPERAWATAN NAMA PASIEN UMUR NO.REGISTER NO



: .............................................................. : ............................................................... : .............................................................



DIAGNOSA KEPERAWATAN (SDKI)



TUJUAN DAN KRITERIA LUARAN (SLKI)



INTERVENSI (SIKI)



TTD



TINDAKAN KEPERAWATAN NAMA PASIEN UMUR NO.REGISTER NO



NO.DX



: .............................................................. : ............................................................... : ............................................................. TGL/JAM



TINDAKAN KEPERAWATAN (SIKI)



TANDA TANGAN



CATATAN PERKEMBANGAN NAMA PASIEN UMUR TANGGAL NO



NO.DX



: .............................................................. : ...............................................................tahun / bulan : ............................................................... JAM



EVALUASI