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

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TANGGAL............s/d..........

A. PENGKAJIAN
1. IDENTITAS
PASIEN
Nama : …………………………....
Umur : ………...…...…………......
Jenis kelamin : .......................................
Pendidikan : .......................................
Pekerjaan : .......................................
Status perkawinan : .......................................
Agama : .......................................
Suku : .......................................
Alamat : .......................................
Tanggal masuk : .......................................
Tanggal pengkajian : .......................................
Sumber informasi : .......................................

PENANGGUNG
Nama penanggung jawab : .......................................
Hub dgn pasien : .......................................

2. STATUS KESEHATAN
a. Status Kesehatan Saat Ini
 Keluhan utama
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  Alasan masuk Rumah Sakit
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 Riwayat Penyakit Sekarang
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b. Status Kesehatan Masa Lalu

 Riwayat Kesehatan Masa Lalu
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 Riwayat Kesehatan Keluarga
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 Riwayat Alergi
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  Kebiasaan :(merokok/kopi/ alkohol/lain-lain yang merugikan
kesehatan)
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c. Diagnosa Medis dan therapy

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3. 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
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain
dan alat, 4: tergantung total.
Okigenasi:
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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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4. PEMERIKSAAN FISIK
a. Keadaan umum :..........................
Tingkat kesadaran : komposmentis/ apatis/ somnolen/ sopor/ koma
GCS : verbal :_______ psikomotor :______
mata:_______
b. Tanda-tanda vital : Nadi :_____Temp: _____ RR :______TD
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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) Ekremitas
 Atas
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 Bawah
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5. PEMERIKSAAN PENUNJANG
a. Data laboratorium yang berhubungan
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B. DIAGNOSA KEPERAWATAN
1. .................................................................................................................
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Lembar Pengesahan

Denpasar,..........................2018

Mengetahui,
Clinical Instructure/CI Mahasiswa,

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NIP. NIM.

Mengetahui,
Pembimbing Akademik

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NIP