FORMAT LAPORAN ASUHAN KEPERAWATAN

BERDASARKAN FORMAT HENDERSON

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

DENGAN DIAGNOSA MEDIS ...........................................................
DENGAN DIAGNOSA KEPERAWATAN..........................................
DI RUANG …………………..
TANGGAL…………………………………………………………………………

 PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama : ..................................................................................
Umur : ..................................................................................
Agama : ....................................................................................
Jenis Kelamin :......................................................................................
Status : ...........................................................................................
Pendidikan :............................................................................................
Pekerjaan : ............................................................................................
Suku Bangsa :............................................................................................
Alamat : ..........................................................................................
Tanggal Masuk : ...........................................................................................
Tanggal Pengkajian : ...........................................................................................
No. Register : .............................................................................................
Diagnosa Medis : ............................................................................................

b. Identitas Penanggung Jawab

Nama :
............................................................................................
Umur :
.............................................................................................
Hub. Dengan Pasien : ...........................................................................................
Pekerjaan : .............................................................................................
Alamat : ..............................................................................................
2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
Saat MRS :..........................................................................................................
Saat ini : ..........................................................................................................

2) Upaya yang dilakukan untuk mengatasinya

...........................................................................................................................

b. Satus Kesehatan Masa Lalu

1) Penyakit yang pernah dialami
...........................................................................................................................
Pernah dirawat
...........................................................................................................................
Alergi
...........................................................................................................................
2) Kebiasaan (merokok/kopi/alkohol dll)
...........................................................................................................................

3) Riwayat Penyakit Keluarga

...........................................................................................................................

4) Diagnosa Medis dan therapy

...........................................................................................................................

3. Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)

a. Pola Bernapas
 Sebelum sakit
...........................................................................................................................
 Saat sakit
...........................................................................................................................
b. Pola makan-minum
 Sebelum sakit :
...........................................................................................................................
 Saat sakit :
...........................................................................................................................
c. Pola Eliminasi
 Sebelum sakit :
...........................................................................................................................
  Saat sakit :
..........................................................................................................................
d. Pola aktivitas dan latihan
 Sebelum sakit :
...........................................................................................................................
 Saat sakit :
...........................................................................................................................
e. Pola istirahat dan tidur
 Sebelum sakit :
...........................................................................................................................
 Saat sakit :
...........................................................................................................................
f. Pola Berpakaian
 Sebelum sakit :
...........................................................................................................................
 Saat sakit :
...........................................................................................................................
g. Pola rasa nyaman
 Sebelum sakit :
...........................................................................................................................
 Saat sakit :
...........................................................................................................................
h. Pola Aman
 Sebelum sakit :
...........................................................................................................................
 Saat sakit :
...........................................................................................................................
i. Pola Kebersihan Diri
 Sebelum sakit :
...........................................................................................................................
  Saat sakit :
...........................................................................................................................
j. Pola Komunikasi
 Sebelum sakit :
...........................................................................................................................
 Saat sakit :
...........................................................................................................................
k. Pola Beribadah
 Sebelum sakit :
...........................................................................................................................
 Saat sakit :
...........................................................................................................................
l. Pola Produktifitas
 Sebelum sakit :
...........................................................................................................................
 Saat sakit :
...........................................................................................................................
m. Pola Rekreasi
 Sebelum sakit :
...........................................................................................................................
 Saat sakit :
...........................................................................................................................
n. Pola Kebutuhan Belajar
 Sebelum sakit :
.................................................................................................................................
 Saat sakit :
...........................................................................................................................
 4. Pengkajian Fisik
a. Keadaan umum :
Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma
GCS : verbal:……….Psikomotor:……….Mata :……………..
b. Tanda-tanda Vital : Nadi = ……, Suhu = …………., TD =………, RR =………
c. Keadaan fisik
1) Kepala dan leher :

....................................................................................................................................
2) Dada :
 Paru

....................................................................................................................................
 Jantung

....................................................................................................................................

3) Payudara dan ketiak :

....................................................................................................................................
4) Abdomen :

....................................................................................................................................
5) Genetalia :

....................................................................................................................................
6) Integumen :

....................................................................................................................................
7) Ekstremitas :

 Atas

................................................................................................................................
 Bawah

....................................................................................................................................
8) Neurologis :

 Status mental dan emosi :

....................................................................................................................................
 Pengkajian saraf kranial :
....................................................................................................................................
  Pemeriksaan refleks :
....................................................................................................................................

d. Pemeriksaan Penunjang
1) Data laboratorium yang berhubungan

....................................................................................................................................
2) Pemeriksaan radiologi

....................................................................................................................................
3) Hasil konsultasi

....................................................................................................................................
4) Pemeriksaan penunjang diagnostic lain

....................................................................................................................................
5. ANALISA DATA
DATA INTERPRETASI MASALAH
(Sesuai dengan
patofisiologi)
 DAFTAR DIAGNOSA KEPERAWATAN /MASALAH KOLABORATIF BERDASARKAN PRIORITAS

TANGGAL / JAM TANGGAL

NO DIAGNOSA KEPERAWATAN Ttd
DITEMUKAN TERATASI
 RENCANA TINDAKAN KEPERAWATAN
Rencana Perawatan Ttd
Hari/
No Dx
Tgl Tujuan dan Kriteria Hasil Intervensi
 IMPLEMENTASI KEPERAWATAN

No Jam Ttd
Hari/ Tgl/Jam Tindakan Keperawatan
Dx
 Evaluasi Keperawatan
Hari/Tgl
No No Dx Evaluasi TTd
jam