ASUHAN KEPERAWATAN PADA _________ DENGAN _________________

DI RUANG CEMPAKA 1 RSUD KARANGANYAR

Tanggal Pengambilan Data :

MRS :

Ruangan :

Reg :

DX :

I. A. Identitas Klien

Nama :

Tempat/tgl lahir :

Jenis Kelamin :

B. Identitas Orangtua Klien

Nama ayah/ibu :

Pekerjaan Ayah :

Pekerjaan Ibu :

Alamat :

Suku bangsa :

Agama :

Biaya ditanggung oleh :

II. Keluhan Utama :

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III. Riwayat Munculnya Masalah Saat Ini

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IV. Riwayat Medis Masa Lalu

1. Prenatal

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2. Natal

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3. Postnatal

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4. Penyakit yang pernah diderita

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5. Hospitalisasi/Tindakan (operasi)

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6. Obat-obatan yang digunakan

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7. Alergi

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8. Kecelakaan

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9. Imunisasi

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10. Pengobatan

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V. Riwayat Pertumbuhan

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VI. Riwayat Keluarga

a. Sosial ekonomi

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b. Penyakit keluarga

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c. Genogram
VII. Perkembangan

a. Motorik Kasar

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b. Motorik halus

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c. Bicara dan Bahasa

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d. Sosial dan kognitif

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VIII. Kesehatan Fungsional

a. Pemeliharaan dan persepsi terhadap kesehatan, pemilihan pemberi pelayanan

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b. Nutrisi

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c. Aktifitas

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d. Tidur dan istirahat

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e. Eliminasi BAK & BAB

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f. Pola Hubungan

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g. Koping

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h. Kognitif dan persepsi

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i. Konsep diri

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j. Seksual dan menstruasi

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k. Nilai/kepercayaan

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IX. Pengkajian Head To Toe Kepala

 Rambut :

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 Kulit Kepala :

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 Mata

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 Hidung

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 Mulut

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 Telinga

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 Leher

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 Dada

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 Paru

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 Jantung

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 Abdomen

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 Genetalia

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X. Pemeriksaan Diagnostik Penunjang
a. Data Lab

Pemeriksaan Hasil Satuan Nilai Rujukan

b. Terapi
 XI. Analisa Data
No Data Etiologi Masalah

XII. Diagnosa Keperawatan

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 XIII. Rencana Keperawatan
No Dx Keperawatan Tujuan dan KH Intervensi
 XIV. Implementasi

No Waktu Implementasi Evaluasi Formatif Paraf

Dx
No Waktu Implementasi Evaluasi Formatif Paraf
Dx
No Waktu Implementasi Evaluasi Formatif Paraf
Dx
No Waktu Implementasi Evaluasi Formatif Paraf
Dx
No Waktu Implementasi Evaluasi Formatif Paraf
Dx
No Waktu Implementasi Evaluasi Formatif Paraf
Dx
 XV. Evaluasi Sumatif
No Waktu Diagnosa Keperawatan Evaluasi Sumatif Paraf