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  FORMAT PENGKAJIAN HENDERSON

FORMAT LAPORAN ASUHAN KEPERAWATAN

BERDASARKAN FORMAT HENDERSON

aaaaaaaaaaaa MEDIS ...........................................................

DI ...............................................................................................

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

.  Identitas Penan!!"n! Ja#a

 Nama : ............................................................................................

Umur : .............................................................................................

Hu. Dengan Pasien : ...........................................................................................

Pekerjaan : .............................................................................................

Alamat : ..............................................................................................

$.  Stat"s Kese%atan

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a.  Stat"s Kese%atan Saat Ini

!"  Kelu#an Utama $Saat MRS dan saat ini"

Saat MRS :..........................................................................................................Saat ini : ..........................................................................................................

%"  U&a'a 'ang dilakukan untuk mengatasin'a...........................................................................................................................

.  Sat"s Kese%atan Masa La&"

!"  Pen'akit 'ang &erna# dialami

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

Perna# dira(at...........................................................................................................................

Alergi

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

%" 

Keiasaan $merokok)ko&i)alko#ol dll"...........................................................................................................................

*"  Ri(a'at Pen'akit Keluarga

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

+"  Diagnosa Medis dan t#era&'

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

'.  P(&a Ke"t"%an Dasa) * Data Bi(+,si-(+s(si(+-"&t")a&+s,i)it"a&

a.  Pola Berna&as

•  Seelum sakit

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

•  Saat sakit

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

 .  Pola makan,minum

•  Seelum sakit :

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

•  Saat sakit :...........................................................................................................................

-.  Pola liminasi

•  Seelum sakit :

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

•  Saat sakit :

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

d.  Pola akti/itas dan lati#an

•  Seelum sakit :

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

•  Saat sakit :

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

e.  Pola istira#at dan tidur

•  Seelum sakit :

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

•  Saat sakit :

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

0.  Pola Ber&akaian

•  Seelum sakit :

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

•  Saat sakit :

...........................................................................................................................g.  Pola rasa n'aman

•  Seelum sakit :

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

•  Saat sakit :

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

#.  Pola Aman

•  Seelum sakit :

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

•  Saat sakit :

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

i.  Pola Keersi#an Diri

•  Seelum sakit :

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

•  Saat sakit :

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

 j.  Pola Komunikasi

•  Seelum sakit :

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

•  Saat sakit :

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

k.  Pola Beriada#

•  Seelum sakit :

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

•  Saat sakit :

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

l.  Pola Produkti0itas

•  Seelum sakit :

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

•  Saat sakit :

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

m.  Pola Rekreasi

•  Seelum sakit :

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

•  Saat sakit :

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

n.  Pola Keutu#an Belajar 

•  Seelum sakit :

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

•  Saat sakit :

  .........................................................................................................................../.  Pen!-a0ian Fisi- 

a.  Keadaan umum :

Tingkat kesadaran : kom&osmetis ) a&atis ) somnolen ) so&or)koma

12S : /eral:333.Psikomotor:333.Mata :33333..

 .  Tanda,tanda 4ital : Nadi 5 3336 Su#u 5 3333.6 TD 53336 RR 5333

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-.  Keadaan 0isik

!"  Ke&ala dan le#er :........................................................................................................................................

%"  Dada :

•  Paru

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

•  Jantung

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

*"  Pa'udara dan ketiak :

.............................................................................................................................................+"  Adomen :

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

7"  1enetalia :........................................................................................................................................

8"  9ntegumen :

............................................................................................................................................."  kstremitas :

•  Atas

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

•  Ba(a#

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

;"   Neurologis :

•  Status mental dan emosi :

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

•  Pengkajian sara0 kranial :

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

•  Pemeriksaan re0leks :.........................................................................................................................................

d.  Pemeriksaan Penunjang

!"  Data laoratorium 'ang er#uungan

.............................................................................................................................................%"  Pemeriksaan radiologi

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

*"  Hasil konsultasi........................................................... . . . .. . .