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FORMAT LAPORAN ASUHAN KEPERAWATAN

BERDASARKAN FORMAT HENDERSON

1. PENGKAJIAN

a. Identitas Pasien

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

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

Agama : .........................................................................................

Jenis Kelamin : ...........................................................................................

Status : ...........................................................................................

Pendidikan :............................................................................................

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

Suku Bangsa :............................................................................................

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

Tanggal Masuk : ...........................................................................................

Tanggal Pengkajian : ...........................................................................................

No. Register : .............................................................................................

Diagnosa Medis : ............................................................................................

b. Identitas Penan!n Ja"ab

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

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

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

Agama : .........................................................................................

Jenis Kelamin : ...........................................................................................

Status : ...........................................................................................

Pendidikan :............................................................................................

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

Suku Bangsa :............................................................................................

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#. Stat!s Kese$atan

a. Stat!s Kese$atan Saat Ini

1 Kelu!an Utama "Saat MRS dan saat ini

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

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

# U$a%a %ang dilakukan untuk mengatasin%a

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

b. Sat!s Kese$atan Masa La%!

1 Pen%akit %ang $erna! dialami

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

Perna! dira&at

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

Alergi

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

# Ke'iasaan "merokok(ko$i(alko!ol dll

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

) Ri&a%at Pen%akit Keluarga

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

* Diagnosa Medis dan t!era$%

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

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

a. Pola Berna$as Se'elum sakit

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

Saat sakit

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

'. Pola makan+minum

Se'elum sakit :

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

Saat sakit :

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i. Pola Ke'ersi!an Diri

Se'elum sakit :

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

Saat sakit :

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

j. Pola Komunikasi

Se'elum sakit :

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

Saat sakit :

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

k. Pola Beri'ada!

Se'elum sakit :

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

Saat sakit :

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

l. Pola Produkti/itas

Se'elum sakit :

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

Saat sakit :

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

m. Pola Rekreasi

Se'elum sakit :

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

Saat sakit :

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

n. Pola Ke'utu!an Belajar

Se'elum sakit :

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

Saat sakit :

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

. Pen,a/ian Fisi,

a. Keadaan umum :

Tingkat kesadaran : kom$osmetis ( a$atis ( somnolen ( so$or(koma

0S : er'al:222.Psikomotor:222.Mata :22222..'. Tanda+tanda 3ital : Nadi 4 2225 Su!u 4 2222.5 TD 42225 RR 4222

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,. Keadaan /isik

1 Ke$ala dan le!er :

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

.

# Dada : Paru

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

Jantung

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

) Pa%udara dan ketiak :

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

* A'domen :

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

6 0enetalia :

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

7 8ntegumen :

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

9 -kstremitas :

Atas

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

Ba&a!

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

Neurologis :

Status mental dan emosi :

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

Pengkajian sara/ kranial :

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

Pemeriksaan re/leks :

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

d. Pemeriksaan Penunjang

1 Data la'oratorium %ang 'er!u'ungan

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

# Pemeriksaan radiologi

.......................................................................................................................................) ;asil konsultasi

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

* Pemeriksaan $enunjang diagnosti, lain

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