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Nama/NIM : ………………………………………………….Kelompok : ………………………………………………….Ruangan : ………………………………………………….Tanggal Praktik : …………………………… Tanggal Pengkajian : …………….….

A. Identitas Pasien Nama : ……………………. Suku : …………………….Umur : ……………………. Agama : …………………….Jenis Kelamin : Laki / Perempuan Tgl.MRS : …………………….Pendidikan : ……………………. No.RMK : …………………….Alamat : …………………….

…………………….Dx.Medis : …………………….

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B. Riwayat Penyakit Keluhan Utama

…………………………………………………………………………………………………...…………………………………………………………………………………………………...

Riwayat Penyakit Sekarang

…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...

Riwayat Penyakit Dahulu

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Riwayat Penyakit Keluarga…………………………………………………………………………………………………...…………………………………………………………………………………………………...…………………………………………………………………………………………………...C. Pemeriksaan Fisik

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Tanda-tanda VitalTD = mmHgN = x/mR = x/mT = 0C

Pengkajian Head to ToeKeadaan Umum ……………………………………………………………………

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Kepala dan Rambut ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Mata ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………….

Hidung …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………..

Telinga ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Mulut dan Gigi ……………………………………………………………………

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Leher ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Thoraks/ Fungsi Pernafasan

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Abdomen ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Genetalia ……………………………………………………………………

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Ekstrimitas …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Intergumen ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Jantung …………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

DATA PENUNJANG

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PROGRAM STUDI ILMU KEPERAWATAN

UNIVERSITAS LAMBUNG MANGKURAT

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FORMAT ASUHAN KEPERAWATAN

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PROGRAM STUDI ILMU KEPERAWATAN

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ANALISIS DATA

No. Data Penyebab Masalah

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……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

FORMAT ASUHAN KEPERAWATAN

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PROGRAM STUDI ILMU KEPERAWATAN

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…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

FORMAT ASUHAN KEPERAWATAN

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PROGRAM STUDI ILMU KEPERAWATAN

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FORMAT ASUHAN KEPERAWATAN

KRITIS DAN GAWAT DARURAT

PROGRAM STUDI ILMU KEPERAWATAN

UNIVERSITAS LAMBUNG MANGKURAT

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FORMAT ASUHAN KEPERAWATAN

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PRIORITAS MASALAH

No. Masalah KeperawatanTanggal Paraf

(nama perawat)Ditemukan Teratasi

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FORMAT ASUHAN KEPERAWATAN

KRITIS DAN GAWAT DARURAT

PROGRAM STUDI ILMU KEPERAWATAN

UNIVERSITAS LAMBUNG MANGKURAT

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