FORMAT
PENGKAJIAN HENDERSON
FORMAT LAPORAN ASUHAN
KEPERAWATAN
BERDASARKAN
FORMAT HENDERSON
ASUHAN KEPERAWATAN PADA
........................................
DENGAN DIAGNOSA 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 :
............................................................................................
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
(Sesuai dengan
patofisiologi)
|
MASALAH
|
|
|
|
· DAFTAR DIAGNOSA KEPERAWATAN /MASALAH KOLABORATIF
BERDASARKAN PRIORITAS
NO
|
TANGGAL / JAM DITEMUKAN
|
DIAGNOSA KEPERAWATAN
|
TANGGAL
TERATASI
|
Ttd
|
|
· RENCANA TINDAKAN KEPERAWATAN
Hari/
Tgl
|
No Dx
|
Rencana Perawatan
|
Ttd
|
||
Tujuan dan Kriteria Hasil
|
Intervensi
|
Rasional
|
|||
|
|
|
|
|
· IMPLEMENTASI KEPERAWATAN
Hari/ Tgl/Jam
|
No Dx
|
Tindakan Keperawatan
|
Evaluasi proses
|
Ttd
|
|
|
· Evaluasi Keperawatan
No
|
Hari/Tgl
jam
|
No Dx
|
Evaluasi
|
TTd
|
|
|
Tidak ada komentar:
Posting Komentar