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