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Jumat, 16 Maret 2012

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































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