Format Asuhan Keperawatan Puskesmas.docx

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ASUHAN KEPERAWATAN PADA .. .…… DI PUSKESMAS SITIUNG II KAB. DHARMASRAYA : ……… : ………………….

Tgl pengkajian Diagnosa medis A. Pengkajian 1. Identitas pasien Nama

:

Umur

:

Agama

:

Jenis kelamin Alamat

: :

Suku / bangsa : Pekerjaan

:

Status

:

2. Riwayat kesehatan a. Riwayat kesehatan sekarang

b. Riwayat kesehatan dahulu

c. Riwayat kesehatan keluarga

B. Pemeriksaan fisik 1. Penampakan umum Keadaan umum: Kesadaran

:

GCS

:

BB

:

kg

TB:

TD

:

mmHg

Suhu :

cm ºC

RR :

x/mnt

Nadi :

x/mnt

C. Data penunjang

D. Data fokus Data subyektif

Data obyektif

E. Analisa data Symtom

Etiologi

Problem

F. Diagnosa keperawatan dan prioritas masalah 1. ……….......................................................................................................... 2. ...................................................................................................................... 3. ……………………………………………………………………………..

G. TUJUAN

H. Perencanaan dan Implementasi Hr Tgl

no dx

intervensi

Implementasi

Ttd

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