Format Revisi Askep.docx

ASUHAN KEPERAWATAN PADA PASIEN............ DENGAN.............................................................. DI RUANG............................ BRSU TABANAN TANGGAL..............................

I.

PENGKAJIAN

A. Identitas Pasien Nama

:

No RM

:

Umur

:

Jenis Kelamin

:

Pekerjaan

:

Agama

:

Status

:

Tanggal MRS

:

Tanggal Pengkajian : B. Keluhan Utama .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... ........................................................................................................................................ C. Riwayat Kesehatan 1. Riwayat Kesehatan Dahulu .............................................................................................................................................. .............................................................................................................................................. ...................................................................................................................................... .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. ...................................................................................................................................

2. Riwayat Kesehatan Sekarang .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. ..................................................................................................................................... 3. Riwayat Kesehatan Keluarga .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. ....................................................................................................................................

D. Fisiologis 5. Aktivitas dan Istirahat b

Gangguan Pola Tidur Gejala dan Tanda Mayor Mengeluh sulit tidur Mengeluh sering terjaga Mengeluh tidak puas tidur Mengeluh pola tidur berubah Mengeluh istirahat tidak cukup

Gejala dan Tanda Minor Mengeluh kemampuan beraktivitas menurun

II. ANALISA DATA Ruang Nama Pasien No. Register No

Data Fokus

: : : Masalah

Kemungkinan penyebab

III. DIAGNOSA KEPERAWATAN Ruang Nama Pasien No. Register

: : :

IV. INTERVENSI No

Diagnosa keperawatan

Tujuan

Intervensi

Rasional

V. IMPLEMENTASI Ruang Nama Pasien No. Register NO

TANGGAL

: : : NO DX. KEP

TINDAKAN DAN HASIL

TT

VI. EVALUASI Ruang Nama Pasien No. Register Tanggal

: : : NO. DX. Kep.

TT