format pengkajian henderson sitong nitip
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8/19/2019 Format Pengkajian Henderson Sitong Nitip
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FORMAT PENGKAJIAN HENDERSON
FORMAT LAPORAN ASUHAN KEPERAWATAN
BERDASARKAN FORMAT HENDERSON
aaaaaaaaaaaa 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 : ............................................................................................
. Identitas Penan!!"n! Ja#a
Nama : ............................................................................................
Umur : .............................................................................................
Hu. Dengan Pasien : ...........................................................................................
Pekerjaan : .............................................................................................
Alamat : ..............................................................................................
$. Stat"s Kese%atan
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a. Stat"s Kese%atan Saat Ini
!" Kelu#an Utama $Saat MRS dan saat ini"
Saat MRS :..........................................................................................................Saat ini : ..........................................................................................................
%" U&a'a 'ang dilakukan untuk mengatasin'a...........................................................................................................................
. Sat"s Kese%atan Masa La&"
!" Pen'akit 'ang &erna# dialami
...........................................................................................................................
Perna# dira(at...........................................................................................................................
Alergi
...........................................................................................................................
%"
Keiasaan $merokok)ko&i)alko#ol dll"...........................................................................................................................
*" Ri(a'at Pen'akit Keluarga
...........................................................................................................................
+" Diagnosa Medis dan t#era&'
...........................................................................................................................
'. P(&a Ke"t"%an Dasa) * Data Bi(+,si-(+s(si(+-"&t")a&+s,i)it"a&
a. Pola Berna&as
• Seelum sakit
...........................................................................................................................
• Saat sakit
...........................................................................................................................
. Pola makan,minum
• Seelum sakit :
...........................................................................................................................
• Saat sakit :...........................................................................................................................
-. Pola liminasi
• Seelum sakit :
...........................................................................................................................
• Saat sakit :
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...........................................................................................................................
d. Pola akti/itas dan lati#an
• Seelum sakit :
...........................................................................................................................
• Saat sakit :
...........................................................................................................................
e. Pola istira#at dan tidur
• Seelum sakit :
...........................................................................................................................
• Saat sakit :
...........................................................................................................................
0. Pola Ber&akaian
• Seelum sakit :
...........................................................................................................................
• Saat sakit :
...........................................................................................................................g. Pola rasa n'aman
• Seelum sakit :
...........................................................................................................................
• Saat sakit :
...........................................................................................................................
#. Pola Aman
• Seelum sakit :
...........................................................................................................................
• Saat sakit :
...........................................................................................................................
i. Pola Keersi#an Diri
• Seelum sakit :
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...........................................................................................................................
• Saat sakit :
...........................................................................................................................
j. Pola Komunikasi
• Seelum sakit :
...........................................................................................................................
• Saat sakit :
...........................................................................................................................
k. Pola Beriada#
• Seelum sakit :
...........................................................................................................................
• Saat sakit :
...........................................................................................................................
l. Pola Produkti0itas
• Seelum sakit :
...........................................................................................................................
• Saat sakit :
...........................................................................................................................
m. Pola Rekreasi
• Seelum sakit :
...........................................................................................................................
• Saat sakit :
...........................................................................................................................
n. Pola Keutu#an Belajar
• Seelum sakit :
...........................................................................................................................
• Saat sakit :
.........................................................................................................................../. Pen!-a0ian Fisi-
a. Keadaan umum :
Tingkat kesadaran : kom&osmetis ) a&atis ) somnolen ) so&or)koma
12S : /eral:333.Psikomotor:333.Mata :33333..
. Tanda,tanda 4ital : Nadi 5 3336 Su#u 5 3333.6 TD 53336 RR 5333
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-. Keadaan 0isik
!" Ke&ala dan le#er :........................................................................................................................................
%" Dada :
• Paru
.........................................................................................................................................
• Jantung
.........................................................................................................................................
*" Pa'udara dan ketiak :
.............................................................................................................................................+" Adomen :
.............................................................................................................................................
7" 1enetalia :........................................................................................................................................
8" 9ntegumen :
............................................................................................................................................." kstremitas :
• Atas
................................................................................................................................
• Ba(a#
.........................................................................................................................................
;" Neurologis :
• Status mental dan emosi :
.........................................................................................................................................
• Pengkajian sara0 kranial :
.........................................................................................................................................
• Pemeriksaan re0leks :.........................................................................................................................................
d. Pemeriksaan Penunjang
!" Data laoratorium 'ang er#uungan
.............................................................................................................................................%" Pemeriksaan radiologi
.............................................................................................................................................
*" Hasil konsultasi........................................................... . . . .. . .