Format Pengkajian Henderson

FORMAT LAPORAN ASUHAN KEPERAWATAN BERDASARKAN FORMAT HENDERSON 1. PENGKAJIAN 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

: .........................................................................................

Alamat

: ..........................................................................................

Umur

: .........................................................................................

Agama

: .........................................................................................

Jenis Kelamin

: ...........................................................................................

Status

: ...........................................................................................

Pendidikan

:............................................................................................

Pekerjaan

: ............................................................................................

Suku Bangsa

:............................................................................................

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 .......................................................................................................................................