askep fraktur femur
DESCRIPTION
askep fraktur femurTRANSCRIPT
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PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBERFORMAT PENGKAJIAN ASUHAN KEPERAWATAN DEWASA
Nama Mahasiswa :NIM :Tempat Pengkajian :Tanggal :
I. Identitas KlienNama : No. RM :Umur : Pekerjaan :Jenis Kelamin : Status Perkawinan :Agama : Tanggal MRS :Pendidikan : Tanggal
Pengkajian:
Alamat : Sumber Informasi :
II. Riwayat Kesehatan1. Diagnosa Medik:
………………………………………………………………………….................................………………..
2. Keluhan Utama: ……………..………………………………………………………………………….………....……………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………
3. Riwayat penyakit sekarang: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...................................................................................................................………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………................
4. Riwayat kesehatan terdahulu:a. Penyakit yang pernah dialami: ………………………………………………………………………….................................………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................………………..b. Alergi (obat, makanan, plester, dll): ………………………………………………………………………….................................………………..
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……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................………………..c.Imunisasi:………………………………………………………………………….................................………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
d.Kebiasaan/pola hidup/life style: ………………………………………………………………………….................................………………..…………………………………………………………………………………………………………………………………………………………………………………………….................................………………..…………………………………………………………………………………………………………………………………………………………………………………………….................................………………..
e. Obat-obat yang digunakan: ………………………………………………………………………….................................………………..…………………………………………………………………………………………………………………………………………………………………………………………….................................………………..………………………………………………………………………….................................………………..………………………………………………………………………….................................………………..
5. Riwayat penyakit keluarga:………………………………………………………………………….................................………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................………………..
Genogram:
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III. Pengkajian Keperawatan1. Persepsi kesehatan & pemeliharaan kesehatan
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
2. Pola nutrisi/ metabolik (ABCD)- Antropometeri
………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………
- Biomedical sign : ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………
- Clinical Sign : ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………
- Diet Pattern (intake makanan dan cairan):………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3. Pola eliminasi: BAK
- Frekuensi :…………………………………………………………………………….. - Jumlah :……………………………………………………………………………..- Warna : ……………………………………………………………………………..- Bau : ……………………………………………………………………………..- Karakter : ……………………………………………………………………………..- BJ : …………………………………………………………………………….. - Alat Bantu : ……………………………………………………………………………..- Kemandirian : mandiri/dibantu - Lain : ……………………………………………………………………………..
BAB
- Frekuensi :…………………………………………………………………………….. - Jumlah :……………………………………………………………………………..- Konsistensi : ……………………………………………………………………………..- Warna : ……………………………………………………………………………..- Bau : ……………………………………………………………………………..- Karakter : ……………………………………………………………………………..- BJ : …………………………………………………………………………….. - Alat Bantu : ……………………………………………………………………………..- Kemandirian : mandiri/dibantu - Lain : ……………………………………………………………………………..
Interpretasi :
Balance cairan: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
4. Pola aktivitas & latihan…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
c.1. Aktivitas harian (Activity Daily Living) Kemampuan perawatan diri 0 1 2 3 4Makan / minumToileting Berpakaian Mobilitas di tempat tidur
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Berpindah Ambulasi / ROM
Ket: 0: tergantung total, 1: dibantu petugas dan alat, 2: dibantu petugas, 3: dibantu alat, 4: mandiriStatus Oksigenasi : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Fungsi kardiovaskuler : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Terapi oksigen : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
5. Pola tidur & istirahatDurasi : ……………………………………………………………………………………………………Gangguan tidur : ……………………………………………………………………………………….Keadaan bangun tidur : ………………………………………………………………..……………Lain-lain : …………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
6. Pola kognitif & perceptualFungsi Kognitif dan Memori : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Fungsi dan keadaan indera : ……………………………………………………………………………………………………………………………………………………….....................................................................................................................................................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
7. Pola persepsi diriGambaran diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Identitas diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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Harga diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Ideal Diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Peran Diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
8. Pola seksualitas & reproduksiPola seksualitas ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Fungsi reproduksi …………………………………….................................................................................................................................................................................................................................................................................................................................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
9. Pola peran & hubungan……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
10. Pola manajemen koping-stress……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
11. System nilai & keyakinan……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………
IV. Pemeriksaan FisikKeadaan umum:……………………………………………………………..……………………………..........................................……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Tanda vital:
- Tekanan Darah : mm/Hg- Nadi : X/mnt- RR : X/mnt- Suhu : C
Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
Pengkajian Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi) 1. Kepala
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
2. Mata …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3. Telinga.…………………………………………………………………………………….........................................………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
4. Hidung………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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…………………………………………………………………………………………………………………………………………………
5. Mulut ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
6. Leher………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
7. Dada.………………………………………………………………………………………...….…………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………………………………………
8. Abdomen……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
9. Urogenital………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
10. Ekstremitas……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
11. Kulit dan kuku……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
12. Keadaan lokal………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
V. Terapi (jenis terapi, dosis, rute, indikasi, KI, implikasi keperawatan)
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VI. Pemeriksaan Penunjang & Laboratorium (bisa dikembangkan)No Jenis
pemeriksaanNilai normal
(rujukan)Hasil
(hari/tanggal)nilai Satuan
……………,…...........................20...Pengambil Data,
(__________________________) NIM
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ANALISA DATANO DATA PENUNJANG ETIOLOGI MASALAH
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DIAGNOSA KEPERAWATAN
Daftar Diagnosa Keperawatan (sesuai prioritas):
No Diagnosa Tanggal perumusan
Tanggal pencapaian
Keterangan
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PERENCANAAN KEPERAWATANNO DIAGNOSA TUJUAN DAN
KRITERIA HASILINTERVENSI RASIONAL
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CATATAN PERKEMBANGANDIAGNOSA:
WAKTU IMPLEMENTASI PARAF EVALUASIJAM:
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