askep fraktur femur

17
PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER FORMAT PENGKAJIAN ASUHAN KEPERAWATAN DEWASA Nama Mahasiswa : NIM : Tempat Pengkajian : Tanggal : I. Identitas Klien Nama : No. RM : Umur : Pekerjaan : Jenis Kelamin : Status Perkawinan : Agama : Tanggal MRS : Pendidikan : Tanggal Pengkajian : Alamat : Sumber Informasi : II. Riwayat Kesehatan 1. Diagnosa Medik: ………………………………………………………………………….......................... .......……………….. 2. Keluhan Utama: ……………..…………………………………………………………………………. ………....………………………. ……………………………………………………………………………………………………………………………………………… ………………………………………………………………………… 3. Riwayat penyakit sekarang: ……………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………….......... ...................................................... ................................................... ……………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………

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askep fraktur femur

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Page 1: Askep Fraktur Femur

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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