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ASUHAN KEPERAWATAN PADA ................DENGAN ...................................................................
DI RUANG .......................................... RSU TIDAR MAGELANG
Tanggal pengkajian : ...................................................
Tanggal masuk : ...................................................Ruangan : ...................................................
I. PENGKAJIAN
A. Identitas
1. Identitas Klien
Nama : .............................................................
No. RM : .............................................................
Umur : .............................................................
Jenis kelamin : .............................................................
Agama : .............................................................
Pendidikan : .............................................................Pekerjaan : .............................................................
Suku : .............................................................
Bahasa : .............................................................
Alamat : .............................................................
Pembiaaan kesehatan : .............................................................
!. Identitas Penanggung Jawa
Nama : .............................................................
Umur : .............................................................
Pendidikan : .............................................................
Pekerjaan : ............................................................."ubungan dengan klien : .............................................................
Suku : .............................................................
Bahasa : .............................................................
Alamat : .............................................................
No. telepon : .............................................................
!. Kelu"an Uta#a
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$. Riwa%at Kese"atan Se&a'ang
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D. Riwa%at Pen%a&it Da"ulu
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E. Riwa%at Kese"atan Kelua'ga#. Ri$aat penakit dalam keluarga:........................................................................................................................................................
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!. %enogram
Kete'angan ga#a' (: perempuan
: laki&laki
: laki&laki meninggal
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: perempuan meninggal
: klien
: tinggal serumah
: garis pernikahan
: garis keturunan
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). Keadaan U#u#
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G. Ting&at Kesada'an...............................................................................................................................................................
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H. Tanda*tanda +ital
Suhu Nadi Perna'asan Tekanan (arah
I. Pengu&u'an Ant',-,#et'i
#. Berat badan : ............... kg!. Tinggi badan : ............... )m
*. +ndeks Masa Tubuh ,+MT- :
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J. Pe#e'i&saan )isi& Head t, T,e
1. Pe#e'i&saan Ke-alaInspeksi:
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Palpasi:
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. Pe#e'i&saan Mata
Inspeksi:
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Palpasi:......................................................................................................................................................
/. Pe#e'i&saan Hidung
Inspeksi:
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......................................................................................................................................................Palpasi:
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0. Pe#e'i&saan Mulut
Inspeksi :......................................................................................................................................................
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Paplasi :
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. Pe#e'i&saan Telinga
Inspeksi:......................................................................................................................................................
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Palpasi:......................................................................................................................................................
2. Pe#e'i&saan Le"e'
Inspeksi :
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Palpasi: ........................................................................................................................................
..............3. Pe#e'i&saan dada dan -a'u
Inspeksi:
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Perkusi :......................................................................................................................................................
Palpasi:
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Auskultasi: ...................................................................................................................................
...................4. Pe#e'i&saan Jantung
Inspeksi:
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Palpasi:......................................................................................................................................................
Perkusi:......................................................................................................................................................
Auskultasi :......................................................................................................................................................
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5. Pe#e'i&saan Pa%uda'a dan A&sila
Inspeksi :
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Palpasi:
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16. Pe#e'i&saan Ad,#en
Inspeksi :......................................................................................................................................................
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......................................................................................................................................................Auskultasi :......................................................................................................................................................
Perkusi :......................................................................................................................................................
Palpasi : ......................................................................................................................................
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11. Pe#e'i&saan Genetalia
Inspeksi :......................................................................................................................................................
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Palpasi : ......................................................................................................................................
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1. Pe#e'i&saan Re&tu# dan Anus
Inspeksi :
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Palpasi :
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1/. Pe#e'i&saan E&st'e#itas .
a. kstermitas Atas:
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................................................................................................................................................b. kstermitas Ba$ah:
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/ekuatan otot:
10. Pe#e'i&saan &ulit dan &u&u
Inspeksi :......................................................................................................................................................
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Palpasi :......................................................................................................................................................
K. Peng&a7ian Keutu"an Dasa'
1. Keutu"an 8&sigenasi
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. Keutu"an Nut'isi dan $ai'an
a. Keutu"an Nut'isi
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N,. Pe#anding Seelu# sa&it Saat di&a7i
#. 0rekuensi makanan
!. Jumlah makanan
*. Jenis makanan
1. Alergi makanan
2. Na'su makan
3.
/eluhan ,mual4
muntah4 kembung4
anoreksia-
5.Makanan
Pantangan
. Keutu"an 9ai'an
#- Balan)e )airan ,hitung jumlah dan jenis )airan masuk dan keluar- :
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!- (iuresis :
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.........................................................................................................................................*- Rute )airan masuk ,oral4 parenteral4 enteral4 dsb- :
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1- Jenis )airan :
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2- /eluhan :
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/. Keutu"an Eli#inasi
a. !A!
N,. Pe#anding Seelu# sa&it Saat di&a7i
#. 0rekuensi
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!. 6arna
*. Bau
1. /onsistensi
. !AK
N,. Pe#anding Seelu# sa&it Saat di&a7i
#. 0rekuensi
!. 6arna
*. Bau
1. Perasaan0. Keutu"an Te'#,'egulasi
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. Keutu"an A&ti:itas dan Lati"an
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Tael Ting&at Ke#andi'ian(
/emampuan Pera$atan (iri 7 # ! * 1
Makan8minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
/eterangan :
7 9 mandiri * 9 dibantu orang lain dan alat
# 9 dengan alat bantu 1 9 tergantung total
! 9 dibantu orang lain
2. Keutu"an Se&sualitas
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3. Keutu"an Psi&,s,sial ;St'ess K,-ing dan K,nse- Di'iJAMD@ KEP
INTER+ENSITTD
TUJUAN TINDAKAN
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N8TGL
>JAMD@ KEP
INTER+ENSITTD
TUJUAN TINDAKAN
+. IMPLEMENTASI
N8 [email protected] TGL >JAM IMPLEMENTASI RESP8N TTD
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N8 [email protected] TGL >JAM IMPLEMENTASI RESP8N TTD
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+I. E+ALUASI
;Pe'&e#angan setia- "a'i dala# entu& S8APJAM D@ KEP E+ALUASI TTD
N8 TGL>JAM D@ KEP E+ALUASI TTD
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PEM!AHASAN(
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