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ASUHAN KEPERAWATAN PADA AN. ”W” DENGAN FEBRIS HARI KE V ec SUSP. DHF Gr. I
DI RUANG ANGGREK 3.1 A BRSU TABANAN
Nama Mahasiswa :
NIM :
Ruang :
Tanggal pengkajian :
Tanggal praktek :
Tanggal MRS :
I. IDENTITAS KLIEN
No. Rekam Medis : .......................................
Nama Klien : .......................................
Nama Panggilan : .......................................
Tempat/tanggal : .......................................
Umur : .......................................
Jenis kelamin : .......................................
Bahasa yang dimengerti : .......................................
Orangtua/wali
Nama Ayah/Ibu/Wali : .......................................
Pekerjaan Ayah/Ibu/Wali : .......................................
Pendidikan : .......................................
Alamat Ayah/Ibu/Wali : .......................................
II. KELUHAN UTAMA
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III. RIWAYAT KELUHAN SAAT INI
Alasan Masuk Rumah Sakit dan Perjalanan Penyakit Saat Ini
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Upaya yang Dilakukan untuk Mengatasinya
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IV. RIWAYAT KESEHATAN SAAT INI
A. Prenatal
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B. Perinatal dan postnatal
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C. Penyakit yang pernah diderita
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D. Hospitalisasi/tindakan operasi
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...........................................................................................................................E. Injury/kecelakaan
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F. Alergi
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G. Imunisasi dan tes laboratorium
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H. Pengobatan
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V. RIWAYAT PERTUMBUHAN
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VI. RIWAYAT SOSIAL
a. Yang mengasuh
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...........................................................................................................................b. Hubungan dengan anggota keluarga
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c. Hubungan dengan teman sebaya
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d. Pembawaan secara umum
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VII. RIWAYAT KELUARGA
a. Sosial ekonomi
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b. Lingkungan rumah
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c. Penyakit keluarga
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d. Genogram
Keterangan genogram
= Laki-Laki
= Perempuan
= Sudah Meninggal
= Pasien
= Tinggal Serumah
VIII.PENGKAJIAN TINGKAT PERKEMBANGAN SAAT INI
a. Personal sosial
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b. Adaptif motorik halus
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c. Bahasa
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d. Motorik kasar
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...........................................................................................................................IX. PENGKAJIAN POLA KESEHATAN KLIEN SAAT INI
a. Pemeliharaan dan persepsi terhadap kesehatan
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b. Nutrisi
Pola Makan :
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Berat Badan :......................................................................................................................................................................................................................................................
c. Cairan
Minum :
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d. Aktivitas Kemampuan perawatan diri 0 1 2 3 4Makan/minumMandiToiletingBerpakaianMobilisasi di tempat tidurBerpindah
Ambulasi ROM0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total.
Okigenasi: .................................................................................................................................................................................................................................................................................................................................................................................
e. Pola tidur dan istirahat
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f. Eliminasi
BAK :
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BAB :
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g. Pola hubungan
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h. Koping atau temperamen dan disiplin yang
diterapkan
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i. Kognitif dan persepsi
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...........................................................................................................................j. Konsep diri
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k. Pola seksual dan reproduksi
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l. Nilai
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X. PEMERIKSAAN FISIK
a. Keadaan umum :
Tingkat kesadaran : Composmentis/ apatis/ somnolen/ sopor/ koma
GCS : E M V
Tanda-tanda vital : Nadi : x/menit Temp : 0C
RR : x/menit TD : mmHg
b. Kulit, Rambut, dan Kuku
Distribusi rambut :
Lesi Ya Tidak
Warna kulit Ikterik Sianosis Kemerahan Pucat
Akral Hangat Panas Dingin kering Dingin
Turgor:
Oedem Ya Tidak Lokasi:
Warna kuku: Pink Sianosis lain-lain
Lain-lain:
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c. Kepala
Kepala Simetris Asimetris
Lesi: ya Tidak
Lain-lain:
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d. Mata
Gangguan pengelihatan Ya Tidak
Menggunakan kacamata Ya Tidak
Visus :
Pupil Isokor Anisokor
Ukuran :
Sklera/ konjungtiva Anemis Ikterus
Lain-lain:
e. Telinga
Gangguan pendengaran Ya Tidak
Menggunakan alat bantu dengar Ya Tidak
Tes weber:
Tes Rinne:
Tes Swabach:
Lain-lain:
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f. Hidung
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g. Mulut
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h. Leher
Deviasi trakea Ya Tidak
Pembesaran kelenjar tiroid Ya Tidak
Lain-lain :
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i. Dada
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :.................................................................................................................................................................................................................................................................................................................................................................................
j. Payudara
Inspeksi :
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Palpasi :
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k. Paru-paru
Batuk: Ya Tidak
Sesak: Ya Tidak
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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...........................................................................................................................l. Jantung
Nyeri dada Ya Tidak
Palpitasi Ya Tidak
CRT < 3 dtk > 3 dtk
Lain-lain :
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m.Abdomen
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
n. Genitalia
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o. Anus dan rektum
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p. Muskuloskeletal
Kemampuan pergerakan sendi Bebas Terbatas
Deformitas Ya Tidak
Lokasi:
Fraktur Ya tidak Lokasi:
Kekakuan Ya Tidak
Nyeri sendi/otot Ya Tidak
Kekuatan otot :
Lain-lain :
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q. Neurologi
GCS: Eye: Verbal: Motorik:
Rangsangan meningeal Kaku kuduk Kernig
Brudzinski I Brudzinski II
Refleks fisiologis Patela Trisep
Bisep Achiles
Refleks patologis Babinski Chaddock Oppenheim
Rossolimo Gordon Schaefer
Stransky Gonda
Gerakan involunter :
Lain-lain:
XI. PEMERIKSAAN DIAGNOSTIK/PENUNJANG
a. Data laboratorium yang berhubungan
Tanggal:
Pemeriksaan Hasil Nilai normal
b. Pemeriksaan Radiologi :
c. Pemeriksaan EKG:
d. Dll:
XII. INFORMASI LAIN (mencangkup rangkuman kesehatan klien dari Gizi,
Fisioterapis, Terapi Medis, dll)
XIII. ANALISA DATA
N
o
Tgl Data Penyebab/Interpretasi Masalah
1 DO:
DS:
2 DO:
DS:
3 DO:
DS:
4 DO:
DS:
5 DO:
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6 DO:
DS:
XIV. PRIORITAS MASALAHDaftar Diagnosa Keperawatan dan masalah PK, Menurut prioritas dan keluasan diagnosa
1
2
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XV. RENCANA PERAWATAN
Hari/Tgl
No Dx
Rencana KeperawatanTujuan dan kriteria
hasilIntervensi Rasional
XVI. IMPLEMENTASI
Hari/Tgl
No Dx
Jam Implementasi Tindakan Keperawatan
Respon PasienTTD
XVII. EVALUASI
Hari/Tgl No Dx Jam Evaluasi Ttd
S:
O:
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P:
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O:
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P:
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O:
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P:S:
O:
A:
P:
S:
O:
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P:
S:
O:
A:
P:
S:
O:
A:
P: