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

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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

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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 :

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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:

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XI. PEMERIKSAAN DIAGNOSTIK/PENUNJANG

a. Data laboratorium yang berhubungan

Tanggal:

Pemeriksaan Hasil Nilai normal

b. Pemeriksaan Radiologi :

c. Pemeriksaan EKG:

d. Dll:

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XII. INFORMASI LAIN (mencangkup rangkuman kesehatan klien dari Gizi,

Fisioterapis, Terapi Medis, dll)

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XIII. ANALISA DATA

N

o

Tgl Data Penyebab/Interpretasi Masalah

1 DO:

DS:

2 DO:

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3 DO:

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4 DO:

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5 DO:

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6 DO:

DS:

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XIV. PRIORITAS MASALAHDaftar Diagnosa Keperawatan dan masalah PK, Menurut prioritas dan keluasan diagnosa

1

2

3

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XV. RENCANA PERAWATAN

Hari/Tgl

No Dx

Rencana KeperawatanTujuan dan kriteria

hasilIntervensi Rasional

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XVI. IMPLEMENTASI

Hari/Tgl

No Dx

Jam Implementasi Tindakan Keperawatan

Respon PasienTTD

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XVII. EVALUASI

Hari/Tgl No Dx Jam Evaluasi Ttd

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S:

O:

A:

P:

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O:

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P:

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O:

A:

P:S:

O:

A:

P:

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S:

O:

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P:

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O:

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