View
37
Download
3
Category
Preview:
Citation preview
ASUHAN KEPERAWATAN MEDIKEL BEDAH
……………………………………………………………………………………………
DI RUANG ……………… RSUD ……………………………………
Nama Mahasiswa : ……………………………………
NIM : ……………………………………
Tempat Praktik : Ruang ……………………………
RSUD ……………………………
Tanggal Pengkajian : ……………………………… 2014
A. PENGKAJIAN
Pengkajian dilakukan pada Hari ………… Tanggal ……………………… 2014 di
Ruang ………… RSUD ………………………………… secara alloanamnesa dan
autoanamnesa.
1. IDENTITAS
a. Identitas Klien
Nama : ………………………………………………
Jenis Kelamin : ………………………………………………
Umur : ………………………………………………
Pendidikan Terakhir : ………………………………………………
Agama : ………………………………………………
Suku : ………………………………………………
Status Perkawinan : ………………………………………………
Pekerjaan : ………………………………………………
Alamat : ………………………………………………
Diagnosa medis : ………………………………………………
No RM : ………………………………………………
Tanggal masuk : ………………………………………………
b. Identitas Penanggungjawab
Nama : ………………………………………………
Umur : ………………………………………………
Jenis Kelamin : ………………………………………………
Agama : ………………………………………………
Suku : ………………………………………………
Hubungan dng pasien : ………………………………………………
Pekerjaan : ………………………………………………
2. RIWAYAT KESEHATAN
a. Keluhan Utama :
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
b. Riwayat kesehatan sekarang :
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
c. Riwayat kesehatan dahulu :
............................................................................................................................
............................................................................................................................
............................................................................................................................
d. Riwayat kesehatan keluarga :
............................................................................................................................
............................................................................................................................
............................................................................................................................
3. POLA PENGKAJIAN FUNGSIONAL
a. Pola persepsi-Management Kesehatan
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
b. Pola nutrisi
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
c. Pola Eliminasi
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
d. Pola latihan – Aktivitas
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
e. Pola kognitif perseptual
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
f. Pola istirahat – tidur
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
g. Pola Konsep Diri/Persepsi Diri
1) Gambaran diri (citra tubuh)
....................................................................................................................
....................................................................................................................
2) Identitas
....................................................................................................................
....................................................................................................................
3) Peran
....................................................................................................................
....................................................................................................................
4) Ideal diri
....................................................................................................................
....................................................................................................................
5) Harga diri
....................................................................................................................
....................................................................................................................
h. Pola Peran dan Hubungan
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
i. Pola Reproduksi / Seksual
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
j. Pola Pertahanan Diri (Coping toleransi stress)
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
k. Pola Keyakinan Dan Nilai
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
............................................................................................................................
4. PEMERIKSAAN FISIK
a. Tanda – tanda Vital
TANDA-TANDA VITAL
HARI & TANGGAL
Hari :Tgl :
Hari :Tgl :
Hari :Tgl :
Tekanan Darah ……… mmHg ……… mmHg ……… mmHg
Nadi ……… x/menit ……… x/menit ……… x/menit
Respiratory Rate ……… x/menit ……… x/menit ……… x/menit
Suhu ……… 0C ……… 0C ……… 0C
b. Pemeriksaan head to toe
1) Kepala : ………………………………………………
………………………………………………
………………………………………………
2) Mata : ………………………………………………
………………………………………………
………………………………………………
3) Hidung : ………………………………………………
………………………………………………
………………………………………………
4) Mulut dan tenggorokan : ………………………………………………
………………………………………………
………………………………………………
5) Telinga : ………………………………………………
………………………………………………
………………………………………………
6) Dada :
Thorak
I : ………………………………………………………………………
P : ………………………………………………………………………
P : ………………………………………………………………………
A : ………………………………………………………………………
Jantung
I : ………………………………………………………………………
P : ………………………………………………………………………
P : ………………………………………………………………………
A : ………………………………………………………………………
7) Abdomen :
I : ………………………………………………………………………
P : ………………………………………………………………………
P : ………………………………………………………………………
A : ………………………………………………………………………
8) Genetalia : ………………………………………………
………………………………………………
………………………………………………
9) Integumen : ………………………………………………
………………………………………………
………………………………………………
10) Ekstremitas : ………………………………………………
………………………………………………
………………………………………………
5. DATA PENUNJANG
a. Laboratorium
Hari / Tanggal : ………………………………………………
Jenis Pemeriksaan HasilSatuan
Nilai Normal Ket.
b. Radiologi
Hari / Tanggal : ………………………………………………
c. Terapi
Hari / Tanggal : ………………………………………………
No. TANGGAL NAMA OBAT DOSISCARA
PEMBERIAN
B. ANALISA DATA
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
No.HARI
TANGGALJAM
DATA FOKUS MASALAH ETIOLOGI
No.HARI
TANGGALJAM
DATA FOKUS MASALAH ETIOLOGI
C. PERIORITAS DIAGNOSA KEPERAWATAN
1. ……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
2. ……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
3. ……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
4. ……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
5. ……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
D. RENCANA TINDAKAN KEPERAWATAN
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
HARITANGGAL
JAM
No. DP
TUJUAN & KRITERIA HASIL(NOC)
INTERVENSI (NIC) Ttd.
HARITANGGAL
JAM
No. DP
TUJUAN & KRITERIA HASIL(NOC)
INTERVENSI (NIC) Ttd.
E. TINDAKAN KEPERAWATAN
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
HARI & TANGGAL
PUKUL
No.DP
IMPLEMENTASI RESPON PASIEN Ttd.
HARI & TANGGAL
PUKUL
No.DP
IMPLEMENTASI RESPON PASIEN Ttd.
F. EVALUASI
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
No.HARI
TANGGALJAM
DIAGNOSA KEPERAWATAN EVALUASI TTD
No.HARI
TANGGALJAM
DIAGNOSA KEPERAWATAN EVALUASI TTD
Recommended