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LAPORAN
ASUHAN KEPERAWATAN
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DI RUANG CENDANA II RSUP Dr. SARDJITO YOGYAKARTA
A s u h a n K e p e r a w a t a nDibuat Dalam Rangka Ujian Praktek Profesi Stase KMB
Program Studi Ilmu Keperawatan Universitas Gadjah MadaTanggal : 8 Mei 2008
Oleh:Nama : Edi Purwanto
NIM: 06/200164/EIK/00594KLP: II/B 2.1
PROGRAM STUDI ILMU KEPERAWATANUNIVERSITAS GADJAH MADA
2008
PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KEDOKTERAN UGM
FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH
Nama mahasiswa : ……………………………………………………………………
Tempat Praktik : ………………………………………………………………………
Waktu Praktik : ………………………………………………………………………
I. Identitas diri klien
Nama......................................................................................................................................
Umur: ....................................................................................................................................
No. RM..................................................................................................................................
Jenis kelamin..........................................................................................................................
Status Perkawinan: ................................................................................................................
Agama ...................................................................................................................................
Suku.......................................................................................................................................
Pendidikan..............................................................................................................................
Pekerjaan ...............................................................................................................................
Lama bekerja..........................................................................................................................
Tanggal masuk RS ...............................................................................................................
Tanggal Pengkajian................................................................................................................
Sumber informasi ...............................................................................................................
Alamat....................................................................................................................................
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II. Riwayat Penyakit
Keluhan utama saat masuk RS :
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Keluhan yang dirasakan saat ini
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Riwayat penyakit sekarang:
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Riwayat Penyakit Dahulu
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Diagnosa medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah di
lakukan, mulai dari pasien MRS (UGD/Poli), sampai diambil kasus kelolaan .
Masalah atau Dx medis pada saat MRS.
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Tindakan yang telah dilakukan di Poliklinik atau UGD
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Catatan Penanganan Kasus (Dimulai saat pasien di rawat di ruang rawat sampai pengambilan
kasus kelolaan)
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PENGKAJIAN KEPERAWATAN
1. Persepsi dan pemeliharaan kesehatan
Pengetahuan tentang penyakit/perawatan
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2. Pola nutrisi / metabolik
Program diit RS :
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Intake makanan :
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Intake cairan:
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3. Pola Eliminasi
a. Buang air besar
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b. Buang air kecil
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4. Pola aktivitas dan latihan
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi/ROM
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung
total
5. Oksigenasi
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6. Pola tidur dan istirahat (lama tidur, gangguan tidur, perawasaan saat bangun tidur)
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7. Pola perceptual (penglihatan, pendengaran, pengecap, sensasi):
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8. Pola persepsi diri (pandangan klien tentang sakitnya, kecemasan, konsep diri)
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9. Pola seksualitas dan reproduksi (fertilitas, libido, menstruasi, kontrasepsi, dll)
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10. Pola peran-hubungan (komunikasi, hubungan dengan orang lain, kemampuan keuangan)
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11. Pola managemen koping-stress (perubahan terbesar dalam hidup pada akhir-akhir ini, dll)
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12. Sistem nilai dan keyakinan (pandangan klien tentang agama, kegiatan keagamaan, dll)
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III. Pemeriksaan Fisik (Cephalocaudal)
Keadaan Umum…………………………………………………………………………………………………...
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TD: ......................mmHg. P:................x/m N: ..................x/m S:..................C
BB: .............................................TB:.......................................................
1. Kepala
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2. Leher
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3. Thorak
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4. Abdomen
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5. Inguinal
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6. Ekstremitas (termasuk keadaan kulit, kekuatan)
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Pemeriksaan Penunjang (Lab/Radiologi):
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PENANGANAN KASUS (dimulai saat anda mengambil sebagai kasus kelolaan, sampai
akhir praktik)
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ANALISA DATA
No. Data Etiologi Masalah Kep
TINDAKAN KEPERAWATAN
No. Dx
Hari/ tanggalShift IMPLEMENTASI EVALUASI
NURSING CARE PLAN
No Dx. Kep/Masalah Kolaborasi
Tujuan Intervensi Rasional
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