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