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ASUHAN KEPERAWATAN

Nama Mahasiswa

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NIM

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Tempat praktek

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Tanggal/jam

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A. IDENTITAS KLIEN 1. Pasien Nama

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Tempa Tanggal Lahir/Umur : ........................................................................................ Jenis Kelamin

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Agama

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Status Perkawinan

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Pendidikan

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Pekerjaan

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Suku/Bangsa

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Alamat

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No.Rekam Medis

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Tgl Masuk RS

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Diagnosa Medis

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2. Penanggung Jawab Nama

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Umur

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Pendidikan

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Pekerjaan

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Alamat

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Hubungan Dengan Pasien

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B. RIWAYAT KESEHATAN 1. Riwayat Pasien a. Riwayat kesehatan saat ini : .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ............................................................................................................................... b. Riwayat kesehtan dahulu : .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ............................................................................................................................... 2. Riwayat Keluarga Genogram (3 generasi) a. Riwayat Kesehatan .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ............................................................................................................................... Genogram 3 generasi :

A. POLA DAN KEBIASAAN PASIEN 1. ASPEK FISIK – BIOLOGIS a. Pola Nutrisi 1) Sebelum Sakit .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ......................................................................................................................... 2) Selama Sakit .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .......................................................................................................................... b. Pola Eliminasi 1) Sebelum Sakit .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .......................................................................................................................... 2) Selama Sakit .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ..........................................................................................................................

c. Pola Aktivitas, Istrahat, Tidur 1) Sebelum Sakit a) Aktivitas sehari – hari ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ .................................................................................................................... b) Kebutuhan tidur ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ..................................................................................................................... c) Kebutuhan istrahat ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ .................................................................................................................... 2) Selama sakit a) Penilaian kemampuan pasien dalam beraktivitas selama sakit (√) KEMAMPUAN DIRI Makan/minum Berpakaian Mobilisasi tempat tidur Berpindah Ambulasi

0

1

2

3

4

Keterangan : 0

= mandiri

1

= dengan alat bantu

2

= dibantu orang lain

3

= dibantu orang lain dan alat

4

= tergantung total

b) Kebutuhan tidur ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ c) Kebutuhan istrahat ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ d. Pola kebersihan diri Sebelum dan selama sakit 1) Kulit .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ................................................................................................................ 2) Rambut .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ................................................................................................................

3) Telinga .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ................................................................................................................ 4) Mata .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ................................................................................................................ 5) Mulut .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ................................................................................................................ 6) Genetalia .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ................................................................................................................ 7) Kuku .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ................................................................................................................

e. Pola reproduksi seksual 1) Sebelum sakit .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ................................................................................................................ 2) Selama sakit .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. ................................................................................................................ 2. ASPEK MENTAL – INTELEKTUAL – SOCIAL – SPIRITUAL a. Konsep diri 1) Identitas diri ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… 2) Harga diri ………………………………………………………………………… ………………………………………………………………………… ……………………………………………………………………….... 3) Gambaran diri/citra diri ………………………………………………………………………… ………………………………………………………………………… …………………………………………………………….................... 4) Peran diri ………………………………………………………………………… ………………………………………………………………………… …………………………………………………………………………

5) Ideal diri ………………………………………………………………………… ……………………………………………………………………….... b. Intelektual …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… c. Hubungan interpersonal 1) Sebelum sakit ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………….......... 2) Selama sakit ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… ……………………………………………………………………… d. Mekanisme koping …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… e. Support system …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………... f. Mental – emosional …………………………………………………………………………… …………………………………………………………………………… ……………………………………………………………………………

g. Sosial …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… h. Spiritual …………………………………………………………………………… …………………………………………………………………………… ………………………………………………………………………….... B. PEMERIKSAAN FISIK 1. Keadaan umum a. Kesadaran ………………………………………………………………………… ………………………………………………………………………… b. Status gizi (TB,BB,Antropometri ) ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… c. Tanda – tanda vital ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… 2. PEMERIKSAAN CEPPALOCAUDAL a. Kepala ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………... b. Leher ………………………………………………………………………… ……………………………………………………………………… c. Tengkuk ………………………………………………………………………… …………………………………………………………………………

d. Sirkulasi ………………………………………………………………………… ……………………………………………………………………....... e. Dada 1) Jantung ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… 2) Paru ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… f. Payudara ………………………………………………………………………… ………………………………………………………………………… g. Abdomen ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… h. Punggung dan panggul ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… i. Genetalia ………………………………………………………………………… ………………………………………………………………………… …………………………………………………………………………

j. Anus dan rectum ………………………………………………………………………… ………………………………………………………………………

k. Ekstremitas atas dan bawah ………………………………………………………………………… ………………………………………………………………………… ………………………………………………………………………….

C. PEMERIKSAAN PENUNJANG

D. PENATALAKSANAAN

E. ANALISA DATA NO

DATA

PENYEBAB

MASALAH

F. PRIORITAS MASALAH

G. ASUHAN KEPERAWATAN NO DIAGNOSA KEPERAWATAN

TUJUAN

RENCANA

H. CATATAN PERKEMBANGAN Tangga

No,diagno

l/

sa

Jam

implementasi

proses

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