Askep Ruangan-1.docx

ASUHAN KEPERAWATAN

A. PENGKAJIAN 1. Pengumpulan Data a. Identitas Klien 1) Nama/ Nama Panggilan : 2) Tempat, Tanggal Lahir

:

3) Jenis Kelamin

:

4) Agama

:

5) Pendidikan

:

6) Alamat

:

7) Tanggal Masuk

:

8) Tanggal Pengkajian

:

9) Diagnosa Medis

:

10) Nomor Rekam Medis

:

b. Identitas Penanggungjawab 1) Nama

:

2) Usia

:

3) Hubungan Pasien

:

4) Alamat

:

c. Riwayat Kesehatan 1) Keluhan Utama 2) Riwayat Kesehatan Sekarang 3) Riwayat Kesehatan Dahulu 4) Riwayat Kesehatan Keluarga d. Pemeriksaan Fisik 1) Penampilan Umum a) Keadaan Umum

:

b) Kesadaran

:



GCS

:

c) Tanda-tanda Vital (a) Tekanan darah : (b) Suhu

:

(c) Nadi

:

(d) RR

:

2) Sistem pernafasan ........................................................................................................................ ........................................................................................................................ 3) Sistem Kardiovaskuler ........................................................................................................................ ........................................................................................................................ 4) Sistem Pencernaan ........................................................................................................................ ........................................................................................................................ 5) Sistem Persyarafan  Kesadaran :  Orientasi :  Orang :  Tempat :  Waktu :  Memori :  Gaya Bicara :  Fungsi nervus cranial: -

Nervus I Olfaktorius ( Sensori Hidung ) ................................................................................................................

-

Nervus II Oftikus ( Sensori Mata ) .................................................................................................................

-

Nervus III Okulomotorius ( Motorik Mata ) .................................................................................................................

-

Nervus IV Trochlearis ( Motorik Mata ) .................................................................................................................

-

Nervus V Trigeminus ( Motorik dan Sensorik Wajah ) .................................................................................................................

-

Nervus VI Abdusen ( Motorik Mata ) .................................................................................................................

-

Nervus VII Fasialis ( Motorik & Sensorik Wajah ) .................................................................................................................

-

Nervus VIII Vestibulo-Kokhlearis ( Sensori Telinga ) .................................................................................................................

-

Nervus IX Glosofaringeus .................................................................................................................

-

Nervus X Vagus ( Sensori Mulut, Faring dan bagian lainnya ) .................................................................................................................

-

Nervus XI Assesorius ( Motorik Fisik ) .................................................................................................................

-

Nervus XII Hipoglosus ( Sensori Mulut dan Lidah ) .................................................................................................................

6) Sistem Perkemihan ........................................................................................................................ ........................................................................................................................ 7) Sistem Muskuloskeletal Ektremitas atas: Ektremitas bawah: Kekuatan otot :

8) Sistem Integumen ........................................................................................................................ ........................................................................................................................ 9) Wicara dan THT ........................................................................................................................ ........................................................................................................................ 10) Sistem Persepsi Sensori ........................................................................................................................ ........................................................................................................................

e. Data Psikologis 1) Status Emosi : 2) Kecemasan: 3) Pola Koping : 4) Gaya Komunikasi : f. Data Sosial ..............................................................................................................................

PROGRAM PROFESI NERS XII CATATAN PERKEMBANGAN PASIEN TERINTEGRASI Hari/ Tanggal/ Jam

RAHASIA

No. Rekam Medis : Nama : Jenis kelamin : Tanggal lahir : Umur :

Dibuat berdasarkan prinsip subjektif, obyektif, assessment dan perencanaan (SOAP)

Tanda tangan dan Nama jelas

PROGRAM PROFESI NERS XII

LEMBAR OBSERVASI

Hari/ Tanggal/ Jam

Implementasi

No. Rekam Medis : Nama : Jenis kelamin : Tanggal lahir : Umur : Hasil

Tanda tangan dan Nama jelas