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RESUME ASUHAN KEPERAWATAN PADA TN.B DENGAN DIAGNOSA MEDIS HERNIA INGUALIS LATERALIS SINISTRA DI RUANG OK RSUD KOTA MATARAM TANGGAL 17 DESEMBER 2018 I.
PENGKAJIAN 1. Identitas a. Identitas Pasien Nama
: ......................................................................................... ......
Umur
: ......................................................................................... ......
Agama
: ......................................................................................... ......
Jenis Kelamin
: ........................................................................................... ....
Status
: ........................................................................................... ....
Pendidikan
:............................................................................................ ....
Pekerjaan
: ............................................................................................ ...
Suku Bangsa
:............................................................................................ ....
Alamat
: .......................................................................................... .....
Tanggal Masuk
: ........................................................................................... ....
Tanggal Pengkajian
: ........................................................................................... ....
No. Register
: ............................................................................................. ..
Diagnosa Medis
: ............................................................................................ ...
b. Identitas Penanggung Jawab Nama : ............................................................................................ ... Umur
: ............................................................................................. ..
Hub. Dengan Pasien
: ........................................................................................... ...
Pekerjaan
: ............................................................................................. ..
Alamat
: .............................................................................................. .
2. Riwayat Perjalanan Penyakit ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ......................................................
3. Riwayat Perioperatif a. Preoperatif ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... b. Intraoperatif ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................
...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... c.Postoperatif ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................
4. Pengkajian (Data Fokus) a. Data Subyektif Preoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ .............................................................................................................................. Intraoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ .............................................................................................................................. Postoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ....................................................................
b. Data Obyektif Preoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ .............................................................................................................................. Intraoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................... Postoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................
........................................................................................................................................ ....................................................................
c. Terapi dan Instruksi .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... ................................................................................
4. ANALISA DATA A. Tabel Analisa Data DATA
Etiologi
MASALAH
B. Tabel Daftar Diagnosa Keperawatan NO
TANGGAL / JAM DITEMUKAN
DIAGNOSA KEPERAWATAN
TANGGAL TERATASI
Ttd
C. Rencana Tindakan Keperawatan Hari/
No
Tgl
Dx
Rencana Perawatan Tujuan dan Kriteria Hasil
Intervensi
Ttd Rasional
D. Hari/ Tgl/Jam
Implementasi Keperawatan No Dx
Tindakan Keperawatan
Evaluasi proses
Ttd
E.
Evaluasi Keperawatan Hari/Tgl No Jam
No. Dx
Evaluasi
Ttd
PENGKAJIAN 1. Identitas a. Identitas Pasien Nama
: ......................................................................................... ......
Umur
: ......................................................................................... ......
Agama
: ......................................................................................... ......
Jenis Kelamin
: ........................................................................................... ....
Status
: ........................................................................................... ....
Pendidikan
:............................................................................................ ....
Pekerjaan
: ............................................................................................ ...
Suku Bangsa
:............................................................................................ ....
Alamat
: .......................................................................................... .....
Tanggal Masuk
: ........................................................................................... ....
Tanggal Pengkajian
: ........................................................................................... ....
No. Register
: ............................................................................................. ..
Diagnosa Medis
: ............................................................................................ ...
b. Identitas Penanggung Jawab Nama : ............................................................................................ ... Umur
: ............................................................................................. ..
Hub. Dengan Pasien
: ........................................................................................... ...
Pekerjaan
: ............................................................................................. ..
Alamat
: .............................................................................................. .
2. Riwayat Perjalanan Penyakit ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ......................................................
3. Riwayat Perioperatif a. Preoperatif ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... b. Intraoperatif ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................
...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... c.Postoperatif ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ...................................................................................................................................................... ......................................................................................................................................................
4. Pengkajian (Data Fokus) a. Data Subyektif Preoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ .............................................................................................................................. Intraoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ .............................................................................................................................. Postoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ....................................................................
b. Data Obyektif Preoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ .............................................................................................................................. Intraoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................... Postoperatif ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................ ........................................................................................................................................
........................................................................................................................................ ....................................................................
c. Terapi dan Instruksi .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... ................................................................................
4. ANALISA DATA A. Tabel Analisa Data DATA
Etiologi
MASALAH
B. Tabel Daftar Diagnosa Keperawatan NO
TANGGAL / JAM DITEMUKAN
DIAGNOSA KEPERAWATAN
TANGGAL TERATASI
Ttd
C. Rencana Tindakan Keperawatan Hari/
No
Tgl
Dx
Rencana Perawatan Tujuan dan Kriteria Hasil
Intervensi
Ttd Rasional
D. Hari/ Tgl/Jam
Implementasi Keperawatan No Dx
Tindakan Keperawatan
Evaluasi proses
Ttd
E.
Evaluasi Keperawatan Hari/Tgl No Jam
No. Dx
Evaluasi
Ttd
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