Format Askep Gabungan.doc

ASUHAN KEPERAWATAN PADA AN. DENGAN………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………… I.

Pengkajian (tgl……………, pukul: ………….WIB) 1.1 Identitas Klien Nama :.......................................................................................................... Umur : ......................................................................................................... Jenis Kelamin : ......................................................................................................... Agama : ......................................................................................................... Suku/ Bangsa : ......................................................................................................... Pendidikan : ......................................................................................................... Pekerjaan : ......................................................................................................... Penghasilan : ......................................................................................................... Alamat : ......................................................................................................... MRS tgl/ jam : ......................................................................................................... Ruangan : ......................................................................................................... No. Reg : ......................................................................................................... Dx. Medis : ......................................................................................................... 1.2 Identitas penanggung jawab Nama : ......................................................................................................... Umur : ......................................................................................................... Jenis Kelamin : ......................................................................................................... Agama : ......................................................................................................... Suku/ Bangsa : ......................................................................................................... Pendidikan : ......................................................................................................... Pekerjaan : ......................................................................................................... Penghasilan : ......................................................................................................... Alamat : ......................................................................................................... Hub. Dengan klien : ......................................................................................................... 1.3 Keluhan Utama : ......................................................................................................... .......................................................................................................... 1.4 Riwayat Penyakit Sekarang : ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ 1.5 Riwayat Penyakit Dahulu : ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ 1.6 Riwayat Penyakit Keluarga : ............................................................................................ ............................................................................................

............................................................................................ ............................................................................................ ............................................................................................ 1.7 Riayat Psiko, Sosio, Spiritual: Riwayat Psiko :......................................................................................................... :......................................................................................................... Riwayat Sosial

: ........................................................................................................ .........................................................................................................

Riwayat Spiritual

: ......................................................................................................... .........................................................................................................

1.8 Riwayat Tumbuh Kembang: Riwayat Pre Natal : ........................................................................................................ ......................................................................................................... ......................................................................................................... Riwayat Natal

: ......................................................................................................... ......................................................................................................... .........................................................................................................

Riwayat Post Natal

: ......................................................................................................... ......................................................................................................... .........................................................................................................

1.9 Riwayat Imunisasi : …………………………………………………………………… ......................................................................................................... ......................................................................................................... ......................................................................................................... 1.10

ADL (Activity Daily of Life): 1. Pola Nutrisi Sebelum sakit : ........................................................................................................ ......................................................................................................... ......................................................................................................... ......................................................................................................... Selama sakit

:........................................................................................................ ......................................................................................................... ......................................................................................................... .........................................................................................................

2. Pola Eliminasi Sebelum sakit : ......................................................................................................... :......................................................................................................... :......................................................................................................... :......................................................................................................... Selama sakit

: ..................................................................................................... :.........................................................................................................

:......................................................................................................... :.........................................................................................................

3. Pola Istirahat Sebelum sakit : ........................................................................................................ :......................................................................................................... :......................................................................................................... :......................................................................................................... Selama sakit

:......................................................................................................... :......................................................................................................... :......................................................................................................... :.........................................................................................................

4. Pola Personal Higiene Sebelum sakit : ......................................................................................................... :......................................................................................................... :......................................................................................................... :......................................................................................................... Selama sakit

:..................................................................................................... :......................................................................................................... :......................................................................................................... :.........................................................................................................

5. Pola Aktivitas Sebelum sakit : ......................................................................................................... :......................................................................................................... :......................................................................................................... :......................................................................................................... Selama sakit

2. 2.1

:................................................................................................... :......................................................................................................... :......................................................................................................... :.........................................................................................................

Pemeriksaan Pemeriksaan Umum Kesadaran:..................................., GCS: ................................................ Suhu : Nadi : RR : BB : TB : 2.2 Pemeriksaan Fisik: Kepala : .................................................................................................................... .................................................................................................................... .................................................................................................................... Mata : .................................................................................................................... .................................................................................................................... ... .................................................................................................................

Hidung Mulut Telinga Leher Thorax I: P: P: A: Abdomen I: A: P: P: Genetalia

: .................................................................................................................... .................................................................................................................... : .................................................................................................................... .................................................................................................................... : .................................................................................................................... .................................................................................................................... : .................................................................................................................... .................................................................................................................... : .................................................................................................................... ... ................................................................................................................. .................................................................................................................... ... ................................................................................................................. .................................................................................................................... ... ................................................................................................................. .................................................................................................................... .................................................................................................................... : .................................................................................................................... ... ................................................................................................................. .................................................................................................................... ... ................................................................................................................. .................................................................................................................... ... ................................................................................................................. .................................................................................................................... .................................................................................................................... : ..................................................................................................................

Ekstremitas Atas

: : Kanan: ....................................................................................................... ......................................................................................................... Kiri : ......................................................................................................... .......................................................................................................... Bawah : Kanan: ....................................................................................................... ......................................................................................................... Kiri : ......................................................................................................... ..........................................................................................................

2.3 Pemeriksaan Penunjang: (tanggal:.............................) ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. ..............................................................................................................................................

............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. ..............................................................................................................................................

2.4 Therapi (oleh dr tanggal ) ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ............................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ............................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ............................................................................................................................................ ...............................................................................................................................................

Lamongan ,...................................... Mahasiswa Yang mengkaji

---------------------------------------NIM.

ASUHAN KEPERAWATAN PADA Tn / Ny./ Sdr ……. DENGAN………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………… I.

Pengkajian (tgl……………, pukul: ………….WIB) 1.11 Identitas Klien Nama :.......................................................................................................... Umur : ......................................................................................................... Jenis Kelamin : ......................................................................................................... Agama : ......................................................................................................... Suku/ Bangsa : ......................................................................................................... Pendidikan : ......................................................................................................... Pekerjaan : ......................................................................................................... Penghasilan : ......................................................................................................... Alamat : ......................................................................................................... MRS tgl/ jam : ......................................................................................................... Ruangan : ......................................................................................................... No. Reg : ......................................................................................................... Dx. Medis : ......................................................................................................... 1.12 Identitas penanggung jawab Nama : ......................................................................................................... Umur : ......................................................................................................... Jenis Kelamin : ......................................................................................................... Agama : ......................................................................................................... Suku/ Bangsa : ......................................................................................................... Pendidikan : ......................................................................................................... Pekerjaan : ......................................................................................................... Penghasilan : ......................................................................................................... Alamat : ......................................................................................................... Hub. Dengan klien : ......................................................................................................... 1.13 Keluhan Utama : ......................................................................................................... .......................................................................................................... 1.14 Riwayat Penyakit Sekarang : ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ 1.15 Riwayat Penyakit Dahulu : ............................................................................................ ............................................................................................ ............................................................................................

............................................................................................ 1.16 Riwayat Penyakit Keluarga : ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ 1.17 Riwayat Psiko, Sosio, Spiritual: Riwayat Psiko :......................................................................................................... :......................................................................................................... Riwayat Sosial

: ........................................................................................................ .........................................................................................................

Riwayat Spiritual

: ......................................................................................................... .........................................................................................................

1.18

ADL (Activity Daily of Life): 1. Pola Nutrisi Sebelum sakit : ........................................................................................................ ......................................................................................................... ......................................................................................................... ......................................................................................................... Selama sakit

:........................................................................................................ ......................................................................................................... ......................................................................................................... .........................................................................................................

2. Pola Eliminasi Sebelum sakit : ......................................................................................................... :......................................................................................................... :......................................................................................................... :......................................................................................................... Selama sakit

: ..................................................................................................... :......................................................................................................... :......................................................................................................... :.........................................................................................................

3. Pola Istirahat Sebelum sakit : ........................................................................................................ :......................................................................................................... :......................................................................................................... :......................................................................................................... Selama sakit

:......................................................................................................... :......................................................................................................... :......................................................................................................... :.........................................................................................................

4. Pola Personal Higiene Sebelum sakit : ......................................................................................................... :.........................................................................................................

:......................................................................................................... :......................................................................................................... Selama sakit

:..................................................................................................... :......................................................................................................... :......................................................................................................... :.........................................................................................................

5. Pola Aktivitas Sebelum sakit : ......................................................................................................... :......................................................................................................... :......................................................................................................... :......................................................................................................... Selama sakit

2. 2.1

:................................................................................................... :......................................................................................................... :......................................................................................................... :.........................................................................................................

Pemeriksaan Pemeriksaan Umum Kesadaran:..................................., GCS: ................................................ Suhu : Nadi : RR : BB : TB : 2.5 Pemeriksaan Fisik: Kepala : .................................................................................................................... .................................................................................................................... .................................................................................................................... Mata : .................................................................................................................... .................................................................................................................... ... ................................................................................................................. Hidung : .................................................................................................................... .................................................................................................................... Mulut : .................................................................................................................... .................................................................................................................... Telinga : .................................................................................................................... .................................................................................................................... Leher : .................................................................................................................... .................................................................................................................... Thorax : I: .................................................................................................................... ... ................................................................................................................. P: .................................................................................................................... ... ................................................................................................................. P: .................................................................................................................... ... ................................................................................................................. A: .................................................................................................................... .................................................................................................................... Abdomen : I: .................................................................................................................... ... .................................................................................................................

A: P: P: Genetalia

.................................................................................................................... ... ................................................................................................................. .................................................................................................................... ... ................................................................................................................. .................................................................................................................... .................................................................................................................... : ..................................................................................................................

Ekstremitas Atas

: : Kanan: ....................................................................................................... ......................................................................................................... Kiri : ......................................................................................................... .......................................................................................................... Bawah : Kanan: ....................................................................................................... ......................................................................................................... Kiri : ......................................................................................................... ..........................................................................................................

2.6 Pemeriksaan Penunjang: (tanggal:.............................) ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. ..............................................................................................................................................

............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. ..............................................................................................................................................

2.7 Therapi (oleh dr tanggal ) ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ............................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ............................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ............................................................................................................................................ ...............................................................................................................................................

Lamongan ,...................................... Mahasiswa Yang mengkaji

---------------------------------------NIM.

ASUHAN KEPERAWATAN PADA Ny. DENGAN………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………… I.

Pengkajian (tgl……………, pukul: ………….WIB) 1.19 Identitas Klien Nama :.......................................................................................................... Umur : ......................................................................................................... Jenis Kelamin : ......................................................................................................... Agama : ......................................................................................................... Suku/ Bangsa : ......................................................................................................... Pendidikan : ......................................................................................................... Pekerjaan : ......................................................................................................... Penghasilan : ......................................................................................................... Alamat : ......................................................................................................... MRS tgl/ jam : ......................................................................................................... Ruangan : ......................................................................................................... No. Reg : ......................................................................................................... Dx. Medis : ......................................................................................................... 1.20 Identitas penanggung jawab Nama : ......................................................................................................... Umur : ......................................................................................................... Jenis Kelamin : ......................................................................................................... Agama : ......................................................................................................... Suku/ Bangsa : ......................................................................................................... Pendidikan : ......................................................................................................... Pekerjaan : ......................................................................................................... Penghasilan : ......................................................................................................... Alamat : ......................................................................................................... Hub. Dengan klien : ......................................................................................................... 1.21 Keluhan Utama : ......................................................................................................... .......................................................................................................... 1.22 Riwayat Penyakit Sekarang : ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................

1.23 Riwayat Penyakit Dahulu : ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ 1.24 Riwayat Penyakit Keluarga : ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ 1.25 Riwayat Psiko, Sosio, Spiritual: Riwayat Psiko :......................................................................................................... :......................................................................................................... Riwayat Sosial

: ........................................................................................................ .........................................................................................................

Riwayat Spiritual

: ......................................................................................................... .........................................................................................................

1.26 Riwayat Menstruasi: Menarche : ................................................................................................. HPHT : ................................................................................................. HPL : ................................................................................................. Lama Menstruasi : ................................................................................................. Bentuk : ................................................................................................. Warna : ................................................................................................. Jumlah : ................................................................................................. Fluor albus : ................................................................................................. Warna : ................................................................................................. Jumlah : ................................................................................................. Bau : ................................................................................................. Waktu : ................................................................................................. Disminore : ................................................................................................. 1.27 Riwayat Kehamilan, Persalinan, Nifas dan KB saat ini: ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. 1.28 Riwayat Kehamilan, Persalinan, Nifas dan KB yang lalu: ………………………………………………………………………………………………. ……………………………………………………………………………………………….

………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. ………………………………………………………………………………………………. 1.29

ADL (Activity Daily of Life): 1. Pola Nutrisi Sebelum sakit : ........................................................................................................ ......................................................................................................... ......................................................................................................... ......................................................................................................... Selama sakit

:........................................................................................................ ......................................................................................................... ......................................................................................................... .........................................................................................................

2. Pola Eliminasi Sebelum sakit : ......................................................................................................... :......................................................................................................... :......................................................................................................... :......................................................................................................... Selama sakit

: ..................................................................................................... :......................................................................................................... :......................................................................................................... :.........................................................................................................

3. Pola Istirahat Sebelum sakit : ........................................................................................................ :......................................................................................................... :......................................................................................................... :......................................................................................................... Selama sakit

:......................................................................................................... :......................................................................................................... :......................................................................................................... :.........................................................................................................

4. Pola Personal Higiene Sebelum sakit : ......................................................................................................... :......................................................................................................... :......................................................................................................... :......................................................................................................... Selama sakit

:..................................................................................................... :......................................................................................................... :......................................................................................................... :.........................................................................................................

5. Pola Aktivitas Sebelum sakit : ......................................................................................................... :......................................................................................................... :......................................................................................................... :......................................................................................................... Selama sakit

2. 2.1

:................................................................................................... :......................................................................................................... :......................................................................................................... :.........................................................................................................

Pemeriksaan Pemeriksaan Umum Kesadaran:..................................., GCS: ................................................ Suhu : Nadi : RR : BB : TB : 2.8 Pemeriksaan Fisik: Kepala : .................................................................................................................... .................................................................................................................... .................................................................................................................... Mata : .................................................................................................................... .................................................................................................................... ... ................................................................................................................. Hidung : .................................................................................................................... .................................................................................................................... Mulut : .................................................................................................................. ..................................................................................................................... Telinga : .................................................................................................................... .................................................................................................................... Leher : .................................................................................................................... ................................................................................................................... Thorax : I: .................................................................................................................... ... ................................................................................................................. .................................................................................................................. ................................................................................................................... P: .................................................................................................................... ... ................................................................................................................. …………………………………………………………………………… …………………………………………………………………………… P: .................................................................................................................... ... ................................................................................................................. A: .................................................................................................................... .................................................................................................................... Abdomen : I: .................................................................................................................... ... ................................................................................................................. A: .................................................................................................................... ... ................................................................................................................. P: .................................................................................................................... ... ................................................................................................................. .................................................................................................................... ....................................................................................................................

P: Genetalia

.................................................................................................................... .................................................................................................................... .................................................................................................................... .................................................................................................................... .................................................................................................................... .................................................................................................................... .................................................................................................................... : .................................................................................................................. .................................................................................................................... ....................................................................................................................

Ekstremitas Atas

: : Kanan: ....................................................................................................... ......................................................................................................... Kiri : ......................................................................................................... .......................................................................................................... Bawah : Kanan: ....................................................................................................... ......................................................................................................... Kiri : ......................................................................................................... ..........................................................................................................

2.9 Pemeriksaan Penunjang: (tanggal:.............................) ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................

.............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. ..............................................................................................................................................

2.10 Therapi (oleh dr tanggal ) ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ............................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ............................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ............................................................................................................................................ ...............................................................................................................................................

Lamongan,...................................... Mahasiswa Yang mengkaji

---------------------------------------NIM.

ANALISA DATA NAMA UMUR NO

: :

RUANG: NO.REG: ANALISIS DATA

ETIOLOGI

PROBLEM

RUMUSAN DIAGNOSA NAMA UMUR NO

: : RUMUSAN DIAGNOSA

RUANG: NO.REG: TANGGAL TANGGAL DITEMUKAN TERATASI

TTD

IMPLEMENTASI NAMA : UMUR : NO DX. KEP

TGL/ JAM

RUANG: NO.REG: IMPLEMENTASI

TTD

EVALUASI NAMA : UMUR : NO DX. KEP

TGL/ JAM

RUANG: NO.REG: CATATAN PERKEMBANGAN

TTD

INTERVENSI NAMA : UMUR : TGL/ DX. KEP JAM

TUJUAN

INTERVENSI

RUANG : NO. REG : RASIONAL

TTD