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PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG
Nama Mahasiswa Tempat Praktek
: ……………………………… : ………………………………
Tanggal Praktek
: ………………………………
Pengkajian Dilakukan Tanggal................jam................WIB 1.
2.
Identitas Klien Nama :
No RM
:
Usia
:
Tgl Masuk
:
Jenis
:
Tgl Pengkajian
:
Kelamin
:
Sumber Informasi
:
Alamat
:
Keluarga Terdekat
:
No Telepon
:
status
:
Status
:
Alamat
:
Agama
:
No Telepon
:
Suku
:
Pendidikan
:
Pekerjaan
:
Pekerjaan
:
Lama
:
Bekerja
:
Riwayat Kesehatan a. Keluhan Utama (saat masuk RS) ....................................................................................................................................... ....................................................................................................................................... .......................................................................... b. Keluhan utama (saat pengkajian) ....................................................................................................................................... ....................................................................................................................................... ........................................................................ c. Riwayat Kesehatan Saat Ini ............................................................................................................................................. .. ........................................................................................................................................... d. Riwayat Kesehatan Terdahulu 1. Penyakit yang pernah dialami: a. Kecelakaan :…………………………………………………… b. Operasi (jenis dan waktu):…………………………………………………… c. Penyakit (kronis dan akut) :………………………………………………… d. Terakhir masuk RS :……………………………………………………
2. Alergi (obat, makanan, plester, dsb) …………………………………………………………………………………… … …………………………………………………………………………………… …
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG ............................................................................................................................. 3. Imunisasi (tambahan; flu, pneumonia, tetanus, dll) …………………………………………………………………………………… … 4. Kebisasaan Jenis Frekuensi Jumlah Lamanya a. Merokok
: ………………….. ………………….. …………………..
b. Kopi
: ………………….. ………………….. …………………..
c. Alkohol
: ………………….. ………………….. …………………..
5. Obat-obatan yang digunakan Jenis
3.
Lamanya
Dosis
………………………..
………………………..
………………………..
………………………..
………………………..
………………………..
Riwayat Keluarga .............................................................................................................................................
............................................................................................................................................. 4.
Catatan Penanganan Kasus (Dimulai saat pasien di rawat di ruang rawat sampai pengambilan kasus kelolaan) ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................
5.
Pengkajian Keperawatan (12 Domain NANDA) Intruksi: Beri tanda cek () pada istilah yang tepat/ sesuai dengan data-data di bawah ini. Gambarkan semua temuan abnormal secara objektif, gunakan kolom data tambahan bila perlu. 1. Peningkatan Kesehatan Pengetahuan tentang penyakit/perawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................. ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ 2. Nutrisi a. Mulut Trismus (
), Halitosis ( )
Bibir: lembab( )
), pucat(
),sianosis(
),labio/palatoskizis(
), stomatitis(
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG Gusi: (
b.
), plak putih(
), lesi(
Gigi: Normal(
), Ompong(
Lidah: bersih (
), kotor/ putih (
)
), Caries(
), Jumlah gigi:...................
), jamur (
)
Leher Kaku Kuduk (
) Simetris(
Kelenjar Tiroid : normal ( Tenggorok
:
), Benjolan (
) Tonsil (
), pembesaran (
kesulitan
)
)
menelan
(
),
dll..................................................................................................
Kebutuhan Nutrisi dan Cairan BB sebelum sakit:
kg
BB sakit:
kg
Program Diit RS : Makanan yang disukai:.......................... Selera makan:........................... Alat makan yang digunakan:........................ Pola makan( x/ hari):...................... Porsi makan yang dihabiskan:............................ Pola
Minum
.............................gelas/hari)
jenis
air
minum:.....................................................
c.
Intake Makanan
:
Intake Cairan
:
Abdomen Inspeksi : Bentuk: simetris( Palpasi : massa (
), nyeri (
), tidak simetris(
), kembung(
), asites(
),
)
Kuadran I : Kuadran II : Kuadran III : Kuadran IV : Auskultasi : bising usus........................x/mnt Perkusi : Timpani (
), redup (
)
BAB : warna........................................Frekuensi................................x/hari Konsisitensi:.................................... lendir ( Konstipasi (
), darah (
), ampas (
)
)
Data Tambahan : ........................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 3. Eliminasi dan Pertukaran a. BAK: b.
Warna:
c.
Konsistensi:
d.
Frekuensi:
e.
Urine Output :
f.
Penggunaan Kateter:.............................................................................................
g.
Vesika Urinaria: Membesar .....................Nyeri tekan............................
h.
Gangguan; Anuaria (
x/ hari cc
Inkontinensia Urin (
), Oliguria ( ), Poliuria (
Jalan nafas: Sputum (
), Retensi Uria ( ), Dysuria (
), nokturia (
),
)
), warna sputum (
)
konsisitensi:........................................ Batuk (
) frekuensi:..............................
Dada Bentuk: Simetris ( benjolan (
), Barrel chest/dada tong(
), pigeon chest/dada burung (
)
), dll………………..
Paru-paru: Inspeksi: RR………x/ min, Palpasi: Normal (
), ekspansi pernafasan(
Perkusi: Normal/ Sonor( Auskultasi: irama(
), hiper sonor(
)
)
), teratur( ),
Suara nafas: vesicular( (
), redup/pekak(
), taktil fremitus(
), bronkial(
), Amforik ( ), Cog Wheel Breath Sound
) metamorphosing breath sound ( )
Suara Tambahan: Ronki (
), pleural friction(
)
Data Tambahan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 4. Aktivitas/Istirahat Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa saat tidur,dll): Kebiasaan Tidur siang:......................................jam/hari Skala Aktivitas:
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG Kemampuan perawatan diri
0
1
2
3
4
Makan/minum Mandi Toileting Berpakaian Mobilitas di tempat tidur Berpindah Ambulasi/ROM 0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total Persendian: Nyeri Sendi (
), pergerakan sendi:.......................
ROM ( Range Of Motion):
Kekuatan Otot :
Kelainan Otot: Tonus/aktifitas Aktif (
)
Tenang (
Menagis keras (
)
)
Letargi (
lemah (
)
Kejang (
) melengking (
)
), Sulit menangis (
)
Ekstremitas Amelia ( ), Sindaktili (
), Polidaktili(
)
Reflek Pat0logis : Babinsky
: + ( ), - ( )
Kernig
: + ( ), - ( )
Brudzinsky
: + ( ), - ( )
Reflek Fisiologis Biceps
: + ( ), - ( )
Triceps
: + ( ), - ( )
Patella
: + ( ), - ( )
Jantung Inspeksi: ictus cordis/denyut apeks( Palpasi: kardiomegali( Perkusi: redup(
), normal(
) melebar(
)
)
), pekak(
)
Auskultasi: HR...............x/mnt. Aritmia( Mandi:...................x/mnt Sikat gigi :........................................x/mnt Ganti Pakaian :..................................x/mnt
),Disritmia(
) , Murmur (
)
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG Memotong kuku:...............................x/mnt
DATA TAMBAHAN : ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 5. Persepsi/Kognitif Kesan Umum Tampak Sakit: ringan (
),sedang( ),berat (
), pucat (
), sesak (
), kejang(
) 1.
2.
Kepala a. Fontanel anterior Lunak( ), Tegas( ), Datar( ), Menonjol( ), Cekung( ) b. Rambut: warna...............mudah dicabut ( ), ketombe( ), kutu( ) Mata Mata: jernih( Visus: 6/6( Pupil: Isokor(
), mengalir, kemerahan( ), 6/300(
), sekret(
), 6/ tak terhingga(
), anisokor(
), miosis(
)
),
), midriasis(
),
reaksi terhadap cahaya: kanan Positif( ), negatif( ),kiri negatif(
) positif(
), alat bantu: kacamata(
), Softlens(
Conjungtiva: merah jambu( Sklera: Putih( 3.
), Ikterik(
), anemis(
)
)
Bibir, Lidah a. Bibir : normal (
) sumbing (
)
b. Sumbing langit-langit/palatum (
)
c. Lidah: bersih ( 4.
)
), kotor/ putih (
), jamur (
)
Telinga, Hidung, Tenggorok a. Telinga: Normal (
)Abnormal (
) Sekret(
b. Hidung: Simetris (
)Asimetris (
) Sekret (
) ) Nafas cuping hidung (
) c. Tenggorok: Tonsil(
), radang(
)
Data Tambahan ........................................................................................................................................... ...........................................................................................................................................
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 6. Persepsi Diri Perasaaan klien terhadap penyakit yang dideritanya..................................................... Persepsi klien terhadap dirinya....................................................................................... Konsep diri...................................................................................................................... Tingkat kecemasan......................................................................................................... Citra Diri/Bodi image:..................................................................................................... Data tambahan ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ............................. Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 7. Peran Hubungan Budaya: Suku: Agama yang di anut: Bahasa yang digunakan : Masalah sosial yang penting: Hubungan dengan orang tua: Hubungan dengan saudara kandung: Hubungan dengan lingkungan sekitar
Data Tambahan ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan:
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 8. Seksualitas Dan Reproduksi Genitalia dan Anus Laki-laki Penis: normal/ada (
), Abnormal…………………,
Scrotum dan testis: normal( Anus ; normal/ada (
), hernia(
), atresia ani(
), hidrokel(
)
)
Perempuan Vagina: sekret(
), warna(
Anus: normal/ada (
)
), atresia ani(
)
Riwayat kehamilan dan kelahiran : Data Tambahan ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 9. Toleransi/Koping Stress GCS :....... E:........................................................................................ V: ....................................................................................... M:....................................................................................... Data Tambahan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG 10. Prinsip Hidup Budaya
:
Spritual / Religius
Budaya yang diikuti pasien dengan aktifitasnya Masalah terkait budaya
:
Aktifitas ibadah dan kegiatan keagamaan yang biasa dilakukan sehari-hari Aktifitas ibadah dan kegiatan keagamaan yang sekarang tidak dapat dilaksanakan Perasaan pasien akibat tidak dapat melaksanakan hal tersebut Upaya pasien mengaasi perasaan tersebut Keyakinan pasien tentang peristiwa/masalah kesehatan yang sekarang sedang dialami
Psikologis
:
Perasaan pasien setelah mengalami masalah ini Cara mengatasi perasaan tersebut Rencana pasien setelah masalahnya terselesaikan Jika rencana ini tidak dapat dilaksanakan Pengetahuan pasien tentang masalah/penyakit yang
Aktifitas/peran pasien di masyarakat Masalah social
ada Sosial
:
Data Tambahan ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................
Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 11. Keselamatan/Perlindungan Tingkat Kesadaran : Composmentis ( ),Soporocoma ( ) Coma (
), Apatis ( ), Somnolen ( ), Sopor (
)
TTV : Suhu.............O C, Nadi........x/min, TD...............mmHg, RR..........x/min Warna kulit :
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG Sianosis ( ), I kterus (
), eritematosus rash (
), discoid lupus (
), oedema (
), Bula ( ), Ganggren ( ), nekrotik jaringan ( Echimosis (
), Petekie (
Turgor Kulit:
), Hiperpigmentasi (
)
) elastis ( ), tidak elastis (
)
Data Tambahan ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................
Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 12. Kenyamanan Provaiking : Quality
:
Regio
:
Scala
:
Time
:
Data Tambahan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG
Terapi Tanggal Terapi : No
Nama Terapi
Dosis
Cara
Golongan
Pemberian
Obat
Pemeriksaan Penunjang : Laboratorium ( Tanggal Pemeriksaan )
USG ( Tanggal Pemeriksaan ) EKG ( Tanggal Pemeriksaan ) Rontsen ( Tanggal Pemeriksaan ) EEG ( Tanggal Pemeriksaan ) Dll.....
Indikasi
Kontra Indikasi
Nama Mahasiswa Tempat Praktek
: ……………………………… : ………………………………
Tanggal Praktek
: ………………………………
Pengkajian Dilakukan Tanggal................jam................WIB 1.
2.
Identitas Klien Nama :
No RM
:
Usia
:
Tgl Masuk
:
Jenis
:
Tgl Pengkajian
:
Kelamin
:
Sumber Informasi
:
Alamat
:
Keluarga Terdekat
:
No Telepon
:
status
:
Status
:
Alamat
:
Agama
:
No Telepon
:
Suku
:
Pendidikan
:
Pekerjaan
:
Pekerjaan
:
Lama
:
Bekerja
:
Riwayat Kesehatan a. Keluhan Utama (saat masuk RS) ....................................................................................................................................... ....................................................................................................................................... .......................................................................... b. Keluhan utama (saat pengkajian) ....................................................................................................................................... ....................................................................................................................................... ........................................................................ c. Riwayat Kesehatan Saat Ini ............................................................................................................................................. .. ........................................................................................................................................... d. Riwayat Kesehatan Terdahulu 1. Penyakit yang pernah dialami: a. Kecelakaan :…………………………………………………… b. Operasi (jenis dan waktu):…………………………………………………… c. Penyakit (kronis dan akut) :………………………………………………… d. Terakhir masuk RS :……………………………………………………
2. Alergi (obat, makanan, plester, dsb) …………………………………………………………………………………… … …………………………………………………………………………………… …
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG ............................................................................................................................. 3. Imunisasi (tambahan; flu, pneumonia, tetanus, dll) …………………………………………………………………………………… … 4. Kebisasaan Jenis Frekuensi Jumlah Lamanya a. Merokok
: ………………….. ………………….. …………………..
b. Kopi
: ………………….. ………………….. …………………..
c. Alkohol
: ………………….. ………………….. …………………..
5. Obat-obatan yang digunakan Jenis
3.
Lamanya
Dosis
………………………..
………………………..
………………………..
………………………..
………………………..
………………………..
Riwayat Keluarga .............................................................................................................................................
............................................................................................................................................. 4.
Catatan Penanganan Kasus (Dimulai saat pasien di rawat di ruang rawat sampai pengambilan kasus kelolaan) ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. .............................................................................................................................................
5.
Pengkajian Keperawatan (12 Domain NANDA) Intruksi: Beri tanda cek () pada istilah yang tepat/ sesuai dengan data-data di bawah ini. Gambarkan semua temuan abnormal secara objektif, gunakan kolom data tambahan bila perlu. 1. Peningkatan Kesehatan Pengetahuan tentang penyakit/perawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................. ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ 2. Nutrisi a. Mulut Trismus (
), Halitosis ( )
Bibir: lembab( )
), pucat(
),sianosis(
),labio/palatoskizis(
), stomatitis(
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG Gusi: (
b.
), plak putih(
), lesi(
Gigi: Normal(
), Ompong(
Lidah: bersih (
), kotor/ putih (
)
), Caries(
), Jumlah gigi:...................
), jamur (
)
Leher Kaku Kuduk (
) Simetris(
Kelenjar Tiroid : normal ( Tenggorok
:
), Benjolan (
) Tonsil (
), pembesaran (
kesulitan
)
)
menelan
(
),
dll..................................................................................................
Kebutuhan Nutrisi dan Cairan BB sebelum sakit:
kg
BB sakit:
kg
Program Diit RS : Makanan yang disukai:.......................... Selera makan:........................... Alat makan yang digunakan:........................ Pola makan( x/ hari):...................... Porsi makan yang dihabiskan:............................ Pola
Minum
.............................gelas/hari)
jenis
air
minum:.....................................................
c.
Intake Makanan
:
Intake Cairan
:
Abdomen Inspeksi : Bentuk: simetris( Palpasi : massa (
), nyeri (
), tidak simetris(
), kembung(
), asites(
),
)
Kuadran I : Kuadran II : Kuadran III : Kuadran IV : Auskultasi : bising usus........................x/mnt Perkusi : Timpani (
), redup (
)
BAB : warna........................................Frekuensi................................x/hari Konsisitensi:.................................... lendir ( Konstipasi (
), darah (
), ampas (
)
)
Data Tambahan : ........................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 3. Eliminasi dan Pertukaran a. BAK: b.
Warna:
c.
Konsistensi:
d.
Frekuensi:
e.
Urine Output :
f.
Penggunaan Kateter:.............................................................................................
g.
Vesika Urinaria: Membesar .....................Nyeri tekan............................
h.
Gangguan; Anuaria (
x/ hari cc
Inkontinensia Urin (
), Oliguria ( ), Poliuria (
Jalan nafas: Sputum (
), Retensi Uria ( ), Dysuria (
), nokturia (
),
)
), warna sputum (
)
konsisitensi:........................................ Batuk (
) frekuensi:..............................
Dada Bentuk: Simetris ( benjolan (
), Barrel chest/dada tong(
), pigeon chest/dada burung (
)
), dll………………..
Paru-paru: Inspeksi: RR………x/ min, Palpasi: Normal (
), ekspansi pernafasan(
Perkusi: Normal/ Sonor( Auskultasi: irama(
), hiper sonor(
)
)
), teratur( ),
Suara nafas: vesicular( (
), redup/pekak(
), taktil fremitus(
), bronkial(
), Amforik ( ), Cog Wheel Breath Sound
) metamorphosing breath sound ( )
Suara Tambahan: Ronki (
), pleural friction(
)
Data Tambahan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 4. Aktivitas/Istirahat Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa saat tidur,dll): Kebiasaan Tidur siang:......................................jam/hari Skala Aktivitas:
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG Kemampuan perawatan diri
0
1
2
3
4
Makan/minum Mandi Toileting Berpakaian Mobilitas di tempat tidur Berpindah Ambulasi/ROM 0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total Persendian: Nyeri Sendi (
), pergerakan sendi:.......................
ROM ( Range Of Motion):
Kekuatan Otot :
Kelainan Otot: Tonus/aktifitas Aktif (
)
Tenang (
Menagis keras (
)
)
Letargi (
lemah (
)
Kejang (
) melengking (
)
), Sulit menangis (
)
Ekstremitas Amelia ( ), Sindaktili (
), Polidaktili(
)
Reflek Pat0logis : Babinsky
: + ( ), - ( )
Kernig
: + ( ), - ( )
Brudzinsky
: + ( ), - ( )
Reflek Fisiologis Biceps
: + ( ), - ( )
Triceps
: + ( ), - ( )
Patella
: + ( ), - ( )
Jantung Inspeksi: ictus cordis/denyut apeks( Palpasi: kardiomegali( Perkusi: redup(
), normal(
) melebar(
)
)
), pekak(
)
Auskultasi: HR...............x/mnt. Aritmia( Mandi:...................x/mnt Sikat gigi :........................................x/mnt Ganti Pakaian :..................................x/mnt
),Disritmia(
) , Murmur (
)
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG Memotong kuku:...............................x/mnt
DATA TAMBAHAN : ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 5. Persepsi/Kognitif Kesan Umum Tampak Sakit: ringan (
),sedang( ),berat (
), pucat (
), sesak (
), kejang(
) 1.
2.
Kepala a. Fontanel anterior Lunak( ), Tegas( ), Datar( ), Menonjol( ), Cekung( ) b. Rambut: warna...............mudah dicabut ( ), ketombe( ), kutu( ) Mata Mata: jernih( Visus: 6/6( Pupil: Isokor(
), mengalir, kemerahan( ), 6/300(
), sekret(
), 6/ tak terhingga(
), anisokor(
), miosis(
)
),
), midriasis(
),
reaksi terhadap cahaya: kanan Positif( ), negatif( ),kiri negatif(
) positif(
), alat bantu: kacamata(
), Softlens(
Conjungtiva: merah jambu( Sklera: Putih( 3.
), Ikterik(
), anemis(
)
)
Bibir, Lidah a. Bibir : normal (
) sumbing (
)
b. Sumbing langit-langit/palatum (
)
c. Lidah: bersih ( 4.
)
), kotor/ putih (
), jamur (
)
Telinga, Hidung, Tenggorok a. Telinga: Normal (
)Abnormal (
) Sekret(
b. Hidung: Simetris (
)Asimetris (
) Sekret (
) ) Nafas cuping hidung (
) c. Tenggorok: Tonsil(
), radang(
)
Data Tambahan ........................................................................................................................................... ...........................................................................................................................................
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 6. Persepsi Diri Perasaaan klien terhadap penyakit yang dideritanya..................................................... Persepsi klien terhadap dirinya....................................................................................... Konsep diri...................................................................................................................... Tingkat kecemasan......................................................................................................... Citra Diri/Bodi image:..................................................................................................... Data tambahan ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ............................. Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 7. Peran Hubungan Budaya: Suku: Agama yang di anut: Bahasa yang digunakan : Masalah sosial yang penting: Hubungan dengan orang tua: Hubungan dengan saudara kandung: Hubungan dengan lingkungan sekitar
Data Tambahan ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan:
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 8. Seksualitas Dan Reproduksi Genitalia dan Anus Laki-laki Penis: normal/ada (
), Abnormal…………………,
Scrotum dan testis: normal( Anus ; normal/ada (
), hernia(
), atresia ani(
), hidrokel(
)
)
Perempuan Vagina: sekret(
), warna(
Anus: normal/ada (
)
), atresia ani(
)
Riwayat kehamilan dan kelahiran : Data Tambahan ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 9. Toleransi/Koping Stress GCS :....... E:........................................................................................ V: ....................................................................................... M:....................................................................................... Data Tambahan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG 10. Prinsip Hidup Budaya
:
Spritual / Religius
Budaya yang diikuti pasien dengan aktifitasnya Masalah terkait budaya
:
Aktifitas ibadah dan kegiatan keagamaan yang biasa dilakukan sehari-hari Aktifitas ibadah dan kegiatan keagamaan yang sekarang tidak dapat dilaksanakan Perasaan pasien akibat tidak dapat melaksanakan hal tersebut Upaya pasien mengaasi perasaan tersebut Keyakinan pasien tentang peristiwa/masalah kesehatan yang sekarang sedang dialami
Psikologis
:
Perasaan pasien setelah mengalami masalah ini Cara mengatasi perasaan tersebut Rencana pasien setelah masalahnya terselesaikan Jika rencana ini tidak dapat dilaksanakan Pengetahuan pasien tentang masalah/penyakit yang
Aktifitas/peran pasien di masyarakat Masalah social
ada Sosial
:
Data Tambahan ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................
Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 11. Keselamatan/Perlindungan Tingkat Kesadaran : Composmentis ( ),Soporocoma ( ) Coma (
), Apatis ( ), Somnolen ( ), Sopor (
)
TTV : Suhu.............O C, Nadi........x/min, TD...............mmHg, RR..........x/min Warna kulit :
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG Sianosis ( ), I kterus (
), eritematosus rash (
), discoid lupus (
), oedema (
), Bula ( ), Ganggren ( ), nekrotik jaringan ( Echimosis (
), Petekie (
Turgor Kulit:
), Hiperpigmentasi (
)
) elastis ( ), tidak elastis (
)
Data Tambahan ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................
Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ 12. Kenyamanan Provaiking : Quality
:
Regio
:
Scala
:
Time
:
Data Tambahan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Masalah keperawatan: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................
PROGRAM STUDI PROFESI NERS STIKES MUHAMMADIYAH PALEMBANG
Terapi Tanggal Terapi : No
Nama Terapi
Dosis
Cara
Golongan
Pemberian
Obat
Pemeriksaan Penunjang : Laboratorium ( Tanggal Pemeriksaan )
USG ( Tanggal Pemeriksaan ) EKG ( Tanggal Pemeriksaan ) Rontsen ( Tanggal Pemeriksaan ) EEG ( Tanggal Pemeriksaan ) Dll.....
Indikasi
Kontra Indikasi
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