Pengkajian Anak.docx
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Pengkajian Anak.docx as PDF for free.
More details
- Words: 1,457
- Pages: 23
PENGKAJIAN KEPERAWATAN ANAK DATA IDENTITAS KLIEN Nama : ................................................................................. Tempat / Tanggal lahir :.................................................................................. Jenis Kelamin : .................................................................................. Nama Ayah/lbu :.................................................................................. Pekerjaan Ayah :.................................................................................. Pendidikan Ayah :.................................................................................. Pekerjaan lbu :.................................................................................. Pendidikan Ibu :.................................................................................. Alamat :.................................................................................. Kultur :.................................................................................. Agama :.................................................................................. Diagnosis Medis : .................................................................................. Tanggal Pengkajian : .................................................................................. I.
KELUHAN UTAMA
a.
Keluhan Masuk Rumah Sakit ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
b. Keluhan Saat ini ......................................................................................................................................... ......................................................................................................................................... .........................................................................................................................................
II. RIWAYAT KESEHATAN a. Riwayat penyakit sekarang: ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
b. Riwayat penyakit dahulu ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... III. RIWAYAT IMUNISASI ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
IV. RIWAYAT PENYAKIT KELUARGA ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
GENOGRAM
Keterangan: ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. V. RIWAYAT SOSIAL 1. Sistem pendukung/ keluarga terdekat yang dapat dihubungi ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 2. Lingkungan rumah ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 3.
Problem sosial yang penting ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
VI. KEADAAN KESEHATAN SAAT INI 1. Tindakan Operasi ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 2. Status Nutrisi ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
3. Status Cairan: ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 4. Aktivitas Anak Sebelum Masuk Rumah Sakit: ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... Saat Dirawat Di Rumah Sakit: ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
5. Obat-Obatan No
Obat Dosis Indikasi .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ ....................................................
.......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ ....................................................
.......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ ....................................................
6. Hasil Laboratorium Pemeriksaan HEMATOLOGI Hemoglobin Lekosit Eritrosit Hematokrit Trombosit RDW-CV MCV,MCH, MCHC MCV MCH MCHC HITUNG JENIS Gran% Limfosit% MID% Gran# Limfosit# MID# KIMIA DARAH Glukosa Darah Sewaktu HATI SGOT SGPT GINJAL Ureum Kreatinin ELEKTROLIT Natrium Kalium Chlorida
Hasil
Nilai Normal
Satuan
................. ................. ................. ................. ................. .................
14.00-18.00 4.0-10.5 4.00-5.50 32.00-50.00 150-450 12.1-14.0
g/dl ribu/ul juta/ul vol% ribu/ul %
................. ................. .................
75.0 – 96.00 28.0 – 32.0 32.0 – 37.0
fl pg %
................. ................. ................. ................. ................. .................
50.0 – 70.0 25.0 – 40.0 4.0-11.0 2.50 – 7.00 1.25-4.0
% % % ribu/ul ribu/ul ribu/ul
.................
<200
mg/dl
................. .................
0-46 0-45
u/l u/l
................. .................
10-50 0.7-1.4
mg/dl mg/dl
................. ................. .................
135-146 3.4-5.4 95-100
mmol/l mmol/l mmol/l
7. Pemeriksaan Penunjang Hasil Pemeriksaan Keterangan: ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... VII. PEMERIKSAAN FISIK 1. Keadaan Umum: .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 2. Kesadaran
: .......................................................................................................
Tanda Vital
: .......................................................................................................
Nadi
:
x/ menit
Suhu
:
°C
RR
:
x/ menit
3. Pengkajian Skala Nyeri
.................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................
4. Kepala dan Leher .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 5. Mata Posisi bola mata : ...................................................................................................... Gerakan mata : .......................................................................................................... .................................................................................................................................... Konjungtiva : ............................................................................................................. Kornea : ..................................................................................................................... Sklera : ...................................................................................................................... Pupil :......................................................................................................................... 6. THT .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 7. Ekstremitas .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 8. Toraks .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 9. Jantung .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................
10. Abdomen .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................
11. Genitalia Frekuensi BAK: ......................../hari , Jumlah Urine: ........................ cc Warna Urine: ............................................................................................................. Penggunaan Alat bantu berkemih: ............................................................................ Kondisi Blast: ............................................................................................................ Tanggal defekasi terakhir: ......................................................................................... Frekuensi BAB: .........../hari, Konsistensi: ..............., Warna: ...................... Penggunaan Alat bantu (Laksatif): ............................................................................
12. Tumbuh Kembang .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................
13. Hospitalisasi .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................
ANALISIS DATA Nama Klien
: ..............................................
Umur
: ..............................................
Ruangan/Kamar : .............................................. No.
Data ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... .......................................................................
Penyebab
Masalah
....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... .......................................................................
PRIORITAS MASALAH Nama klien
: ..............................................
Umur
: ..............................................
Ruangan/kamar : .............................................. No. RM No.
: .............................................. Masalah Keperawatan ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
Tanggal Ditemukan ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... .........................................
Teratasi ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... .........................................
Paraf (Nama Perawat) ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. .................................
........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ........................................ ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................
......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ........................................ ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ........................................ ......................................... ......................................... ......................................... ......................................... ........................................
................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................
RENCANA KEPERAWATAN No.
Diagnosa Keperawatan ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................
Tujuan Dan Kriteria Hasil .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... ..........................................
Intervensi
Rasional
............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................
......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .................................................... ....................................................
........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................
.......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... ..........................................
............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................
......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .........................................................
........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................
.......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... ..........................................
............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................
......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .........................................................
IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN No. Dx Kep
Waktu Tgl/jam
Implementasi ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................
TT
Waktu Tgl/jam
Evaluasi ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
TT
..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................
........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................
........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................
........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................
........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
KELUHAN UTAMA
a.
Keluhan Masuk Rumah Sakit ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
b. Keluhan Saat ini ......................................................................................................................................... ......................................................................................................................................... .........................................................................................................................................
II. RIWAYAT KESEHATAN a. Riwayat penyakit sekarang: ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
b. Riwayat penyakit dahulu ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... III. RIWAYAT IMUNISASI ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
IV. RIWAYAT PENYAKIT KELUARGA ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
GENOGRAM
Keterangan: ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. V. RIWAYAT SOSIAL 1. Sistem pendukung/ keluarga terdekat yang dapat dihubungi ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 2. Lingkungan rumah ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 3.
Problem sosial yang penting ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
VI. KEADAAN KESEHATAN SAAT INI 1. Tindakan Operasi ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 2. Status Nutrisi ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
3. Status Cairan: ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 4. Aktivitas Anak Sebelum Masuk Rumah Sakit: ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... Saat Dirawat Di Rumah Sakit: ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................
5. Obat-Obatan No
Obat Dosis Indikasi .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ ....................................................
.......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ ....................................................
.......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ .................................................... .......................................... ................................ ....................................................
6. Hasil Laboratorium Pemeriksaan HEMATOLOGI Hemoglobin Lekosit Eritrosit Hematokrit Trombosit RDW-CV MCV,MCH, MCHC MCV MCH MCHC HITUNG JENIS Gran% Limfosit% MID% Gran# Limfosit# MID# KIMIA DARAH Glukosa Darah Sewaktu HATI SGOT SGPT GINJAL Ureum Kreatinin ELEKTROLIT Natrium Kalium Chlorida
Hasil
Nilai Normal
Satuan
................. ................. ................. ................. ................. .................
14.00-18.00 4.0-10.5 4.00-5.50 32.00-50.00 150-450 12.1-14.0
g/dl ribu/ul juta/ul vol% ribu/ul %
................. ................. .................
75.0 – 96.00 28.0 – 32.0 32.0 – 37.0
fl pg %
................. ................. ................. ................. ................. .................
50.0 – 70.0 25.0 – 40.0 4.0-11.0 2.50 – 7.00 1.25-4.0
% % % ribu/ul ribu/ul ribu/ul
.................
<200
mg/dl
................. .................
0-46 0-45
u/l u/l
................. .................
10-50 0.7-1.4
mg/dl mg/dl
................. ................. .................
135-146 3.4-5.4 95-100
mmol/l mmol/l mmol/l
7. Pemeriksaan Penunjang Hasil Pemeriksaan Keterangan: ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... VII. PEMERIKSAAN FISIK 1. Keadaan Umum: .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 2. Kesadaran
: .......................................................................................................
Tanda Vital
: .......................................................................................................
Nadi
:
x/ menit
Suhu
:
°C
RR
:
x/ menit
3. Pengkajian Skala Nyeri
.................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................
4. Kepala dan Leher .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 5. Mata Posisi bola mata : ...................................................................................................... Gerakan mata : .......................................................................................................... .................................................................................................................................... Konjungtiva : ............................................................................................................. Kornea : ..................................................................................................................... Sklera : ...................................................................................................................... Pupil :......................................................................................................................... 6. THT .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 7. Ekstremitas .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 8. Toraks .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 9. Jantung .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................
10. Abdomen .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................
11. Genitalia Frekuensi BAK: ......................../hari , Jumlah Urine: ........................ cc Warna Urine: ............................................................................................................. Penggunaan Alat bantu berkemih: ............................................................................ Kondisi Blast: ............................................................................................................ Tanggal defekasi terakhir: ......................................................................................... Frekuensi BAB: .........../hari, Konsistensi: ..............., Warna: ...................... Penggunaan Alat bantu (Laksatif): ............................................................................
12. Tumbuh Kembang .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................
13. Hospitalisasi .................................................................................................................................... .................................................................................................................................... ....................................................................................................................................
ANALISIS DATA Nama Klien
: ..............................................
Umur
: ..............................................
Ruangan/Kamar : .............................................. No.
Data ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... .......................................................................
Penyebab
Masalah
....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... .......................................................................
PRIORITAS MASALAH Nama klien
: ..............................................
Umur
: ..............................................
Ruangan/kamar : .............................................. No. RM No.
: .............................................. Masalah Keperawatan ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
Tanggal Ditemukan ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... .........................................
Teratasi ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... .........................................
Paraf (Nama Perawat) ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. .................................
........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ........................................ ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................
......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ........................................ ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ......................................... ........................................ ......................................... ......................................... ......................................... ......................................... ........................................
................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................. ................................
RENCANA KEPERAWATAN No.
Diagnosa Keperawatan ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................
Tujuan Dan Kriteria Hasil .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... ..........................................
Intervensi
Rasional
............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................
......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .................................................... ....................................................
........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................
.......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... ..........................................
............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................
......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .........................................................
........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................ ........................................
.......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... .......................................... ..........................................
............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................
......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... ......................................................... .........................................................
IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN No. Dx Kep
Waktu Tgl/jam
Implementasi ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................
TT
Waktu Tgl/jam
Evaluasi ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
TT
..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................
........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................
........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................
........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... ..................................................................... .....................................................................
........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................ ........................................................................
Related Documents
Pengkajian
June 2020 35
Pengkajian Gerontik.docx
April 2020 39
Pengkajian Kebidanan.docx
December 2019 44
Pengkajian Hirni.docx
November 2019 45
Pengkajian Anak.docx
December 2019 38
Pengkajian Keperawatan
October 2019 59More Documents from "astrid"
Pengkajian Anak.docx
December 2019 38
Cover.docx
June 2020 17
Terminologi Anatomi.ppt
December 2019 15
Format Lembar Askep.docx
December 2019 34