A.

PENGKAJIAN
1. IDENTITAS
a. Identitas klien
Nama

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

Umur

; ............................................................................................................

Jenis Kelamin

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

Pekerjaan

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

Alamat

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

Pendidikan

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

Agama

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

Suku bangsa

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

Tanggal Masuk RS

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

No. CM

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

Dx Medis

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

Tanggal Pengkajian

b. Identitas Penanggung Jawab

Nama

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

Umur

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

Jenis Kelamin

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

Pekerjaan

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

Alamat

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

Pendidikan

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

Agama

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

Hubungan dengan Klien : ............................................................................................................

Giaful Muharam STIKes Karsa Husada Garut

2. RIWAYAT KESEHATAN
a. Keluhan Utama
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b. Riwayat Kesehatan Sekarang
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c. Riwayat Kesehatan Dahulu
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d. Riwayat Kesehatan Keluarga
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e. Riwayat Alergi
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Giaful Muharam STIKes Karsa Husada Garut

3. POLA KESEHATAN FUNGSIONAL

a. Pemeliharaan kesehatan
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b. Nutrisi Metabolik
No
1

Jenis

sehat

sakit

Sebelumt dirawa

Selama dirawat

Pola makan
Jenis
Porsi
Frekuensi
Diet khusus
Makanan disukai
Kesulitan menelan
Gigi palsu
Napsu makan
Pola minum
Jenis
Frekuensi
Jumlah
Pantangan
Minuman yang disukai

c. Pola eliminasi
No
1

Jenis
BAB
Frekuensi
Warna
Masalah
BAK
Frekuensi
Jumlah
Warna
Masalah

Giaful Muharam STIKes Karsa Husada Garut

d. Pola aktivitas sehari hari

No

1
2
3
4
5
6
7
8
9
10

Sehat
JenisKet:
0 1 2 3
0 : Mandiri
1
:
Alat
bantu
Mandi
2 : Dibantu orang lain
berpakaian 3 : dibantu orang lain alat
4 : tergantung / tidak mampu
eliminasi

Selama dirawat
4

mobilisasi di tempat tidur

berpindah
berjalan
berbelanja
memasak
naik tangga
pemeliharaan rumah

e. Pola persepsi kognitif

Berbicara

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

Bahasa

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

Kemampuan membaca

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

Kemampuan berinteraksi : .........................................................................................................

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f. Pola istirahat / tidur
No
1

Jenis

Sebelumt dirawat

Selama dirawat

Tidur siang
Lama tidur
Keluhan
Tidur malam
Lama tidur
Keluhan

g. Pola konsep diri

Giaful Muharam STIKes Karsa Husada Garut

Ideal diri

: .........................................................................................................
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Harga diri

: .........................................................................................................
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Identitas diri

: .........................................................................................................
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Peran diri

: .........................................................................................................
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h. Pola peran dan Hubungan

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i. Pola Reproduksi dan Seksual
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j. Pola pertahanan diri atau koping
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k. Pola keyakinan dan nilai
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4. PEMERIKSAAN FISIK
Keadaan Umum :
Kesadaran
:
TTV
: TD :
Head to toe
1. Rambut
Warna
Tekstur
Penyebaran
Kebersihan

:
:
:
:

2. Kulit
Warna
Tekstur
Kelambaban
Edema

:
:
:
:

GCS:
R:

E:
N:

V:
S:

M:

Giaful Muharam STIKes Karsa Husada Garut

Kebersihan
Cyanosis
Turgor

:
:
:

3. Kuku
Warna
Tekstur
Bentuk
CRT
Kebersihan

:
:
:
:
:

4. Kepala
Bentuk
:
Kebersihan :
Keadaan
:
Bentuk Muka :
Mata
Posisi
Sklera
Konjungtiva
Reflek Pupil
Kebersihan
Ketajaman penglihatan
Lapang pandang
Hidung
Posisi
Warna
Tekstur
Kebersihan
Telinga
Posisi
Warna
Tekstur
Bebersihan
Pola pendengaran
5. Mulut
Bibir
Warna
Tekstur
Mukosa
Kondisi

:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:

:
:
:
:

Gigi
Giaful Muharam STIKes Karsa Husada Garut

Jumlah
Warna
Kondisi
Lidah
Warna
Tekstur
Mukosa
Kondisi
Pergerakan
Fungsi lidah
Reflek menelan
Keluhan
Gusi
Warna
Keluhan

6. Leher
JVP
Kelenjar tiroid
Pergerakan
7. Dada
Jantung
Bunyi
Irama
Frekuensi
Paru-paru
Pengembangan
Bunyi nafas
Frekuensi
8. Abdomen
Bising usus
Bentuk
Tekstur
Kebersihan
Keluhan
Hati
Keadaan
Ginjal
Keadaan

:
:
:
:
:
:
:
:
:
:
:
:
:

:
:
:

:
:
:
:
:
:

:
:
:
:
:
:
:

9. Genetalia
Giaful Muharam STIKes Karsa Husada Garut

Keadaan
Rektal
10. Ekstremitas
Ekstremitas Atas
Bentuk
Pergerakan
Refleks
Keadaan
Edema
Turgor

:
:

:
:
:
:
:
:

Kekuatan otot

Ekstremitas Bawah
Bentuk
Pergerakan
Refleks
Keadaan
Edema
Turgor

:
:
:
:
:
:

Kekuatan otot

Giaful Muharam STIKes Karsa Husada Garut

5. PEMERIKSAAN PENUNJANG
No Lab
Nama
Umur
Alamat
No
1

:
:
:
:

Nama Test
Hematologi
Darah Rutin
Hemoglobin
Hematokrit
Leukosit
Trombosit
Eritrosit
Laju Endap Darah
Morfologi darah
tepi
Eritrosit
Leukosit
Trombosit
Kesan
Kimia Klinik
AST/SGOT
ALT/SGPT
Ureum
Kreatinin
Protein total
Albumin
Glukosa sewaktu
Glukosa puasa
Kolesterol total
Natrium
Kalium
Imunologi
HbsAg
Anti Dengue Igg
Anti Dengue IgM
Widal
Lainnya

No Cm
Ruangan
Jenis Kelamin
Tanggal
Hasil

:
:
:
:

Unit

Nilai Normal

g/dL
%
/mm3
/mm3
juta/mm3
/mm3

13.0-18.0
40-52
3.800-10.000
150.000-440.000
3.5-6.5

u/L
u/L
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL

s/d 37
40
15-50
15-50
0.7-1.2
6.6-8.7
3.5-5
<140
70-110
135-145
3.6-5.5

6. TERAPI :
B. ANALISA DATA
Giaful Muharam STIKes Karsa Husada Garut

No

Data

Etiologi

Problem

Giaful Muharam STIKes Karsa Husada Garut

No

Data

Etiologi

Problem

C. DIAGNOSA KEPERAWATAN
1.
2.
3.
4.
5.

Giaful Muharam STIKes Karsa Husada Garut

D. NURSING CARE PLAN

Diagnosa Keperawatan/ Masalah

Kolaborasi

Rencana keperawatan
Tujuan dan Kriteria Hasil

Intervensi

Giaful Muharam STIKes Karsa Husada Garut

NURSING CARE PLAN

No. DP Tanggal / Jam

Tujuan

Intervensi

Rasional

Implementasi

Evaluasi

Paraf

Giaful Muharam STIKes Karsa Husada Garut

Giaful Muharam STIKes Karsa Husada Garut

Giaful Muharam STIKes Karsa Husada Garut