STANDAR ASUHAN KEPERAWATAN MEDIKAL BEDAH

STIKES HANGTUAH SURABAYA

ASUHAN KEPERAWATAN pada KLIEN TB PARU
A. Pengertian
TB Paru merupakan penyakit infeksi yang disebabkan oleh Mycobacterium
Tubercullosa.
B. Asuhan Keperawatan
PENGKAJIAN
1.
Identitas
Nama
:
Umur
:
Jenis Kelamin
:
Status
:
Agama
:
Suku/Bangsa
:
Bahasa
:
Pendidikan
:
Pekerjaan
:
Alamat
:
Penanggung Jawab
: Askes/ Astek/ Jamsostek/ Sendiri
2.
Riwayat Sakit dan Kesehatan
a. Keluhan
Utama : .........................................................................................
.............
.......................................................................................................
...........................
b. Riwayat Penyakit
Sekarang :.....................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.................................................................................
c. Riwayat Penyakit
Dahulu :........................................................................................
.......................................................................................................
.......................................................................................................
......................................................
d. Riwayat Kesehatan
Keluarga :..................................................................................
.......................................................................................................
..........................
Genogram :

e. Riwayat
alergi : ...........................................................................................
.............

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3.

Review Of System
a. Tanda-tanda Vital
Suhu
: ................C
Nadi
:.................x/menit
Tekanan darah :.................mmHg
Respiratory rate
:.................x/menit
TB
:.................cm
BB
:.................kg
b. Sistem Pernapasan (Breath)
Bentuk dada
:
Pergerakan :
Otot bantu napas
:
jika ada, jelaskan:
Irama napas
Suara napas
Sesak napas
Sputum
Kemampuan aktivitas
c. Sistem Kardiovaskuler

:
:
:
:
:
(Blood)

kelainan :
Batuk : ( )ya ( )tidak
warna :

d. Sistem Persarafan (Brain)

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.....
e. Sistem Perkemihan (Bladder)
.......................................................................................................
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.......................................................................................................
.......................................................................................................
.......................................................................................................
.....
f. Sistem Pencernaan (Bowel)
Inspeksi
:.................................................................................................
............
.......................................................................................................
..........................
Palpasi :......................................................................................
.......................
.......................................................................................................
...........................

Perkusi :......................................................................................
.......................
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...........................
Auskultasi
:............................................................................
.................................
.......................................................................................................
...........................
g. Sistem Muskuloskeletal (Bone)
.......................................................................................................
.......................................................................................................
.......................................................................................................
.................................................................................
4.

Pemeriksaan Penunjang
a. Laboratorium
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b. Photo
.......................................................................................................
.......................................................................................................
.......................................................................................................
.................................................................................
c. Lain - lain
.......................................................................................................
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ANALISA DATA
Nama Klien :
Umur
:
N
o

DATA (Simptom)
DS:

DO:

PENYEBAB
(Etiologi)

MASALAH
(Problem)

DS:

DO: