ASUHAN KEPERAWATAN PADA KLIEN An. .....

DENGAN DIAGNOSA MEDIS DI RUANG .

RUMAH SAKIT ISLAM PDHI YOYAKARTA
A. PENGKAJIAN
Tgl. Masuk
:
Jam
:
No. RM
:
Tgl. Pengakjian :
IDENTITAS PASIEN
PASIEN
Nama

PENANGGUNG JAWAB PASIEN

Nama

Umur

Umur

Agama

Agama

Pendidikan

Pendidikan

Perkerjaan

Perkerjaan

Status Pernikahan

Status Pernikahan

Alamat

Alamat

RIWAYAT KESEHATAN
KELUHAN UTAMA

RIWAYAT PENYAKIT SEKARANG

Waktu terjadinya sakit
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Proses terjadinya sakit
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Upaya yang telah dilakukan
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Hasil pemeriksaan sementara/sekarang

1. TD
:
2. Nadi :
3. RR
:
4. Suhu :
5. BB
:
6.
RIWAYAT PENYAKIT DAHULU
Prenatal :
.............................................................................................................................................
.............................................................................................................................................
Perinatal dan postnatal :
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Penyakit yang Pernah diderita :
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Hospitalisasi/riwayat operasi :
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Injuri/Kecelakaan :
.............................................................................................................................................
.............................................................................................................................................
Alergi :
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Riwayat Imunisasi
Tanggal Pemberian
Jenis Imunisasi

II

III

Umur
I

II

III

HEPATITIS
BCG
DPT
POLIO
CAMPAK

Pengobatan :
.............................................................................................................................................

.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
RIWAYAT PERTUMBUHAN
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
RIWAYAT SOSIAL
Yang Mengasuh :
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Hubungan dengan Anggota Keluarga
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Hubungan dengan Teman Sebaya
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Pembawaan Secara Umum
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
RIWAYAT KELUARGA
Sosial Ekonomi :
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Lingkungan Rumah :
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Penyakit Keluarga :
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................

GENOGRAM

POLA FUNGSI KESEHATAN

POLA MANAJEMEN KESEHATAN PERSEPSI KESEHATAN
Tingkat pengetahuan kesehatan/penyakit
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Perilaku untuk mengatasi masalah kesehatan
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Faktor-Faktor resiko sehubungan dengan kesehatan
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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POLA AKTIVITAS DAN LATIHAN
Sebelum Sakit

Aktivitas
Mandi
Berpakaian
Eliminasi
Mobilisasi T. tidur
Berpindah
Ambulasi

Kemampuan perawatan diri :

Skor :
0 : mandiri
1 : dibantu sebagian
2 : perlu bantuan orang lain
3 : bantuan orang lain dan alat
4 : tergantung/tidak mampu

Kemampuan perawatan diri :

Skor :
0 : mandiri
1 : dibantu sebagian
2 : perlu bantuan orang lain
3 : bantuan orang lain dan alat
4 : tergantung/tidak mampu

Selama Sakit

Aktivitas
Mandi
Berpakaian
Eliminasi
Mobilisasi T. tidur
Berpindah
Ambulasi
Naik tangga

POLA ISTIRAHAT TIDUR

Sebelum Sakit

Selama Sakit

POLA NUTRISI METABOLIK

Sebelum Sakit

Selama Sakit

POLA ELIMINASI

Sebelum Sakit

Selama Sakit

POLA KOGNITIF PERSEPTUAL

Sebelum Sakit

Selama Sakit

POLA KONSEP DIRI

Gambaran Diri :
Identitas Diri :
Peran Diri :
Ideal Diri :
Harga Diri :
POLA TOLERANSI STRES-KOPING

Sebelum Sakit

Selama Sakit

POLA REPRODUKIF SEKSUALITAS

Sebelum Sakit

Selama Sakit

POLA HUBUNGAN PERAN

Sebelum Sakit

Selama Sakit

POLA NILAI DAN KEYAKINAN

Sebelum Sakit

Selama Sakit

A. PEMERIKSAAN FISIK
PENAMPAKAN UMUM
Keadaan umum
Kesadaran
GCS
TD :
Berat badan
Skala Nyeri
HEAD TO TOE

E:
M:
Suhu:

V:

total :
RR :

Nadi :

Tinggi Badan
dari skala 1 10
KEPALA DAN LEHER

Rambut :
Mata :
Telinga :
Hidung :
Mulut :
Gigi :
Leher :

DADA
Inspeksi :
Palpasi :
Perkusi :
Auskultasi :
JANTUNG

Inspeksi :
Palpasi :
Perkusi :
Auskultasi :
ABDOMEN
Inspeksi :
Auskultasi
Perkusi :
Palpasi :
INGUINAL & GENETALIA
Inspeksi :
Palpasi :
EKSTRIMITAS
Inspeksi :

Kekuatan otot

Palpasi :
RSI PDHI Yogyakarta,

, 2015
Dikaji Oleh

B. PEMERIKSAAN PENUNJANG
Waktu
Tgl dan
Jam

Jenis
Pemeriksaan

Hasil Pemeriksaan

Nilai Rujukan

TERAPI OBAT
Waktu
Tgl dan
Jam

Jenis Obat

Dosis

Data Fokus
DATA SUBYEKTIF (DS)

ANALISA DATA

DATA OBYEKTIF (DO)

WAKTU
TGL/JAM

SYMTOM/SIGNS

ETIOLOGI

PROBLEM

C. DIAGNOSA KEPERAWATAN DAN PRIORITAS MASALAH

1.
2.
3.
4.
waktu
Hr/tgl

jam

No.
dx

Tujuan keperawatan (noc)

Rencana Tindakan (nic)

Ttd

D. PELAKSANAAN TINDAKAN
waktu
Hr/tgl
jam

No
.dx

IMPLEMENTASI

RESPON

Ttd

06-022014

08:00

10:00

Kamis

- Memposisikan pasien
semifowler
- Memantau respirasi dan
oksigenasi
- Memberikan terapi obat :
Lasix Inj.
20
mg
Ambroxol oral 30 mg
Sohobion oral 100 mg
Retaphyl oral
300 mg
- Menanyakan keluhan pasien

- Mengukur tekanan darah, nadi,

suhu, RR
- Menambah air pelembab udara
- Memonitor pergerakan dada

Ds : pasien mengatakan sudah

merasa enakan untuk
bernafas
Do : - Pasien terlihat mudah
untuk bernafas
- Oksigen mengealir
lancar dengan canul
nasal 3-4 L / menit
- Obat masuk via Oral :
Ambroxol
30 mg
Sohobion
100 mg
Retaphyl
300 mg
- Obat masuk via IV :
Lasix
20 mg

Ds : pasien mengatakan
terima kasih
Do : - pasien terlihat mudah
untuk bernafas
- Air pelembab udara
sudah ditambahkan
sesuai ukuran
- TD
: 125/ 80 mmHg
- Suhu : 360C
- Nadi
: 70x / menit
- RR
: 24x / menit

EVALUASI
waktu

Dx. Keperwatan

EVALUASI

Ttd

Hr/tgl

jam