ASUHAN KEPERAWATAN PADA PASIEN ................. DENGAN ........................................

DI RUANG ........................................ BRSU TABANAN

TANGGAL ....................................................

NAMA

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

NIM

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

PROGRAM STUDI KEPERAWATAN NERS

SEKOLAH TINGGI ILMU KESEHATAN (STIKES) BALI
DENPASAR
TAHUN 2016

ASUHAN KEPERAWATAN PADA ................ DENGAN ........................................................

DI RUANG .................................... BRSU TABANAN
TANGGAL ....................................................

A. PENGKAJIAN
Pengkajian pada pasien dilakukan pada tanggal ................................. pukul .............. wita, di
Ruang ...................................... BRSU Tabanan dengan metode observasi, wawancara,
pemeriksaan fisik, dan dokumentasi (rekam medis).
I.

PENGUMPULAN DATA
a. Identitas Pasien
Pasien

Penangung
(......................, ............)

Nama

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

..........................................................

Umur

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

..........................................................

Jenis Kelamin : ...................................................

..........................................................

Status Perkawinan : ............................................

..........................................................

Suku/ Bangsa : ..................................................

..........................................................

Agama

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

..........................................................

Pendidikan

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

..........................................................

Pekerjaan

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

..........................................................

Alamat

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

..........................................................

...................................................

..........................................................

Nomor Telp. : ................................................

Nomor RM

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

Tanggal MRS : ................................................

b. Riwayat Kesehatan
1) Keluhan utama masuk rumah sakit

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2) Keluhan utama saat pengkajian
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3) Riwayat penyakit sekarang
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4) Riwayat penyakit sebelumnya
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5) Riwayat penyakit keluarga
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c. Pola Kebiasaan
1) Bernafas
Sebelum
pengkajian : ......................................................................................................................
...........................................................................................................................................

...........................................................................................................................................
....................
Saat pengkajian :
tidak ada keluhan
nyeri waktu bernafas
sesak saat menarik nafas
sesak saat mengeluarkan nafas
batuk ; berdahak tidak berdahak
Data
lain : ..................................................................................................................................
...........................................................................................................................................
.........
2) Makan dan minum
- Makan
Sebelum pengkajian :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Saat pengkajian :
frekuensi makan ( ........ x per hari )
jenis makanan : nasi bubur sayur lauk-pauk
makanan pantangan : .............................................................................................
alergi makanan : ....................................................................................................
porsi makan dalam sehari : ...................................................................................
mual muntah : ( ..........x per hari, volume .......... cc,
konsistensi ....................)
nafsu makan menurun sulit menguyah/ menelan
Data
lain : ............................................................................................................................
.....................................................................................................................................
-

........
Minum
Sebelum pengkajian :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Saat pengkajian :
minuman yang biasa diminum : ............................................................................
jumlah minum sehari ( ................ gelas/ hari )
alkohol ( .............. gelas/ hari )
merokok ( ............... batang/ bungkus dalam sehari )
Data
lain : ............................................................................................................................
.....................................................................................................................................

.........
3) Eliminasi
- BAB (Buang Air Besar)
Sebelum pengkajian :
.....................................................................................................................................
.....................................................................................................................................
....................................................................................................................................

Saat pengkajian :
frekuensi ( ........... x/hari ) : teratur tidak teratur
konsistensi : ...........................................................................................................
warna : ...................................................................................................................
bau : ........................... tidak ada darah/ lendir ada darah/ lendir : ..........
cc
Data
lain : ............................................................................................................................
.....................................................................................................................................
-

........
BAK (Buang Air Kecil)
Sebelum pengkajian :
.....................................................................................................................................
.....................................................................................................................................
....................................................................................................................................
Saat pengkajian :
frekuensi ( ............. x/ hari )
warna : ..................................................................................................................
bau : ................................... jumlah/ volume : ...................... cc/kencing
lancar seret ada darah tidak ada darah nyeri saat kencing tidak
ada nyeri saat kencing tidak terpasang dower kateter terpasang dower kateter
( volume : ............ cc/ ............. jam )
Data lain :
.....................................................................................................................................

.....................................................................................................................................
4) Gerak dan aktivitas
- Gerak
Sebelum pengkajian :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Saat pengkajian :
.....................................................................................................................................
.....................................................................................................................................
....................................................................................................................................
Data lain :
.....................................................................................................................................
-

.....................................................................................................................................
Aktivitas
Sebelum pengkajian :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Saat pengkajian :
jenis kegiatan : .......................................................................................................
aktivitas yang biasa
dilakukan : .............................................................................
aktivitas yang tidak bisa dilakukan : .....................................................................
penyebab : ................................................................................................
ADL : toileting mandiri dibantu
( oleh : .....................................................)

berpakaian mandiri dibantu

( oleh : ................................................ )
berpindah/bergerak mandiri dibantu
( oleh : ...................................)
makan/minum mandiri dibantu
( oleh : ...........................................)
mandi mandiri dibantu
( oleh : ....................................................... )
Data lain :
.....................................................................................................................................
.....................................................................................................................................
5) Istirahat dan Tidur
- Istirahat
Sebelum pengkajian :
.....................................................................................................................................
.....................................................................................................................................
Saat pengkajian :
.....................................................................................................................................
-

.....................................................................................................................................
Tidur
Sebelum pengkajian :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Saat pengkajian :
jumlah jam tidur ( ........... jam / hari )
sering terjaga
susah tidur
menggunakan tidak menggunakan obat tidur
( obat : ......................................)
Data lain :
.....................................................................................................................................
....................................................................................................................................

6) Kebersihan Diri
Sebelum pengkajian :
- mandi; frekuensi ( .......... x/ hari ) memakai sabun tidak memakai sabun
- cuci rambut; frekuensi ( ......... x/minggu ) memakai shampo tidak memakai
shampo
- pemeliharaan mulut dan gigi; frekuensi sikat gigi ( ....... x/hari ) sebelum
sesudah makan memakai pasta gigi tidak memakai pasta gigi
- berpakaian; frekuensi ganti baju ( ..... x/hari )
- kebersihan kuku; bersih cukup bersih kotor, keadaan kuku: panjang
pendek
- kemampuan membersihkan diri;
mandiri dibantu
( oleh : ................................................................................. )
Saat pengkajian :
- mandi; frekuensi ( .......... x/ hari ) memakai sabun tidak memakai sabun
- cuci rambut; frekuensi ( ......... x/minggu ) memakai shampo tidak memakai
shampo

- pemeliharaan mulut dan gigi; frekuensi sikat gigi ( ....... x/hari ) sebelum
sesudah makan memakai pasta gigi tidak memakai pasta gigi
- berpakaian; frekuensi ganti baju ( ..... x/hari )
- kebersihan kuku; bersih cukup bersih kotor, keadaan kuku: panjang
pendek
- kemampuan membersihkan diri;
mandiri dibantu
( oleh : ................................................................................. )
Data
lain : ..................................................................................................................................
...........................................................................................................................................
.........
7) Pengaturan Suhu Tubuh
Sebelum pengkajian :
...........................................................................................................................................
..........................................................................................................................................
Saat pengkajian :
badan teraba hangat
menggigil
berkeringat
kemerahan
Data lain :
...........................................................................................................................................
...........................................................................................................................................
8) Rasa Nyaman
Sebelum pengkajian :
...........................................................................................................................................
...........................................................................................................................................
Saat pengkajian :
merasa tidak nyaman
gatal; area gatal : .........................................................................................................
nyeri;
skala nyeri : 0 1 2 3 4 5 6 7 8 9 10
0 = tidak nyeri
1 3 = ringan
4 6 = sedang
7 9 = berat
10 = nyeri sangat berat
intensitas nyeri : ...................................................................................................
kualitas nyeri : ......................................................................................................
lokasi nyeri : .........................................................................................................
pencetus nyeri : ....................................................................................................
Data lain :
...........................................................................................................................................
...........................................................................................................................................
9) Rasa Aman
Sebelum pengkajian :
...........................................................................................................................................
...........................................................................................................................................
Saat pengkajian :
merasa cemas tidak merasa cemas
penyebab : .................................................................................................................

 merasa takut tidak merasa takut

penyebab : .................................................................................................................
Data lain :
...........................................................................................................................................
...........................................................................................................................................

10) Data Sosial

Sebelum pengkajian :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Saat pengkajian :
peran dalam keluarga : ................................................................................................
keharmonisan keluarga ; harmonis tidak harmonis,
penyebab : ........................................................................................................................
hubungan dengan tetangga ; baik kurang baik
hubungan dengan pasien lain ; baik kurang baik
hubungan dengan perawat/ dokter/ petugas kesehatan lain ; baik kurang baik
Data lain :
...........................................................................................................................................
..........................................................................................................................................
11) Prestasi dan produktivitas
- Prestasi
Sebelum pengkajian :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Saat pengkajian :
prestasi yang pernah dicapai : .....................................................................................
kepuasan terhadap prestasi : merasa puas tidak merasa puas
- Produktivitas
Sebelum pengkajian :
.....................................................................................................................................
.....................................................................................................................................
....................................................................................................................................
Saat pengkajian :
pengaruh pekerjaan terhadap kondisi saat ini : terganggu tidak terganggu
pengaruh kondisi saat ini terhadap produktivitas : terganggu tidak
terganggu
Data lain :
.....................................................................................................................................
...................................................................................................................................

12) Rekreasi
Sebelum pengkajian :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Saat pengkajian :

 hobi : ...........................................................................................................................
kebiasaan rekreasi : .....................................................................................................
Data
lain : ..................................................................................................................................
...........................................................................................................................................
.........
13) Belajar
Sebelum pengkajian :
...........................................................................................................................................
..........................................................................................................................................
Saat pengkajian :
pemahaman pasien terhadap kondisi saat ini : paham tidak paham
pemahaman pasien terhadap pengobatan yang diberikan : paham tidak paham
Data lain :
...........................................................................................................................................
...........................................................................................................................................
14) Ibadah
Sebelum pengkajian :
...........................................................................................................................................
..........................................................................................................................................
Saat pengkajian :
agama/ kepercayaan yang dianut : Hindu Islam Budha Kristen Katolik
Kristen Protestan Konghucuu
kebiasaan beribadah : ..................................................................................................
Data lain : ........................................................................................................................
.........................................................................................................................................
d. Pemeriksaan Fisik
1) Keadaan Umum
a) Kesadaran

: GCS : ........... ( E : ......, V : ......., M : ........ )

composmentis somnolen koma
b) Bangun tubuh : kurus sedang gemuk
c) Postur tubuh : tegak lordosis kifosis skoliosis

d) Cara berjalan : lancar terkoordinir terganggu

e) Gerak motorik : terganggu tidak terganggu
f) Keadaan kulit
warna : ...................................................................................................................
turgor : ...................................................................................................................
kebersihan : ...........................................................................................................
luka : .....................................................................................................................
tidak ada
ada : terbuka tertutup
lokasi : .....................................................
luas luka : ........................... warna : ...................................................
pus : ada tidak ada
g) Gejala kardinal
- Tekanan darah :
/
mmHg
- Nadi
:
x per menit
o
- Suhu
:
C
- Respirasi
:
x per menit
h) Ukuran lain
- Berat badan
:
kg

Tinggi badan
Indeks masaa tubuh

:
:

cm
kg/m2

2) Kepala
a) Inspeksi :
- Kulit kepala : bersih kotor ketombe
- Rambut : rontok warna : beruban hitam
- Luka : ada tidak ada
b) Palpasi :
teraba massa tidak teraba massa nyeri tekan tidak ada nyeri tekan
3) Mata
a) Inspeksi :
- Konjungtiva : merah muda anemis
- Sklera : putih kuning
- Kelopak mata : lingkaran hitam benjolan tidak ada masalah
- Pupil : reflek pupil baik reflek pupil kurang
- Lapang pandang : baik kurang
b) Palpasi :
- Nyeri : tidak ada nyeri tekan ada nyeri tekan
4) Hidung
a) Inspeksi :
- Bentuk : simetris asimetris
- Penciuman : baik terganggu
- Keadaan : bersih cukup bersih kotor sekret darah
- Massa : ada polip tidak ada polip
- Luka : ada luka tidak ada luka
b) Palpasi :
- Nyeri : ada nyeri tekan tidak ada nyeri tekan
5) Telinga
a) Inspeksi
- Keadaan : bersih cukup bersih kotor
b) Palpasi :
- Nyeri : ada nyeri tekan tidak ada nyeri tekan
c) Perdengaran : baik terganggu
6) Mulut
a) Inspeksi :
- Mukosa bibir : lembab kering
- Gusi : tidak berdarah berdarah
- Gigi : lengkap tidak lengkap, karena ................................................................
bersih cukup berih kotor berlubang karies gigi
- Lidah : bersih cukup bersih kotor
- Tonsil : normal membesar
b) Palpasi
- Nyeri : nyeri tekan tidak ada nyeri tekan
- Massa : teraba massa tidak teraba massa
7) Leher
a) Inspeksi :
- Keadaan : baik pembengkakkan kelenjar tiroid
b) Palpasi :
- Keadaan : baik teraba massa tidak teraba massa kelenjar tiroid
membesar
8) Thorax
a) Inspeksi
- Bentuk : simetris asimetris
- Gerakan dada : bebas terbatas
- Payudara : simetris asimetris
b) Palpasi :
- Pengembangan dada : simetris asimetris
- Nyeri : ada nyeri tekan tidak ada nyeri tekan
c) Perkusi :

d)
-

Suara paru : sonor/resonan dullnes hipersonor

Auskultasi :
Suara paru : vesikuler ronchi wheezing
Suara jantung : reguler S1-S2 tunggal murmur gallop

9) Abdomen
a) Inspeksi
- Keadaan : bersih cukup bersih kotor
- Luka : ada luka tidak ada luka
b) Auskultasi
- Peristaltik usus : ........... x /menit
c) Palpasi
- Keadaan : hepatomegali apendiksitis distensi abdomen ascites
massa
- Nyeri : ada nyeri tekan tidak ada nyeri tekan
d) Perkusi : tympani dullnes hipertympani
10) Genetalia
a) Inspeksi
- Jenis kelamin : laki-laki perempuan
- Keadaan : besih cukup bersih kotor
b) Palpasi :
- Nyeri : ada nyeri tekan tidak ada nyeri tekan
- Massa : teraba massa tidak teraba massa
11) Anus
a) Inspeksi :
- Keadaan : besih cukup bersih kotor
b) Palpasi :
- Nyeri : ada nyeri tekan tidak ada nyeri tekan
- Massa : teraba massa tidak teraba massa
12) Ekstremitas
a) Ekstremitas Atas
- Inspeksi :
pergerakan bebas
hambatan gerakan
deformitas tidak ada deformitas
oedema tidak ada oedema
sianosis pada ujung kuku tidak ada sianosis
CRT ............. detik
luka tidak ada luka
terpasang infus ......................................................................................................
tidak terpasang infus
- Palpasi :
Nyeri tekan : ada nyeri tekan tidak ada nyeri tekan
b) Ekstremitas Bawah
- Inspeksi :
pergerakan bebas
hambatan gerakan
deformitas tidak ada deformitas
oedema tidak ada oedema
sianosis pada ujung kuku tidak ada sianosis
CRT ............. detik
luka tidak ada luka
terpasang infus ......................................................................................................
tidak terpasang infus
- Palpasi :
Nyeri tekan : ada nyeri tekan tidak ada nyeri tekan
c) Kekuatan Otot :

e. Pemeriksaan Penunjang
1) Pemeriksaan Laboratorium
Nama Pasien

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

Umur

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

Jenis Kelamin

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

Alamat

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

Ruangan

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

No. RM

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

Diagnosa Medis

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

Tanggal Pemeriksaan : ........................

NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

JENIS
PEMERIKSAAN

HASIL

SATUAN

RENTANG
NORMAL