ASUHAN KEPERAWATAN PADA Ny/Tn.....DENGAN.............

DI RUANG...................................RSUD KOTA SALATIGA

Tgl/jam masuk RS

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

Tgl/jam pengkajian

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

Metode pengkajian

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

Diagnosa medis

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

No RM

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

PENGKAJIAN
I. BIODATA
1. IDENTITAS KLIEN
Nama klien
:...................................................................................
Umur
:...........................................................................
Agama
:............................................................................
Status Perkawinan :............................................................................
Pendidikan
:...........................................................................
Pekerjaan
:.............................................................................
2. Identitas Penanggung jawab
Nama
:...........................................................................
Umur
:...........................................................................
Pendidikan
:...............................................................................
Pekerjaan
:..........................................................................
Alamat
:.............................................................................
Hubungan dgn Klien :..........................................................................
II.

RIWAYAT KEPERAWATAN
1. Keluahan Utama
..................................................................................................................
..................................................................................................................
.............................................................................................................
2. Riwayat penyakit sekarang
..................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
.........................................................................................................

3. Riwayat penyakit dahulu

..................................................................................................................
..................................................................................................................
..................................................................................................................
.......................................................................................................
4. Riwayat kesehatan keluarga
GENOGRAM

5. Riwayat kesehatan lingkungan:

..................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
III.

...............................................................................................................
PENGKAJIAN POLA KESEHATAN FUNGSIONAL
1. Pola Persepsi Dan Pemeliharaan Kesehatan
..................................................................................................................
..................................................................................................................
..................................................................................................................
............................................................................................................
2. Pola Nutrisi/Metabolik
a. Pengkajian Nutrisi (ABCD):
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
.................................................................................................

b. Pengkajian Pola Nutrisi

Sebelum Sakit

Saat Sakit

Frekuensi
Jenis
Porsi
Keluhan
3. Pola Eliminasi
a. BAB
Sebelum Sakit

Saat Sakit

Sebelum Sakit

Saat Sakit

Frekuensi
Konsistensi
Warna
Penggunaan
Pencahar(laktasit
Keluhan

b. BAK
Frekuensi
Jumlah Urine
Warna
Pancaran
Perasaan Setelah
Berkemih
Total Produksi Urin
Keluhan
c. Analisa Keseimbangan Cairan Selama Perawatan
Intake
a. Minuman..........cc
b. Makanan...........cc
c. Cairan IV..........cc
Total......................cc

Output
a. Urine..........cc
b. Feses...........cc
c. Muntah........cc
d. IWL.............cc
Total.................cc

Analisa
intake...............cc
output...............cc
Balance.............cc

4. Pola Aktivitas dan Latihan

Kemampuan perawatan diri
0 1 2 3 4
Makanan/minum
Mandi
Toileting
Berpakaian
Mobilitas ditempat tidur
Berpindah
Ambulasi/ROM
Ket:
0:mandiri, 1:dengan alat bantu, 2:dibantu orang lain, 3:diabntu orang
lain dan alat, 4:tergantung total

5. Pola Istirahat Tidur

Sebelum Sakit

Saat Sakit

Jumlah tidur siang

Jumlah tidur malam
Penggunaan obat
tidur
Gangguan tidur
Perasaan waktu
bangun
Kebiasaan sebelum
tidur
6. Pola Kognitif Perseftual
a. Status mental
............................................................................................................
.................................................................................................
b. Kemampuan penginderaan
............................................................................................................
....................................................................................................
c. Pengkajian nyeri
............................................................................................................
............................................................................................................

............................................................................................................
.......................................................................................................
7. Pola Persepsi Konsep Diri
a. Gambaran diri/citra tubuh
............................................................................................................
.................................................................................................
b. Ideal diri
............................................................................................................
...................................................................................................
c. Harga diri
............................................................................................................
.................................................................................................
d. Peran diri
............................................................................................................
.................................................................................................
e. Identitas diri
............................................................................................................
......................................................................................................
8. Pola Hubungan Peran
..................................................................................................................
......................................................................................................
9. Pola Seksual Reproduksi
..................................................................................................................
......................................................................................................
10. Pola Mekanisme Koping
..................................................................................................................
........................................................................................................
11. Pola Nilai dan Keyakinan
..................................................................................................................
.......................................................................................................
IV.

PEMERIKSAAN FISIK
1. Keadaan/Penampilan Umum
a. Kesadaran
:................................................................
b. Tanda-Tanda Vital
1) Tekanan Darah :...................................................................
2) Nadi

2.

3.

4.

5.

6.

7.

Frekuensi
:................................................................
Irama
:................................................................
Kekuatan
:.................................................................
3) Pernafasan
Frekuensi
:.................................................................
Irama
:.................................................................
4) Suhu
:................................................................
Kepala
a. Bentuk kepala
:................................................................
b. Kulit kepala
:.................................................................
c. Rambut
:................................................................
Muka
a. Mata
1) Palpebra
:.................................................................
2) Konjungtiva
:................................................................
3) Sclera
:.................................................................
4) Pupil
:................................................................
5) Diameter pupil ki/ka
:.....................................................
6) Reflek terhadap cahaya :.....................................................
7) Penggunaan alat bantu penglihatan
:...............................
...........................................................................................
b. Hidung
:..........................................................................
c. Mulut
:..........................................................................
d. Telinga
:..........................................................................
Leher
a. Kelenjar tiroid :...............................................................................
b. Kelenjar limfe :............................................................................
c. JVP
:.............................................................................
Dada (thorax)
a. Paru-Paru
Inspeksi
:............................................................................
Palpasi
:...........................................................................
Perkusi
:...........................................................................
Auskultasi
:...................................................................................
b. Jantung
Inspeksi
:............................................................................
Palpasi
:...........................................................................
Perkusi
:...........................................................................
Auskultasi
:...........................................................................
Abdomen
Inspeksi :.....................................................................................
Palpasi
:......................................................................................
Perkusi :......................................................................................
Auskultasi :.....................................................................................
Genetalia :..............................................................................................

......................................................................................................
8. Rektum :.......................................................................................
......................................................................................................
9. Ekterimitas
a. Atas
Kanan

Kiri

Kanan

Kiri

Kekuatan otot
Rentang gerak
Akral
Edema
CRT
Keluhan
b. Bawah
Kekuatan otot
Rentang gerak
Akral
Edema
CRT
Keluhan
V.

PEMERIKSAAN PENUNJANG
Hari/tgl

Jenis

Nilai

/jam

Pemeriksaan

Normal

Satuan

Hasil

Keterangan
Hasil

VI.

TERAPI MEDIS
Hari/tgl

Jenis Terapi

/jam
Cairan IV
:

Obat Peroral
:
Obat
Parenteral
:

Dosis

Golongan

fungsi &

&Kandungan

Farmakologi

Obat Topikal
:

ANALISIS DATA
Nama :............................................ No RM :.....................................................
Umur :........................................ Diagnosa Medis :.........................................
No

Hari/

Data Fokus

tgl/jam
DS

Problem

Etiologi

Ttd

PRIORITAS DIAGNOSA KEPERAWATAN

1.
2.
3.
4.
5.

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

RENCANA KEPERAWATAN
Nama :............................................ No RM :.....................................................
Umur :........................................ Diagnosa Medis :.........................................
Hari/

No.

Tujuan dan Kreteria Hasil

Intervensi

tgl

Dx

(NOC)

(NIC)

Ttd

TINDAKAN KEPERAAWATAN/IMPLEMENTASI
Nama :............................................ No RM :.....................................................
Umur :........................................ Diagnosa Medis :.........................................
Hari/

No.

tgl

Dx

Implementasi

Respon

Ttd

CATATAN KEPERAWATAN

Nama :............................................ No RM :.....................................................

Umur :........................................ Diagnosa Medis :.........................................
No.

Hari/tgl/

Dx

jam

Evaluasi
S:

O:

A:

P:

Ttd