KMB Woe
KMB Woe
A. IDENTITAS PASIEN
Nama : Penanggung jawab biaya :
Usia : Nama :
Jenis kelamin : Alamat :
Suku /Bangsa : Hub. Keluarga :
Agama : Telepon :
Pendidikan :
Status perkawinan :
Pekerjaan :
Alamat :
GENOGRAM
E. PERILAKU YANG MEMPENGARUHI KESEHATAN
Perilaku sebelum sakit yang mempengaruhi kesehatan
Alkohol ya tidak
Keterangan ..........................................................................................................
Merokok ya tidak
Keterangan ..........................................................................................................
Obat ya tidak
Keterangan ..........................................................................................................
Olahraga ya tidak
Keterangan ..........................................................................................................
MASALAH KEPERAWATAN :
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
2. Sistem Pernafasan (B1)
a. RR : ...............................
b. Keluhan : Sesak Nyeri waktu sesak Orthopnea
Batuk Produktif Tidak Produktif
Sekret : .................... Konsistensi : .......................
Warna : ................... Bau : ....................................
c. Pola nafas irama: Teratur Tidak teratur
d. Jenis Dispnoe Kusmaul Ceyne Stokes Lain-lain:
Pernafasan cuping hidung ada tidak
Septum nasi simetris tidak simetris
Lain-lain :
e. Bentuk dada simetris asimetris barrel chest
Funnel chest Pigeons chest
f. Suara napas vesiculer ronchi D/S wheezing D/S rales D/S
g. Alat bantu nafas Ya Tidak
Jenis .........................Flow ................Lpm
h. Penggunaan WSD :
- Jenis : ....................................................................................................................
- Jumlah Cairan : .........................................................................................................
- Undulasi : .................................................................................................................
- Tekanan : .................................................................................................................
i. Trakeostomy Ya Tidak
................................................................................................................................................
................................................................................................................................................
j. Lain-lain :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
MASALAH KEPERAWATAN :
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
3. Sistem Kardiovakuler (B2)
a. Keluhan nyeri dada ya tidak
P : .....................................................................................
Q : .....................................................................................
R : .....................................................................................
S : .....................................................................................
T : .....................................................................................
b. CRT : ...............
c. Konjungtiva pucat ya tidak
d. Bunyi jantung: Normal Murmur Gallop lain-lain
e. Irama jantung: Reguler Ireguler S1/S2 tunggal Ya Tidak
f. Akral: Hangat Panas Dingin kering Dingin basah
g. Siklus perifer Normal Menurun
h. JVP : ..........................
Lain-lain :
.................................................................................................................................................
.................................................................................................................................................
MASALAH KEPERAWATAN :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
.................................................................................................................................................
MASALAH KEPERAWATAN :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
G. PENGKAJIAN PSIKOSOSIAL
1. Persepsi klien terhadap penyakitnya
Cobaan Tuhan Hukuman Lainnya
2. Ekspresi klien terhadap penyakitnya
Murung Gelisah Tegang Marah/menangis
3. Reaksi saat interaksi kooperatif tak kooperatif curiga
4. Gangguan konsep diri ya tidak
MASALAH KEPERAWATAN :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
H. PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah
- Sebelum sakit sering kadang-kadang tidak pernah
- Selama sakit sering kadang-kadang tidak pernah
b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
MASALAH KEPERAWATAN :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
I. PERSONAL HYGIEN
a. Kebersihan diri :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
K. TERAPI
Tuban,.................................
Perawat Primer,
(.............................................)
ANALISA DATA
DATA ETIOLOGI MASALAH
DIAGNOSA KEPERAWATAN
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
INTERVENSI
No Diagnosa Keperawatan Tujuan/ Tgl/jam Intervensi Rasional
Kriteria Hasil
IMPLEMENTASI DAN EVALUASI
DIAGNOSA IMPLEMENTASI JAM/TGL EVALUASI SOAP TTD