ASUHAN KEPERAWATAN An.

Hari/Tgl Pengkajian : Selasa/ 28 - 11 - 2017 Jam : 13.00

Nama Mahasiswa : Nopalustiyawati
NIM : PN.17.0017
Rumah Sakit / Ruang : RSPAU dr. S. Hardjolukito/ Cendrawasih

A. IDENTITAS
1. Klien
Nama : YN. M Tgl Masuk RS : Selasa 28.11. 2017
Tempat/ tanggal lahir : Bantul/ 01 – 01 – 1951 Sumber Data : Pasien
Jenis Kelamin : Laki – laki No RM : 1578xx
Agama : Islam
Status Perkawinan : Nikah
Pendidikan : Diploma 3
Pekerjaan : Pensiunan
Suku / Bangsa : Jawa/ Indonesia
Alamat : Depok DK Gondekan RT 03 Bantul
Dx Medis : BPH Pro TURP

2. Penanggung Jawab Klien

Nama : NY. M
Umur : 65 tahun
Jenis Kelamin : Perempuan
Pendidikan : Diploma 3
Pekerjaan : Ibu Rumah Tangga
Alamat : Depok DK Gondekan RT 03 Bantul
Hubungan dengan pasien : Istri

B. RIWAYAT KESEHATAN
1. Riwayat Kesehatan Klien
a) Keluhan Utama :
Pasien mengatakan tidak lancar saat Bak 2 hari yang lalu. Dengan jumlah sedikit 10
cc/ hari.
Warna: kuning pekat. Bau, amonia
P : BpH Pro Trup
Q :Seperti ditusuk – tusuk
R : Di area Pubs
S:6
T : Terus menerus
 b) Riwayat Kesehatan Saat Ini :
Pasien mengatakan 2 hari yang lalu sebelum di bawa ke RS tidak bisa BAK dan
pada saat di kaji pasien mengatakan Nyeri.
P : BpH Pro Trup S:6
Q :Seperti ditusuk – tusuk T : Terus menerus
R : Di area Pubs

c) Riwayat Kesehatan Dahulu :

Pasien mengatakan memiliki riwayat hipertensi sesak 10 tahun yang lalu.

2. Riwayat Kesehatan Keluarga :

a) Genogram

b) Riwayat Kesehatan Keluarga

Pasien mengatakan bahwa orang tua mempunyai penyakit hipertensi

C. POLA KEBIASAAN KLIEN

1. Pola Nutrisi
Sebelum Sakit
Pasien makan 3 x sehari setiap makan 1 porsi habis, jenis makanan yang dikonsumsi
tinggi kolestrol (Nasi, Sayur, Lauk) tidak ada pantangan makanan, tidak elergi makanan.
Pasien minum 5 – 6 gelas/ hari (1500 cc – 2000 cc) berupa teh, air putih.

Selama Sakit
1
Pasien mengatakan makan 3 x sehari setiap makan habis porsi.
2

Pasien mengatakan minum 3 gelas/ hari (1500 cc) berupa air putih, Teh.
2. Pola Eliminasi
Sebelum Sakit
Pasien mengatakan bisa Bak tapi tidak lancar

Selama Sakit
Pasien mengatakan terpasang selang DC, sejak 1 hari yang lalu dan di Irigasi dengan
Nacl dengan di guyur berwarna merah.

3. Pola Aktivitas, Istirahat dan Tidur

a. Sebelum Sakit
1) Aktivitas Sehari-hari
Pasien mengatakan aktivitas sehari – hari di rumah yaitu bercocok tanam.

2) Keadaan Pernafasan
Pasien mengatakan tidak ada keluhan pernapasan

3) Keadaan Kardiovaskuler
Pasien mengatakan keadaan kardiovaskuler/ jantung Normal

4) Kebutuhan Tidur
Pasien mengatakan waktu tidur kurang lebih 8 jam
5) Kebutuhan Istirahat
Pasien mengatakan untuk waktu beristirahat 1 jam

b. Selama Sakit
1) Penilaian kemampuan klien dalam beraktivitas selama sakit (beri tanda √)
4
Kemampuan perawatan diri 0 1 2 3

Makan minum 

Toileting 

Berpakaian 

Mobilitas di tempat tidur 

Berpindah 

Ambulasi ROM 

0 = Mandiri
1 = Dengan Alat Bantu
2 = Dibantu orang lain
3 = Dengan alat bantu dan dibantu orang lain
4 = Ketergantungan total
Kesimpulan :
Pasien mengatakan beraktivitas selama sakit mandiri
 2) Keadaan Pernafasan
RR : 20 x /menit
Suara napas vesikuler

3) Keadaan Kardiovaskuler
TD : 150 / 90 mmHg N: 82 x / menit
Denyutan aorta teraba

4) Kebutuhan Tidur
Pasien mengatakan kebutuhan tidur kurang lebih 8 jam, setelah bangun tidur
terasa segar.

5) Kebutuhan Istirahat
Pasien mengatakan waktu untuk tidur lebih siang 7 jam dan 1 jam untuk
istirahat sambil nonton TV.

4. Pola Kebersihan Diri (sebelum dan selama sakit)

a. Kulit
Sebelum Sakit
Pasien mengatakan warna kulit sawoh matang, mandi 2 x sehari setiap pagi dan
sore hari.

Selama Sakit
Pasien mengatakan mandi dengan cara disibin setiap pagi dan sore hari kulit
terasa bersih

b. Rambut
Sebelum Sakit
Pasien mengatakan setiap mandi sore cuci rambut

Selama Sakit
Pasen mengatakan selama di rawat di RS belum pernah cuci rambut, keadaan
rambut kotor, terlihat acak

c. Telinga
Sebelum Sakit
Pasien mengatakan setiap 1 minggu sekali selalu membersihkan serumen yang ada
di telinga.

Selama Sakit
Pasien mengatakan selama di rawat di RS belum pernah membersihkan serumen
yang ada di telingga.
 d. Mata
Sebelum Sakit
Pasien mengatakan bisa merawat mata dengan obat tetes mata dalam keadaan
mata merah.

Selama Sakit
Paseien mengatakan selama sakit belum pernah sakit mata konjugtiva anemis.

e. Mulut
Sebelum Sakit
Pasien mengatakan menggosok gigi setiap pagi dan sore hari 2 x.

Selama Sakit
Pasien mengatakan selama sakit tidak gosok gigi hanya berkumur.
f. Payudara
Sebelum Sakit
Pasien mengatakan tidak ada keluhan

Selama Sakit
Pasien mengatakan tidak ada keluhan.

g. Genitalia
Sebelum Sakit
Pasien mengatakan selalu merawat genitalia.

Selama Sakit
Pasien mengatakan belum bisa merawat genitalianya. Terpasang selang DC no 24,
post operasi protatectemy keadaan genitalia bersih.

h. Kuku/kaki
Sebelum Sakit
Pasien mengatakan setiap 1 minggu seklai memotong kuku.

Selama Sakit
Pasien mengatakan selama sakit belum potong kuku. Tidak terlihat panjang, bersih
capilar refil < 2 detik.

5. Pola Reproduksi dan Seksual

Sebelum Sakit
Pasie mengatakan sudah tidak berhubungan intim
 Selama Sakit
Pasie mengatakan sudah tidak berhubungan intim

6. Aspek mental-intelektual-sosial-spiritual
a) Konsep Diri
1) Identitas
Pasien berjenis kelamin laki – laki berusia 66 tahun, beragama islam.

2) Harga Diri
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3) Gambaran Diri
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4) Peran Diri
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5) Ideal Diri
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b) Intelektual
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c) Hubungan Interpersonal
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d) Mekanisme Koping
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e) Support System
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f) Mental Emosional
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g) Inetelegensi
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h) Sosial
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i) Spiritual
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D. PEMERIKSAAN FISIK
1. Keadaan Umum
a) Tingkat Kesadaran : GCS : E= V= M=
b) Status Gizi :
TB :
BB :
Penilaian Status Gizi :
c) Tanda Vital
Tekanan Darah :
Frekuensi Nadi :
Suhu :
Respirasi Rate :
SpO2 :
2. Pemeriksaan Fisik Sistemik
a) Kepala
Bentuk dan kulit kepala
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Rambut
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Kesan wajah
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Mata
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Telinga
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Hidung
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Mulut dan tenggorokan
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b) Leher
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c) Tengkuk
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d) Sirkulasi
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e) Dada/thoraks
Jantung
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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Paru-Paru
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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f) Payudara
Inspeksi :
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 Palpasi :
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g) Punggung
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h) Abdomen
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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i) Panggul
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j) Anus/rektum
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k) Genetalia
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l) Ekstremitas
Atas :
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Bawah :
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E. PEMERIKSAAN PENUNJANG
1) Laboratorium
 Hari/
tanggal/ Jenis Pemeriksaan Hasil Nilai Normal Interpretasi
jam

2) Radiologi
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3) EEG, USG, MRI, EKG

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4) Scanning
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F. TERAPI MEDIS YANG DIDAPAT

 No Nama Obat Dosis Fungsi Rute

G. ANALISA DATA
Etiologi
Data Problem
H. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS MASALAH

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 RENCANA ASUHAN KEPERAWATAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :

Perencanaan
No Hari/Tgl/Jam Dx. Keperawatan
Tujuan dan Kriteria Hasil Intervensi
 CATATAN PERKEMBANGAN

Nama Klien : Ruang : Diagnosa Medis :

No RM : Umur :
 Evaluasi
No Hari/Tgl/Jam Implementasi Ttd
Proses Hasil