ASUHAN KEPERAWATAN

GANGGUAN PEMENUHAN KEBUTUHAN AMAN NYAMAN

PADA Tn. M DENGAN SPACE OCCUPYING LESION, TUBERCULOSIS
DI RUANG RAJAWALI 6A RSUP Dr. KARIADI SEMARANG

Disusun untuk Memenuhi Tugas Praktik Ketrampilan Dasar Profesi

Pembimbing Akademik : Dr. Luky Dwiantoro, S.Kp., M.Kep
Pembimbing Klinik : Arina Sofia Yarlis, S.Kep., Ns

Oleh :

PROGRAM PENDIDIKAN PROFESI NERS XXXI

JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS DIPONEGORO
SEMARANG
2018
 ASUHAN KEPERAWATAN
GANGGUAN PEMENUHAN KEBUTUHAN AMAN NYAMAN PADA Tn. M
DI RUANG RAJAWALI 6A RSUP Dr. KARIADI

I. PENGKAJIAN
Tanggal Masuk RS : ..................................
Tanggal Masuk Bangsal : ..................................
Tanggal Pengkajian : ..................................
A. Data Demografi
1. Biodata Pasien
a. Nama : ....................................................................
b. Usia : ....................................................................
c. Jenis Kelamin : ....................................................................
d. Agama : ....................................................................
e. No. Rekam Medik : ....................................................................
f. Diagnosa Medis : ....................................................................
g. Pendidikan : ....................................................................
h. Pekerjaan : ....................................................................
i. Alamat Rumah : ....................................................................
2. Penanggung Jawab
a. Nama : ....................................................................
b. Hubungan dg Klien : ....................................................................
c. Usia : ....................................................................
d. Agama : ....................................................................
e. Alamat : ....................................................................

B. Keluhan Utama
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C. Riwayat Kesehatan
1. Riwayat Penyakit Sekarang
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2. Riwayat Penyakit Dahulu

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3. Riwayat Kesehatan Keluarga

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 4. Genogram

Keterangan :
: laki-laki
: perempuan
: meninggal
: klien
: garis pernikahan
: garis keturunan
: tinggal serumah

D. PENGKAJIAN KEBUTUHAN DASAR MANUSIA

1. Kebutuhan Aktivitas dan Latihan
Saat pengkajian:
Index 0 1 2 3 Keterangan
Makan, Minum 0 : Tidak mampu
1 : Dibantu
2 : Mandiri
Mandi 0 : Tergantung orang lain
1 : Mandiri
Perawatan diri (grooming) 0 : Tergantung orang lain
1 : Mandiri
Berpakaian (dressing) 0 : Tidak mampu
1 : Dibantu
2 : Mandiri
BAB (bladder) 0 : Inkontinensia
 (tidak teratur/ perlu enema)
1 : Kadang inkontinensia
(sekali seminggu)
2 : Kontinensia (teratur)
BAK (bowel) 0 : Inkontinensia
(pakai kateter/terkontrol)
1 : Kadang inkontinensia
(maks 1 x 24 jam)
2 : Kontinensia (teratur)
Transfer 0 : Tidak mampu
1 : Butuh bantuan alat dan 2 orang
2 : Butuh bantuan kecil
3 : Mandiri
Mobilitas 0 : Imobile
1 : Menggunakan kursi roda
2 : Berjalan dengan bantuan 1 orang
3 : Mandiri
Penggunaan toilet 0 : Tergantung bantuan orang lain
1 : Membutuhkan bantuan tapi beberapa
hal dilakukan sendiri
2 : Mandiri
Naik turun tangga 0 : Tidak mampu
1 : Membutuhkan bantuan
2 : Mandiri
Total Score 16 (Ketergantungan ringan)
Sumber: Dewi, Sofia Rosma. 2014. Buku Ajar Keperawatan Geriatrik. Yogyakarta: Deepublish.
Interpretasi hasil Barthel Index :
20 : Mandiri
12–19 : Ketergantungan ringan
9 – 11 : Ketergantungan sedang
5–8 : Ketergantungan berat
0–4 : Ketergantungan total
Keterangan:
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2. Kebutuhan Hygiene Integritas Kulit
Hygiene Sebelum sakit Saat sakit

Mandi

Ganti baju

Rambut

Gosok gigi

Kulit

Gatal

3. Kebutuhan Istirahat dan Tidur

Parameter Sebelum sakit Saat sakit

Frekuensi

Kualitas

Gangguan

Obat-obatan

4. Kebutuhan Nutrisi dan Cairan

Nutrisi

Saat Pengkajian
A (Antropometri)

B (Biokimia)
C (Clinic)
 D (Diet)

Cairan (hitung berdasarkan IWL)

Input Output
Infus : BAK :
Minum : BAB :
Jumlah : IWL :
Jumlah:
*BC/24 jam : Output – Input

Keterangan :
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5. Kebutuhan Oksigenasi
Sebelum sakit :
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Setelah sakit :
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6. Kebutuhan Eliminasi
a. BAB
Parameter Sebelum sakit Saat pengkajian

Frekuensi

Jumlah
 Konsistensi

Keluhan

Warna

Bau

Darah

b. BAK
Parameter Sebelum sakit Saat pengkajian

Frekuensi

Jumlah

Konsistensi

Keluhan

Warna

Bau

Darah

7. Kebutuhan Persepsi Sensori dan Kognitif

Persepsi
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Sensori
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Kognitif
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8. Kebutuhan Termoregulasi
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9. Kebutuhan Konsep Diri

PARAMETER SAAT PENGKAJIAN

Gambaran diri

Citra diri

Identitas diri

Ideal diri

Harga diri

10. Kebutuhan Stress Koping

Sebelum sakit : ................................................................................................
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Selama sakit : ....................................................................................................
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 11. Kebutuhan Seksual-Reproduksi
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12. Kebutuhan Komunikasi-Informasi tentang kesehatan
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13. Kebutuhan Rekreasi-Spiritual
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14. Kebutuhan Aman Nyaman
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E. Pemeriksaan Fisik
1. Keadaan Umum
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2. Kesadaran
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3. Tanda-tanda vital
TD : mmHg
Nadi : x/menit
RR : x.menit
0
Suhu : C
SpO2 : %

4. Head to toe
a. Kepala (Kepala, Mata, Telinga, Hidung, Mulut)
Inspeksi :
Kepala :............................................................................................
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Telinga : ............................................................................................
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Mata : ............................................................................................
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Hidung : ............................................................................................
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Mulut : ............................................................................................
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Palpasi :
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b. Leher
Inspeksi :
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Palpasi :
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c. Paru dan Dada
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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d. Jantung
Inspeksi :
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Palpasi :
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Perkusi :
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Auskultasi :
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e. Abdomen
Inspeksi :
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Auskultasi :
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Palpasi :
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Perkusi :
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f. Punggung
Inspeksi :
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Palpasi :
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g. Anus dan Genital
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h. Ekstremitas Atas
Kanan/ Dextra:
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Kiri/ Sinistra:
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i. Ekstremitas Bawah
Kanan/ Dextra:
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Kiri/ Sinistra :
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F. PEMERIKSAAN PENUNJANG
1. Pemeriksaan ............................
Tanggal :

Hasil Pemeriksaan
2. Pemeriksaan Laboratorium
Jenis Pemeriksaan Hasil Nilai Normal Interpretasi
G. TERAPI MEDIS DAN KEPERAWATAN
Jenis Terapi Dosis Rute Waktu/Tanggal Indikasi/Kontraindikasi Efek Samping
Pemberian
Keperawatan
Jenis Terapi Dosis Rute Waktu/Tanggal Indikasi/Kontraindikasi Efek Samping
Pemberian
Medis
II. DIAGNOSA KEPERAWATAN
A. ANALISIS DATA
Nama Klien :
No. Rekam Medik :
Ruang Rawat :
No. Data Masalah Etiologi
 B. PERUMUSAN MASALAH
Nama Klien :
No. Rekam Medik :
Ruang Rawat :
No. Dx Diagnosa Keperawatan Tgl. Ditemukan Tgl. Teratasi
(Kode Nanda)

III. PERENCANAAN KEPERAWATAN

Nama Klien :
No. Rekam Medik :
Ruang Rawat :
Tgl No. Dx Tujuan dan Kriteria Hasil Rencana Tindakan TTD
IV. IMPLEMENTASI KEPERAWATAN
Nama Klien :
No. Rekam Medik :
Ruang Rawat :
Tanggal Diagnosa Jam Tindakan Keperawatan Hasil (Evaluasi Formatif) TTD
Keperawatan
V. EVALUASI KEPERAWATAN
Nama Klien :
No. Rekam Medik :
Ruang Rawat :

Tgl Diagnosa Keperawatan Jam Evaluasi Sumatif TTD