ASUHAN KEPERAWATAN PADA PASIEN STROKE + HIPERTENSI

DENGAN NAUSEA DAN GANGGUAN POLA TIDUR

DI RUANG PENYAKIT SARAF
TANGGAL 25 s/d 27 SEPTEMBER 2018

A. PENGKAJIAN
1. IDENTITAS
PASIEN
Nama : Tn. KS
Umur : 50 Tahun
Jenis kelamin : Laki-laki
Pendidikan : -
Pekerjaan : -
Status perkawinan : -
Agama : -
Suku : -
Alamat : -
Tanggal masuk : 24 september 2018
Tanggal pengkajian : 25 September 2018
Sumber informasi : Pasien, keluarga dan RM

PENANGGUNG
Nama penanggung jawab : -
Hub dgn pasien :-

2. STATUS KESEHATAN
a. Status Kesehatan Saat Ini
 Keluhan utama : pasien mengeluh sakit kepala, mual, pusing, dan
sulit tidur

 Alasan masuk Rumah Sakit dan perjalanan Penyakit saat ini

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 Upaya yang dilakukan untuk mengatasinya
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b. Status Kesehatan Masa Lalu

 Penyakit yang pernah dialami
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 Pernah dirawat
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 Alergi
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 Kebiasaan :(merokok/kopi/ alkohol/lain-lain yang merugikan

kesehatan)
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c. Riwayat Penyakit Keluarga :

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d. Diagnosa Medis dan therapy

Stroke + Hipertensi

3. POLA FUNGSI KESEHATAN (11 Pola Fungsional Gordon)

a. Pemeliharaan dan persepsi terhadap kesehatan
Pasien mengatakan setiap pasien sakit pasti pergi ke tenaga kesehatan

b. Pola Nutrisi/metabolic
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c. Pola eliminasi
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d. Pola aktivitas dan latihan

Kemampuan perawatan diri 0 1 2 3 4
Makan/minum 
Mandi 
Toileting 
Berpakaian 
Mobilisasi di tempat tidur 
Berpindah 
Ambulasi ROM 
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan
alat, 4: tergantung total.
Okigenasi:
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e. Pola tidur dan istirahat
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f. Pola kognitif-perseptual
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g. Pola persepsi diri/konsep diri

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h. Pola seksual dan reproduksi

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i. Pola peran-hubungan
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j. Pola manajemen koping stress

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k. Pola keyakinan-nilai

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4. PEMERIKSAAN FISIK
a. Keadaan umum :..........................
Tingkat kesadaran : komposmentis/ apatis/ somnolen/ sopor/ koma
GCS : verbal :_______ psikomotor :______
mata:_______
b. Tanda-tanda vital : Nadi :_____Temp: _____ RR :______TD
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c. Keadaan fisik (IPPA)

1) Kepala dan leher
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2) Dada
 Paru
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 Jantung
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3) Payudara dan ketiak

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4) Abdomen
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5) Genetalia
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6) Integumen
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7) Ekremitas
 Atas
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 Bawah
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5. PEMERIKSAAN PENUNJANG
a. Data laboratorium yang berhubungan

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 A.ANALISA DATA

No Tanggal Data fokus Analisis Masalah

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 B. DIAGNOSA KEPERAWATAN
No Tanggal Dx Keperawatan Tanggal TTd
Dx Muncul teratasi

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 C. PERENCANAAN
Hari/Tanggal No Tujuan Intervensi Rasional
Dx (NOC) (NIC)

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 D. IMPLEMENTASI
No Evaluasi Formatif
Hari/Tgl Jam Tindakan Keperawata TTD
Dx

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 E. EVALUASI
No
Hari/Tgl Jam Evaluasi Ttd
Dx

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Lembar Pengesahan

Denpasar,..........................2018

Mengetahui,
Clinical Instructure/CI Mahasiswa,

(...................................................) (....................................................)
NIP. NIM.

Mengetahui,
Pembimbing Akademik

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NIP

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