ASUHAN KEPERAWATAN PADA ..........................

DENGAN
MASALAH SISTEM ..........................................................................
DI RUANG …....................... RSUD PANEMBAHAN
SENOPATI BANTUL

Tgl. Masuk : ................................. Tgl. Pengkajian : ..........................

Jam : .................................
No. CM : .................................
Diagnosa Medis :
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Jam : ..........................
Data diperoleh dari :
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IDENTITAS

Pasien Penangguang Jawab Pasien

Nama : .......................................... Nama : ..........................................
Umur : .......................................... Umur : ..........................................
Agama : .......................................... Agama : ..........................................
Pendidikan : .......................................... Pendidikan : ..........................................
Pekerjaan : .......................................... Pekerjaan : ..........................................
Alamat : Hubungan dengan pasien : ......................
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.................................................................
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Status Pernikahan :
Menikah / Belum Menikah

A. RIWAYAT KESEHATAN

Alasan Masuk Rumah Sakit :

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Keluhan Utama Saat Pengkajian :

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Riwayat Kesehatan Sekarang :

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Riwayat pengobatan saat di rumah : Tidak Ya, jika Ya sebutkan :

Nama Obat Dosis Cara Pemberian Frekuensi Waktu dan Tanggal

Terakhir Diberikan

Keterangan :

.............................................................................................................................
.............................................................................................................................
Riwayat pengobatan saat di IGD : Tidak Ya, jika Ya sebutkan :

Nama Obat Dosis Cara Pemberian Frekuensi Waktu dan Tanggal

Terakhir Diberikan

Keterangan :

.............................................................................................................................
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Riwayat Kesehatan Dahulu :
.............................................................................................................................
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Riwayat Pengobatan Alergi : Tidak Ya

Jika Ya : a. Alergi obat : Tidak Ya,

Jenis/nama obat : ...............................................................................

b. Lain-lain Asma Eksim kulit Makanan Debu Udara

Reaksi utama yang timbul : ............................................................

Riwayat merokok : Tidak Ya, Sigaret/Pipa/Kretek

Jumlah/hari ...................................... Lama ........................................................

Riwayat minum-minuman keras: Tidak Ya,

Jenis ................................. jumlah/hari ........................... Lama .........................

Riwayat Kesehatan Keluarga :

Diabetes Kanker Hipertensi Jantung Tuberculosis Anemia

Tidak ada

Genogram :

Keterangan :
 B. POLA FUNGSI KESEHATAN
No. Pola Fungsi Kesehatan Sebelum Masuk Rumah Sakit
1 Presepsi dan Pandangan terhadap kesehatan :
Pemeliharaan Kesehatan ...................................................................................
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Kebiasaan pribadi apabila sakit :
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2 Nutrisi Makan
Jenis makanan :
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Saat Di Rumah Sakit
Pandangan terhadap kesehatan :
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Harapan terhadap penyakit :
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Sikap terhadap pengobatan/perawatan :
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Makan
Jenis makanan :
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Frekuensi :
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Habis berapa porsi :
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Makanan kesukaan :
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BB : ................. , TB : .................. , IMT : ...............
Nausea/Vomitus : .....................................................
Jika ya, jumlah : .......................................................
Frekuensi : ................................................................
Warna/konsisten : .....................................................
Minum
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Frekuensi :
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...................................................................................
Habis berapa porsi :
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Makanan kesukaan :
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...................................................................................
BB : ................. , TB : ................. , IMT : ...............
Nausea/Vomitus : .....................................................
Jika ya, jumlah : .......................................................
Frekuensi : ................................................................
Warna/konsisten : .....................................................
Minum
...................................................................................
...................................................................................
3 Aktivtas dan Latihan ADL 0 1 2 3 4 Keterangan ADL 0 1 2 3 4 Keterangan
Makan / 0 : mandiri Makan / 0 : mandiri
minum 1 : dengan alat minum 1 : dengan alat
bantu bantu
Toileting 2 : dibantu orang Toileting 2 : dibantu orang
lain lain
Berpakaian 3 : dibantu orang Berpakaian 3 :dibantu orang
lain dengan lain dengan
Mobilisasi alat Mobilisasi alat
dari tempat 4 :t ergantung dari tempat 4 :tergantung
tidur total tidur total

Berpindah Berpindah
Ambulasi Ambulasi
Keterangan :
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4 Tidur dan Istirahat Kebutuhan istirahat : Kebutuhan istirahat :

................................................................................... ...................................................................................
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 Kebutuhan tidur : Kebutuhan tidur :
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5 Eleminasi BAB : BAB :

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BAK : BAK :
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6 Presepsi Diri Harga diri :

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Ideal diri :
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Peran diri :
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 Gambaran diri :
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Identitas diri :
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7 Peran dan Hubungan Pekerjaan : Orang yang membantu perawatan di RS :

Sosial ...................................................................................
Tinggal bersama :
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Hubungan dengan keluarga :
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Hubungan dengan tetangga/masyarakat :
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Hubungan dengan keluarga dan tetangga selama di
RS :
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Hubungan dengan teman sekamar/pasien lain :
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Hubungan dengan dokter/perawat/tim kesehatan di
RS :
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8 Seksual dan Reproduksi Wanita :
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Laki-laki :
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9 Nilai dan Kepercayaan Agama : Agama :

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Jenis ibadah :
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Frekuensi beribadah :
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Cara beribadah :
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Hambatan dalam beribadah :
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Jenis ibadah :
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Frekuensi beribadah :
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Cara beribadah :
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Hambatan dalam beribadah :
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Bantuan yang dibutuhkan untuk beribadah :
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10 Manajemen Koping
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11 Kongnitif Preseptual
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C. PEMERIKSAAN FISIK

1. Umum

KU : baik cukup buruk

Kesadaran : komposmentis apatis somnolent sporocoma

koma

GCS : ................ (E : …................, M : ....................., V : .....................)

Buka Mata Respon Motoric Respon Verbal

4 : buka mata 6 : mengikuti perintah 5 : komunikasi
spontan 5 : mengetahui tempat verbal baik,
3 : buka mata rangsangan nyeri jawaban tepat
dengan rangsang 4 : hanya menarik 4 : bingung,
suara bagian tubuhnya disorientasi
2 : buka mata bila dirangsang waktu, tempat
dengan rangsang nyeri dan orang
nyeri 3 : timbul fleksi 3 : dengan
1 : tidak buka mata abnormal bila rangsangan hanya
dengan rangsang dirangsang nyeri ada kata-kata
apapun 2 : ekstensi abnormal 2 : dengan
1 : tidak ada gerakan rangsangan,
dengan rangsangan hanya suara
apapun 1 : tidak ada respons
Catatan :
T : Endotracheal Tube atau tracheostomy (untuk respon verbal)
* : tutup mata karena bengkak (untuk respon buka mata)
TD : ………mmHg, N :………x/mnt, RR : ……..x/mnt, S : ……0C

Nyeri/tidak nyaman : Ya Tidak

Lokasi Intensitas Lama Faktor Kualitas Pola Hal-hal yang

(0-10) nyeri pencetus nyeri serangan menyebabkan
nyeri hilang
 K Kualitas Pola Metode
E Terbakar, Menetap, Istirahat,
Y tumpul, intermetten. obat-obatan,
tertekan, lain-lain,
berat, tajam, panas,
kram. dingin.

Nyeri memprngaruhi : Tidur Aktivitas fisik Emosi Nafsu makan

Konsentrasi Lain-lain

Pakaian, kerapian, dan kebersihan badan :

Bersih Kotor Rapi Serasi Berbau Parfum berlebihan

2. Pemeriksaa Fisik
Kepala
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Rambut
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Wajah
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Mata
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Telinga
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Hidung
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Mulut
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Gigi
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Lidah
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Tenggorokan
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Leher
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Dada
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Respirasi
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Jantung
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Abdomen
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Genitalia
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Anus dan rectum
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Integumen
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Ekstremitas
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D. PEMERIKSAAN PENUNJANG
 DATA FOKUS

Tgl Data Subjektif (DS) Data Obyektif (DO)

 ANALISA DATA
No. Tanggal Data (Subyektif & Obyektif) Etiologi Problem
 DIAGNOSA KEPERAWATAN
No. Tanggal Diagnosa Keperawatan Prioritas

PERENCANAAN KEPERAWATAN
No. Tanggal Diagnoasa Keperawatan NOC NIC
 IMPLEMENTASI DAN EVALUASI
No. Tgl Jam Implementasi Evaluasi