Format Asuhan Keperawatan Profesi Cucomew

LAPORAN ASUHAN KEPERAWATAN PADA…………
DENGAN ………………….....……...…………….………
DI RUANG ................................RSUP SANGLAH
TANGGAL ………......……s.d ………….....…
OLEH:
PROGRAM STUDI SARJANA KEPERAWATAN DAN PROFESI NERS

FAKULTAS KEDOKTERAN
UNIVERSITAS UDANAYA
2019
A. Pengkajian Keperawatan
1. Identitas
 Nama :..................................................................................................
 Jenis kelamin :..................................................................................................
 Umur :..................................................................................................
 Pendidikan :..................................................................................................
 Pekerjaan :..................................................................................................
 Status perkawinan :..................................................................................................
 Agama :..................................................................................................
 Suku :..................................................................................................
 Alamat :..................................................................................................
 Tanggal masuk :..................................................................................................
 Tanggal pengkajian :..................................................................................................
 Nama penanggung jawab :..................................................................................................
 Hubungan penanggung jawab :...................................................................................................
 Diagnosa medis :...................................................................................................
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2. Status kesehatan
 Kesadaran :...................................................................................................
 Tekanan darah :...................................................................................................
 Frekuensi nafas :...................................................................................................
 Frekuensi nadi :...................................................................................................
 Temperatur :...................................................................................................
3. Keluhan utama
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4. Riwayat penyakit saat ini

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5. Riwayat penyakit masa lalu

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6. Riwayat penyakit keluarga

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7. Genogram
Keterangan Genogram
: Laki-laki
: Perempuan
: Sudah Meninggal
----------: Tinggal Serumah
: Klien
8. Riwayat lingkungan
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9. Pengkajian kebutuhan dasar manusia

 Oksigenasi
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 Cairan
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 Nutrisi
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 Eliminasi BAK
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 Eliminasi BAB
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 Rasa nyaman aman

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 Tidur dan istirahat

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 Personal hygiene
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10. Pengkajian dan pemeriksaan fisik (inspeksi, palpasi, perkusi, auskultasi)

a. Kulit, Rambut dan Kuku
Distribusi rambut :
Lesi  Ya  Tidak
Warna kulit  Ikterik  Sianosis  Kemerahan Pucat
Akral  Hangat  Panas  Dingin kering Dingin
Turgor:
Oedem  Ya  Tidak
Lokasi: Warna kuku:  Pink  Sianosis  lain-lain
Lain-lain:
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b. Kepala dan Leher
Kepala Simetris  Asimetris,
Lesi: Ya  Tidak
Deviasi trakea Ya  Tidak
Pembesaran kelenjar tiroid  Ya  Tidak
Lain-lain:
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c. Mata dan Telinga
Gangguan pengelihatan  Ya  Tidak
Menggunakan kacamata  Ya  Tidak Visus:
Pupil  Isokor Anisokor
Ukuran:
Sklera/ konjungtiva  Anemis  Ikterus
Gangguan pendengaran  Ya  Tidak

Menggunakan alat bantu dengar  Ya  Tidak
Tes weber: Tes Rinne: Tes Swabach:
Lain-lain:
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d. Sistem Pernafasan:
Batuk:  Ya  Tidak
Sesak:  Ya  Tidak
 Inspeksi:
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 Palpasi:
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 Perkusi:
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 Auskultasi:
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Lain-lain:
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e. Sistem Kardiovaskular :
Nyeri dada  Ya  Tidak
Palpitasi  Ya  Tidak
CRT  < 3 dtk  > 3 dtk
 Inspeksi:
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 Palpasi:
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 Perkusi:
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 Auskultasi:
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f. Payudara Wanita dan Pria:
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g. Sistem Gastrointestinal:
Mulut  Bersih  Kotor  Berbau
Mukosa  Lembab  Kering  Stomatitis
Pembesaran hepar  Ya  Tidak
Abdomen  Meteorismus  Asites  Nyeri tekan
Peristaltik: x/mnt
Lain-lain :
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h. Sistem Urinarius :
Penggunaan alat bantu/ kateter  Ya  Tidak
Kandung kencing, nyeri tekan  Ya  Tidak
Gangguan  Anuria  Oliguria  Retensi
Inkontinensia Nokturia  Lain-lain:
i. Sistem Reproduksi Wanita/Pria :
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j. Sistem Saraf:
GCS: Eye: Verbal: Motorik:
Rangsangan meningeal  Kaku kuduk  Kernig Brudzinski I
 Brudzinski II
Refleks fisiologis  Patela  Trisep  Bisep  Achiles

Refleks patologis  Babinski  Chaddock Oppenheim
 Rossolimo Gordon  Schaefer
 Stransky Gonda
Gerakan involunter :
Lain-lain:
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k. Sistem Muskuloskeletal:
Kemampuan pergerakan sendi  Bebas  Terbatas
Deformitas  Ya  Tidak Lokasi:
Fraktur  Ya  tidak Lokasi:
Kekakuan  Ya  Tidak
Nyeri sendi/otot  Ya Tidak
Kekuatan otot :
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l. Sistem Imun:
Perdarahan Gusi  Ya  Tidak
Perdarahan lama  Ya  Tidak
Pembengkakan KGB  Ya  Tidak
Lokasi:
Keletihan/kelemahan  Ya  Tidak
Lain-lain:
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m. Sistem Endokrin:
Hiperglikemia  Ya  Tidak
Hipoglikemia  Ya  Tidak
Luka gangrene  Ya Tidak
Lain-lain:
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11. Pemeriksaan penunjang dan diagnostik

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12. Terapi
No Hari/Tanggal Terapi
13. Analisis Data
No Tgl Data Etiologi Masalah
No Tgl Data Penyebab/Intepretai Masalah
No Tgl Data Penyebab/Intepretai Masalah
B. Diagnosa Keperawatan
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C. Perencanaan Keperawatan
Rencana Keperawatan
No
Hari/tgl
Dx Tujuan dan kriteria hasil Intervensi Rasional
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D. Intervensi Keperawatan
No
Hari/tgl Jam Tindakan keperawatan Respon klien TTD
Dx
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E. Evaluasi
No Hari/Tgl No Dx Jam Evaluasi Ttd
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Format Asuhan Keperawatan Profesi Cucomew

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Format Asuhan Keperawatan Profesi Cucomew

Diunggah oleh

Hak Cipta:

Format Tersedia

LAPORAN ASUHAN KEPERAWATAN PADA…………

PROGRAM STUDI SARJANA KEPERAWATAN DAN PROFESI NERS

4. Riwayat penyakit saat ini

5. Riwayat penyakit masa lalu

6. Riwayat penyakit keluarga

----------: Tinggal Serumah

9. Pengkajian kebutuhan dasar manusia

 Rasa nyaman aman

 Tidur dan istirahat

10. Pengkajian dan pemeriksaan fisik (inspeksi, palpasi, perkusi, auskultasi)

Gangguan pendengaran  Ya  Tidak

Refleks fisiologis  Patela  Trisep  Bisep  Achiles

11. Pemeriksaan penunjang dan diagnostik

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