KUMPULAN TUGAS PRAKTIK PROFESI NERS

KEPERAWATAN DASAR PROFESI

Disusun oleh

ARDIAN TRI SETYANA

P 27220019 253

PROGRAM STUDI PROFESI NERS

POLTEKKES KEMENKES SURAKARTA
TAHUN AKADEMIK 2019/ 2020
 FORMAT ASUHAN KEPERAWATAN

ASUHAN KEPERAWATAN
PADA __________ DENGAN GANGGUAN PEMENUHAN KEBUTUHAN
_________________________________________________________________
DI RUANG________________
RSUD KOTA SURAKARTA

Tgl/Jam MRS : ……………………………..

Tanggal/Jam Pengkajian : ……………………………..
Metode Pengkajian : ……………………………..
Diagnosa Medis : ……………………………..
No. Registrasi : ……………………………..

A. PENGKAJIAN
1. BIODATA
a. Identitas Klien
Nama Klien : ………………………………..
Jenis Kelamin : ………………………………..
Alamat : ………………………………..
Umur : ………………………………..
Agama : ………………………………..
Status Perkawinan : ………………………………..
Pendidikan : ………………………………..
Pekerjaan : ………………………………..
b. Identitas Penanggung jawab
Nama : ………………………………..
Jenis Kelamin : ………………………………..
Umur : ………………………………..
Pendidikan : ………………………………..
Pekerjaan : ………………………………..
Alamat : ………………………………...
Hubungan dengan Klien : ………………………………..

2. RIWAYAT KESEHATAN
a. Keluhan Utama
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
b. Riwayat Penyakit Sekarang
...................................................................................................................................
...................................................................................................................................
 c. Riwayat Penyakit Dahulu
...................................................................................................................................
...................................................................................................................................
d. Riwayat Kesehatan Keluarga
...................................................................................................................................
...................................................................................................................................
e. Genogram:

3. PENGKAJIAN POLA FUNGSI GORDON

a. Pola persepsi dan pemeliharaan kesehatan
b. Pola Aktifitas dan Latihan (Kegiatan sehari-hari)
- Sebelum sakit : .....................................................................................
- Selama sakit : .....................................................................................
c. Pola istirahat dan tidur
- Sebelum sakit : .....................................................................................
- Selama sakit : .....................................................................................
1) Kualitas dan kuantitas tidur:
.....................................................................................
2) Gangguan tidur :
.....................................................................................
d. Pola nutrisi metabolik
1) Pengkajian Nutrisi (ABCD)
A (Antropometri) : .....................................................................................
B ( Biomechanical) : .....................................................................................
C (Clinical Sign) : .....................................................................................
D (Diet) : .....................................................................................
2) Pola Nutrisi
Sebelum Sakit : .....................................................................................
a) Frekuensi : .....................................................................................
b) Jenis : .....................................................................................
c) Porsi : .....................................................................................
d) Keluhan : .....................................................................................
Selama Sakit
a) Frekuensi : .....................................................................................
b) Jenis : .....................................................................................
c) Porsi : .....................................................................................
d) Keluhan : .....................................................................................
e. Pola eliminasi
1). BAB
Sebelum Sakit
a) Frekuensi BAB : .....................................................................................
b) Konsistensi : .....................................................................................
c) Warna : .....................................................................................
d) Keluhan/ kesulitan BAB :
..................................................................................................................
e) Penggunaan obat pencahar :
..................................................................................................................
Selama Sakit
a) Frekuensi BAB : .....................................................................................
b) Konsistensi : .....................................................................................
c) Warna : .....................................................................................
d) Keluhan/ Kesulitan BAB :
..................................................................................................................
e) Penggunaan obat pencahar :
..................................................................................................................
2). BAK
Sebelum Sakit
1) Frekuensi BAK : ..................................................
2) Jumlah Urine : ..................................................
3) Warna : ..................................................
4) Keluhan/ kesulitan BAK:
..................................................................................................................
Selama Sakit
1) Frekuensi BAK : ..................................................
2) Jumlah urine : ..................................................
3) Warna : ..................................................
4) Keluhan/ Kesulitan BAK:
..................................................................................................................

ANALISIS KESEIMBANGAN CAIRAN SELAMA PERAWATAN

Intake Output Analisis
a. a. Urine….............cc Intake…..................cc
Minuman ….....cc b. Feses….............cc Output….................cc
b. c. IWL…..............cc
Makanan …......cc
Total ....................cc Total ………..........cc Balance: …….........cc
f. Pola kognitif dan perceptual
1) Nyeri (kualitas, intensitas, durasi, skala, cara mengurangi nyeri)
_____________________________________________________________
_____________________________________________________________
2) Fungsi panca indra (penglihatan, pendengaran, pengecapan, penghidu,
perasa)
_____________________________________________________________
3) Kemampuan bicara
_____________________________________________________________
4) Kemampuan membaca
_____________________________________________________________

g. Pola konsep diri

1) Harga diri
_____________________________________________________________
2) Ideal diri
_____________________________________________________________
3) Identitas diri
_____________________________________________________________
4) Gambaran diri
_____________________________________________________________
5) Peran
_____________________________________________________________

h. Pola koping
1) Masalah utama selama masuk RS (keuangan,dll)
_____________________________________________________________
2) Kehilangan/ perubahan yang terjadi sebelumnya
_____________________________________________________________
3) Pandangan terhadap masa depan
_____________________________________________________________
4) Koping mekanisme yang digunakan saat terjadinya masalah
_____________________________________________________________

i. Pola seksual-reproduksi
1) Masalah menstruasi
_____________________________________________________________
2) Papsmear terakhir
_____________________________________________________________
3) Perawatan payudara setiap bulan
_____________________________________________________________
4) Alat kontrasepsi yang digunakan
_____________________________________________________________
5) Apakah ada kesukaran dalam berhubungan seksual
_____________________________________________________________
6) Apakah penyakit sekarang menggangu fungsi seksual
_____________________________________________________________

j. Pola peran hubungan

 1) Peran pasien dalam keluarga dan masyarakat
_____________________________________________________________
2) Apakah klien punya teman dekat
_____________________________________________________________
3) Siapa yang dipercaya untuk membantu klien jika ada kesulitan
_____________________________________________________________
4) Apakah klien ikut dalam kegiatan masyarakat? Bagaimana keterlibatan klien
_____________________________________________________________

k. Pola nilai dan kepercayaan

1) Agama
_____________________________________________________________
2) Ibadah
_____________________________________________________________

4. PEMERIKSAAN FISIK
a. KeadaanUmum : baik/cukup/lemah
1). Kesadaran
___________________________________________________________________
2). Tanda-Tanda Vital
a) Tekanan Darah : ................................................
b) Nadi
- Frekuensi : ................................................
- Irama : ................................................
- Kekuatan : ................................................
c) Pernafasan
- Frekuensi : ................................................
- Irama : ................................................
d) Suhu : ................................................

b. Pemeriksaan Head To Toe

1). Kepala
a) Bentuk dan ukuran kepala
__________________________________________________________
b) pertumbuhan rambut
__________________________________________________________

c) Kulit kepala
__________________________________________________________

2). Muka
a) Mata
- Kebersihan : ................................................
- Fungsi penglihatan : ................................................
- Palpebra : ................................................
- Konjungtiva : ................................................
 - Sclera : ................................................
- Pupil : ................................................
- Diameter ki/ka : ................................................
- Reflek Terhadap Cahaya : ................................................
- Penggunaan alat bantu penglihatan : ................................................
b) Hidung
- Fungsi penghidung : ................................................
- Sekret : ................................................
- Nyeri sinus : ................................................
- Polip : ................................................
- Napas Cuping hidung : ................................................
c) Mulut
- Kemampuan bicara : ................................................
- Keadaan bibir : ................................................
- Selaput mukosa : ................................................
- Warna lidah : ................................................
- Keadaan gigi : ................................................
- Bau nafas : ................................................
- Dahak : ................................................
d) Gigi
- Jumlah : ................................................
- Kebersihan : ................................................
- Masalah : ................................................
e) Telinga
- Fungsi pendengaran : ................................................
- Bentuk : ................................................
- Kebersihan : ................................................
- Serumen : ................................................
- Nyeri telinga : ................................................
3). Leher
a) Bentuk : ................................................
b) Pembesaran tyroid : ................................................
c) Kelenjar getah bening : ................................................
d) Nyeri waktu menelan : ................................................
e) JVP : ................................................
4). Dada (Thorax)
a) Paru-paru
- Inspeksi : ................................................
- Palpasi : ................................................
- Perkusi : ................................................
- Auskultasi : ................................................
b) Jantung
- Inspeksi : ................................................
- Palpasi : ................................................
 - Perkusi : ................................................
- Auskultasi : ................................................
c) Abdomen
- Inspeksi : ................................................
- Auskultasi : ................................................
- Perkusi : ................................................
- Palpasi : ................................................
d) Genetalia : ................................................
e) Anus dan rektum : ................................................
f) Ekstremitas : ................................................
1) Atas
- Kekuatan otot kanan dan kiri : ................................................
- ROM kanan dan kiri : ................................................
- Perubahan bentuk tulang : ................................................
- Pergerakan sendi bahu : ................................................
- Perabaan Akral : ................................................
- Pitting edema : ................................................
- Terpasang infus : ................................................
2) Bawah
- Kekuatan otot kanan dan kiri : ................................................
- ROM kanan dan kiri : ................................................
- Perubahan bentuk tulang : ................................................
- Varises : ................................................
- Perabaan Akral : ................................................
- Pitting edema : ................................................
g) Integumen : ................................................

5. PEMERIKSAAN PENUNJANG
a. Pemeriksaan laboratorium
Tanggal pemeriksaan : ................................................
Nilai
Jenis Pemeriksaan Satuan Hasil Keterangan Hasil
Normal
b. Pemeriksaan diagnostik
Tanggal pemeriksaan
Jenis Pemeriksaan Hasil Pemeriksaan
6. TERAPI MEDIS
Hari/ Golongan &
Jenis Terapi Dosis Fungsi
Tanggal Kandungan
Cairan IV:

Obat Peroral:
 Obat Parenteral:

Obat Topikal:

7. ANALISA DATA
Nama : No. CM :
Umur : Diagnosa Medis:
Hari/Tangga
No Data Fokus Masalah Etiologi Diagnosa
l/ Jam
8. DIAGNOSA KEPERAWATAN
1.
2.

9. RENCANA KEPERAWATAN/ INTERVENSI

Nama : No. CM :
Umur : Dx. Medis :
 Tujuan&Kriteria Hasil Intervensi
No Tgl/Jm Dx. Kep Ttd
(NOC) (NIC)
10. TINDAKAN KEPERAWATAN/IMPLEMENTASI
Nama : No. CM:
Umur : Diagnosa Medis:
Hari/Tgl /
No Dx Implementasi Respon Ttd
Jam
11. EVALUASI
Nama : No. CM :
Umur : Diagnosa Medis:
No Dx Hari/Tgl/Jam Evaluasi Ttd