Scribd Logo
Unggah

Selamat datang di Scribd!

  • Format Askep KDMisi-1

    Diunggah oleh

    Vina Widiantari
    1 tayangan14 halaman
    No

    Hak Cipta

    © © All Rights Reserved

    Format Tersedia

    DOC, PDF, TXT atau baca online dari Scribd

    Apakah menurut Anda dokumen ini bermanfaat?

    Apakah konten ini tidak pantas?

    Laporkan Dokumen Ini
    No

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    1 tayangan14 halaman

    Format Askep KDMisi-1

    Diunggah oleh

    Vina Widiantari
    No

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 14

    Ruangan Tgl : Nilai Tgl : Nilai Rata - Rata

    Paraf CI Paraf Dosen

    ASUHAN KEPERAWATAN PADA TN. A DI RUANG..............DENGAN DIAGNOSA KEPERAWATAN GANGGUAN ELIMINASI URIN

    1. Pengkajian
    a. Identitas Klien
    Nama : NN. N
    Umur : ..........................................................................................
    Jenis Kelamin : ..........................................................................................
    Agama : ..........................................................................................
    Pendidikan : ..........................................................................................
    Pekerjaan : ..........................................................................................
    Suku/ Bangsa : ..........................................................................................
    Tanggal Masuk RS : 13 JUNI 2015
    Tanggal Pengkajian : 15 JUNI 2015
    No. Medrec : ..........................................................................................
    Diagnosa Medis : Head Injury ( Cedera Kepala)
    Alamat : ..........................................................................................
    b. Identitas penangung jawab
    Nama : .TN. A
    Umur : ..........................................................................................
    Jenis kelamin : ..........................................................................................
    Pendidikan : ..........................................................................................
    Pekerjaan : ..........................................................................................
    Hubungan dengan klien : AYAH
    Alamat : ..........................................................................................
    2. Riwayat Kesehatan
    a. Keluhan utama : SAKIT KEPALA
    ............................................................................................................................................
    b. Riwayat Kesehatan Sekarang ( PQRST)
    Pada saat pengkajian pada tanggal 15 juni 2015, pukul 08.00 pasien mengatakan nyeri pada bagain kepala, nyeri dirasakan seperti di tusuk- tusuk, nyeri
    di rasakan menyebar di daerah kepala, tingkat nyeri dirasakan 8 dari 10, nyeri dirasakan hilang timbul

    c. Riwayat Kesehatan Dahulu


    pasien mengatakan pada tahun 2010 tanggal 29 januari,pasien mengalami benturan kepala karena kecelakaan. Pasien mengatakan sebelumnya pernah di rawat di
    rumah sakit karena demam tinggi kejang. pasien mengatakan bahwa sebelumnya belum pernah di rawat di rumah sakit.
    d. Riwayat Kesehatan Keluarga
    Pasien mengatakan bahwa di dalam keluarga , ayahnya memiliki riwayat penyakit hipertensi.
    Pasien mengatakan bahwa di dalam keluarga , tidak ada riwayat penyakit yang di turunkan/ yang menular. seperti Hipertensi, DM, TBC ataupun penyakit menular
    lainnya.

    3. Pola Aktivitas Sehari-hari


    No Jenis aktivitas Di Rumah Di Rumah Sakit
    1. Nutrisi
    A. Makan
     Jenis ................................................. .................................................
     Frekuensi ................................................. .................................................
     Porsi ................................................. .................................................
     Keluhan Tidak ada Mual muntah
    B. Minum
     Jenis ................................................. .................................................
     Jumlah ................................................. 500 cc / hari
    (cc/ hari) ................................................. Mual, sakit tenggorokan.
     Keluhan
    2. Eliminasi
    A. BAK
     Frekuensi ................................................. 50cc
     Warna ................................................. .................................................
     Keluhan ................................................. Sakit
    B. BAB
     Frekuensi ................................................. .................................................
     Warna ................................................. .................................................
     Konsisten ................................................. .................................................
    si ................................................. .................................................
     Keluhan
    3. Istirahat Tidur
    A. Siang
     Jam ................................................. 3 jam
    B. Malam .................................................
     Jam .................................................
    4. Personal Hygiene
    A. Mandi ................................................. .................................................
    B. Keramas ................................................. .................................................
    C. Gosok Gigi ................................................. .................................................

    5. Aktivitas
    ................................................. .................................................
    ................................................. .................................................
    ................................................. .................................................
    ................................................. .................................................

    4. Pengkajian Fisik
    a. Kesadaran Umum : Baik
    b. Tingkat Kesadaran : CM / compos Mentis
    c. Tanda-tanda Vital : TD : .../...mmHg N : .......x/m
    o
    RR : .......x/m S : ....... C
    d. Pemeriksaan Antropometri
    Tinggi badan : ...........Cm
    Berat Badan : ...........Kg
    e. Pemeriksaan Fisik
    1) Head To Toe
    2)
    a. Pemeriksaan Kepala :
    Inspeksi : Distribusi rambut , Simetris atau tdk, kebersihan rambut
    Palpasi : Kekuatan rambut, pasien mengatakan nyeri pada kepala saat di tekan
    Distribusi rambut merata, bentuk kepala simetris, kebersihan kepala baik, adanya nyeri tekan, kekuatan rambut baik, tidak ada kerontokan.
    b. Pemeriksaan Mata :
    Bentuk mata simetris, Konungtiva anemis, sklera berwana meah (iritasi), refleks pupil baik, refles kornea. lapang pandang baik, tes akomodasi
    pasien baik, pasien tidak mengalami stabismus (juling), ketajaman penglihatan baik, pasien mampu membaca nama perawat.
    c. Pemeriksaan Telinga :
    Bentuk telinga simestris, kebersihan telinga baik, tidak ada lesi tidak ada perdarahan, tidak menggunakan alat bantu pendengaran, tidak ada nyeri
    tekan, pendengaran klien baik.
    d. Pemeriksaan Hidung :
    Bentuk nya simestris, kedaan lubang hidung baik, tidak ada pernafaan cuping hidung, passase udara baik, pasien mampu membedakan bau minyak
    kayu putih dan kopi, tidak ada nyeri tekan.

    e. Pemeriksaan mulut
    Bentuk simetris, tidak ada lesi, tidak terdapat karang gigi, tidak ada perdarahan pada gusi, warna bibir pucat/ tidak, saliva berlebih
    f. Pemeriksaan Kelenjar tyroid
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    g. Pemeriksaan Dada
    Bentuk dada simetris , tidak ada lesi,
    h. Pemeriksaan Jantung
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    i. Pemeriksaan Abdomen
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    j. Pemeriksaan Punggung
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    k. Pemeriksaan Genetalia
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    l. Pemeriksaan Ekstremitas ( Atas dan bawah)
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................
    3) Pemeriksaan fungsi kranial
    Tes Fungsi Kranial
    a) Nervus Olfaktorius : ......................................................................................................
    b) Nervus Optikus : ......................................................................................................
    c) Nervus okulomotorius, Trochlearis, Abdusen :
    ............................................................................................................................................
    ............................................................................................................................................
    d) Nervus Trigeminus : ......................................................................................................
    e) Nervus Fasialis : ......................................................................................................
    f) Nervus Akustikus : ......................................................................................................
    g) Nervus Glosofaringeus dan Vagus :
    ............................................................................................................................................
    h) Nervus assesorius : ......................................................................................................
    i) Nervus Hipoglosus : ......................................................................................................

    5. Data Psikologis
    a. Status Emosi : Pasien tampak tenang
    b. Konsep Diri : Pasien mengatakan ingin segera pulang/ sehat/ pulih
    c. Gaya Komunikasi : Gaya komunikasi baik, pasien mampu menahan emosi
    d. Pola Interaksi : Selama interaksi dg perawat, pasien sangat kooperatif
    e. Pola Koping : .................................?

    f. Data Sosial
     Pendidikan dan Pekerjaan .........................................................................................
     Hubungan Sosial .....................................................................................................
     Faktor Sosialkultural .....................................................................................................
     Gaya Hidup : Pasien mengatakan bahwa klien sering meroko, jarang berolah raga..
    g. Data Spiritual
    ............................................................................................................................................
    ............................................................................................................................................
    ............................................................................................................................................

    6. Data Penunjang
    Pemeriksaan Hasil Nilai Normal Satuan

    ................................................................ ............. ...................................................... ...................


    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................
    ................................................................ ............. ...................................................... ...................

    7. Pengobatan / Farmakologi
    PCT 3x1 Oral
    Cefriaxcon 1 gr IV 3 x 1
    Neurobion 2 x 1amp IM
    Terpasang NGT
    Terpasang Cath
    Terpasng Infus Nacl 0,9 di ektremitas kiri
    terapat luka dekubitus di pinggang
    Terpasang EKG monitor
    Terpasang Oksigen Nasal Canule 3 lt
    Tramadol 3 x 2ampul
    ANALISA DATA
    NO DATA ETIOLOGI MASALAH
    Ds : Pasien mengatakan nyeri pada Terjadi benturan di kepala Gangguan Rasa nyaman Nyeri
    bagian kepala .....................................................
    Do : Adanya nyeri tekan .....................................................
    Kesadaran pasien CM, TTV Td .....................................................
    90/60 mmhg, RR 14 x/menit, Nyeri .....................................................
    96x/menit, S 37. Adanya nyeri .....................................................
    tekan pada kepala, pasien tampak .....................................................
    meringis kesakitan, skla nyeri 8- .....................................................
    10, pasien terpasang infus nacl .....................................................
    0,9%, pasien mendapatkan t/h .....................................................
    Tramadol 3x2 ampul. .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    .....................................................
    DIAGNOSA KEPERAWATAN
    Gangguan rasa nyaman nyeri b/d cedera kepala

    RENCANA ASUHAN KEPERAWATAN


    No DX TUJUAN INTERVENSI RASIONAL

    ...................................................... ................................................................................. ...........................................................................


    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................
    ...................................................... ................................................................................. ...........................................................................

    CATATAN IMPLEMENTASI DAN EVALUASI


    Dinas/ DX Jam IMPLENTASI Jam EVALUASI Paraf
    Hari,
    Tgl

    Anda mungkin juga menyukai