ASUHAN KEPERAWATAN

PADA TN./ NY. ____ DENGAN ___________________ DI RUANG ___________________

RSUD ANNA LASMANAH BANJARNEGARA

DI SUSUN OLEH :
_______________________________________________________
NIM. _________________________________________________

PRAKTIK KLINIK KEPERAWATAN II

UNIVERSITAS HARAPAN BANGSA
2019/2020
A. PENGKAJIAN : TANGGAL .................................. JAM .........

I. IDENTITAS PASIEN
Nama inisial : _____________________________________________________________________
Umur : _____________________________________________________________________
Jenis kelamin : _____________________________________________________________________
Suku/ bangsa : _____________________________________________________________________
Agama : _____________________________________________________________________
Pekerjaan : _____________________________________________________________________
Pendidikan : _____________________________________________________________________
Alamat : _____________________________________________________________________
Tanggal MRS : _____________________________________________________________________
Diagnosa medis : _____________________________________________________________________

II. IDENTITAS PENANGGUNG JAWAB

Nama inisial : _____________________________________________________________________
Umur : _____________________________________________________________________
Jenis kelamin : _____________________________________________________________________
Suku/ bangsa : _____________________________________________________________________
Agama : _____________________________________________________________________
Pekerjaan : _____________________________________________________________________
Pendidikan : _____________________________________________________________________
Alamat : _____________________________________________________________________
Hubungan dengan pasien : ______________________________________________________________

III. RIWAYAT KESEHATAN (NURSING HISTORY)

a. Keluhan Utama saat masuk RS :

_____________________________________________________________________________________________
_____________________________________________________________________________________________

b. Keluhan Utama saat pengkajian :

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

c. Riwayat Penyakit Sekarang :

_____________________________________________________________________________________________
_____________________________________________________________________________________________
 _____________________________________________________________________________________________
_____________________________________________________________________________________________

d. Riwayat Penyakit Dahulu :

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

e. Riwayat Penyakit Keluarga/ Keturunan

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

IV. OBSERVASI DAN PEMERIKSAAN FISIK

A. Vital Sign
Tekanan darah :_______________________________________________
Suhu :_______________________________________________
Nadi :_______________________________________________
Pernafasan :_______________________________________________

B. Kesadaran : ……………… GCS :………..

Eye :…….....
Motorik :….........
Verbal :…….....
C. Keadaan umum :
 Sakit/ nyeri : 1. Ringan 2. Sedang 3. Berat
Skala nyeri : …………………
Nyeri di daerah : …………………

 Status gizi : 1. Gemuk 2. Normal 3. Kurus

BB : …………..TB : ……………. IMT: ..............................

 Sikap : 1. Tenang 2. Gelisah 3. Menahan nyeri

 Personal hygiene : 1. Bersih 2. Kotor 3.…….

 Orientasi waktu/ tempat/ orang :

1. Baik 2. Terganggu……

D. Pemeriksaan Fisik Head To Toe

1. Kepala
 Bentuk : 1. Mesochepale 2. Mikrochepale
 3. lain- lain……

 Lesi/ luka : 1. Hematom 2. Perdarahan 3. Luka sobek

4. lain-lain……..

2. Rambut
 Warna : ……………….
 Kelainan : Rontok/ dll………….

3. Mata
 Penglihatan : 1. Baik 2. Kaca mata/ lensa 3. lain-lain…….
 Sklera : 1. Ikterik 2. Tidak ikterik
 Konjungtiva : 1. Anemis 2. Tidak anemis
 Pupil : 1. Isokor 2. Anisokor
3. Midriasis 4. Miosis
 Kelainan : Kebutaan kanan/kiri……….
 Data tambahan…………….

4. Hidung
 Penghidu :1. Baik 2. Ada gangguan……

 Serumen/ Sekret/ darah/ polip : ……………….

 Tarikan cuping hidung : 1. Ya 2. Tidak

5. Telinga
 Pendengaran : 1. Baik 2. Kerusakan
3. Tuli kanan/kiri 4. Tinnitus 5. Alat bantu dengar 6.
Lainnya
 Sekret/ cairan/ darah : Ada/ Tidak
1. Bau…….. 2. Warna………

6. Mulut dan Gigi

 Bibir : 1. Lembab 2. Kering 3. Sianosis 4. Pecah
 Mulut dan tenggorokan:
1. Baik 2. Lesi 3. Stomatitis
 Gigi :

7. Leher
 Pembesaran tyroid : 1. Ya 2. Tidak
 Lesi : 1. Ya 2. Tidak
 Nadi karotis : 1. Teraba 2. Tidak
 Pembesaran limfoid : 1. ya 2. Tidak
 Peningkatan JVP : 1. Ya 2. Tidak

8. Thorax
  Jantung : 1. Denyut Apikal …………x/ menit, 2. Kuat/ lemah 3.
Irama : teratur/ tidak 4. ………….
I : ______________________________________________________________________________
P : ______________________________________________________________________________
Pe : ______________________________________________________________________________
A : ______________________________________________________________________________

 Paru : 1. Iramanapas: teratur/ tidak

2. Kualitas : normal/ dalam/ dangkal
3. Suara nafas di lapang paru :vesikuler/ ronchi/ wheezing
4. batuk: ya/ tidak
5.sumbatan jalan nafas:sputum/lendir/darah: 1. Ada 2. Tidak
 Retraksi dada : 1. ada 2. tidak ada
 I : ______________________________________________________________________________
P : ______________________________________________________________________________
Pe : ______________________________________________________________________________
A : ______________________________________________________________________________

9. Abdomen
 Bising usus :1. Ada:……x/menit 2. tidak ada 3. lain-lain…
 Kembung : 1. ya 2. tidak
 Nyeri tekan :1. tidak 2. ya, di kuadran……../bagian….
 Ascites :1. ada 2. tidak ada
 I : ______________________________________________________________________________
A : ______________________________________________________________________________
Pe : ______________________________________________________________________________
P : ______________________________________________________________________________

10. Genetalia
 Fimosis : 1. ya 2. tidak
 Alat Bantu : 1. ya 2. tidak
 Kelainan : 1. tidak 2.ya, berupa………

11. Kulit
 Turgor : 1. elastis 2. Kering 3. lain-lain
 Laserasi : 1. luka 2. memar 3. lain-lain di daerah......
 Warna kulit : 1. Tidak ada kelainan 2. Pucat 3. Sianosis
4. Ikterik 5. Hiperpigmentasi
6. Lain-lain……………….

12. Ekstrimitas
 Kekuatan otot :

 ROM : 1. penuh 2. terbatas

 Hemiplegi/parese : 1. tidak 2. ya, kanan/kiri

  Akral : 1. hangat 2. dingin

 Capillary refill time : 1. < 3 detik 2. > 3 detik

 Edema : 1. tidak ada 2. ada di daerah………….

 Lain-lain : ………………..

13. Data pemeriksaan fisik tambahan

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
E. Pola Gordon
No Nama Sebelum sakit Sesudah akit
1 Pola Persepsi dan
Pemeliharaan
kesehatan

2 Pola nutrisi
metabolik

3 Pola eliminasi

4 Pola aktivitas dan

latihan

5 Pola istirahat &

tidur

6 Pola persepsi diri

7 Pola perseptual
kognitif

8 Pola peran dan

hubungan

9 Pola koping stres

10 Pola reproduksi
seksual
 11 Pola nilai &
keyakinan

V. Data Penunjang

a. Pemeriksaan Penunjang:
Laboratorium
Tanggal pemeriksaan
Pemeriksaan Hasil Rentang Normal Interpretasi
 Radiologi:
Tanggal:
Hasil:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

EKG:
Tanggal:
Hasil:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

b. Program Terapi

No Nama Obat Dosis Indikasi

 ANALISIS DATA
No Tgl / jam Data focus Problem Etiologi
B. RUMUSAN DIAGNOSA KEPERAWATAN
1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
3. _______________________________________________________________________________________________
4. _______________________________________________________________________________________________

C. PRIORITAS DIAGNOSA KEPERAWATAN

1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
3. _______________________________________________________________________________________________
4. _______________________________________________________________________________________________