Praktek Profesi Ners

STIKes MERCUBAKTIJAYA Padang

2017/ 2018

BAB I
PENDAHULUAN
A. LATAR BELAKANG
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FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

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FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

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B. ASUHAN KEPERAWATAN TEORITIS
1. PENGKAJIAN
a. Identitas
Identitas Pasien
Nama, Umur, Agama, Jenis Kelamin, Pekerjaan, Agama, Status perkawinan,
Alamat, Tanggal masuk, Yang mengirim, Cara masuk RS, Diagnosa medis
b. Riwayat Kesehatan
a) Riwayat Kesehatan Sekarang
Keluhan utama (saat masuk rumah sakit dan saat ini)
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Alasan masuk rumah sakit
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Upaya yang dilakukan untuk mengatasinya
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b) Riwayat Kesehatan Dahulu
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FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

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c) Riwayat kesehatan keluarga
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c. Pola Persepsi Dan Penanganan Kesehatan
Persepsi terhadap penyakit :
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PENGGUNAAN :
Tembakau:..................................................................................................................
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Alkohol :
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Obat lain :
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Alergi (obat-obatan, makanan, plester, zat warna):
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Obat-obatan warung/tanpa resep dokter :
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d. Pola Nutrisi/Metabolisme
a) Pola Makan
Di rumah
Frekuensi:.............................................................................................................
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FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

Makan
Pagi:.....................................................................................................................
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Makan Siang
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.
Makan Malam
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.
Pantangan/Alergi :
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Makanan yang disukai:
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Di rumah sakit
Diet/Suplemen Khusus
:.............................................................................................................................
.
InstruksiDiet Sebelumnya:
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Nafsu
Makan:..................................................................................................................
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NG tube:
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Kesulitan Menelan (Disfagia):
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Perubahan Berat Badan 6 Bulan Terakhir:
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Gigi:
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Pola Minum
Di rumah Di rumah
sakit

FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018
Frekuensi :________________________ Frekuensi :_______________________
Jenis : _______________________ Jenis : ______________________
Jumlah : _______________________ Jumlah : ______________________
Pantangan :________________________
Minuman : _______________________
disukai
e. Pola Eliminasi
a) BAB
Di rumah Di rumah
sakit
Frekuensi :________________________ Frekuensi :_______________________
Konsistensi : _______________________ Konsistensi : ______________________
Warna : _______________________ Warna : ( ) kuning ( ) ada darah
( ) lainnya, .............
Tgl defekasi terakhir...........................................................................................
Masalah di rumah sakit : .....................................................................................
Kolostomi : ..........................................................................................................
b) BAK
Di rumah Di rumah
sakit
Frekuensi :________________________ Frekuensi :_______________________
Jumlah : _______________________ Jumlah : ______________________
Warna : _______________________ Warna : ______________________
Masalah di rumah sakit :
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Inkontinensia :
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Kateter :
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f. Pola Aktivitas /Latihan
a) Kemampuan Perawatan
Diri:......................................................................................................................
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b) Kebersihan diri (x/hari)

FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018
Di rumah Di rumah
sakit
Mandi :________________________ Mandi :________________________
Gosok gigi : _______________________ Gosok gigi : _______________________
Keramas : _______________________ Keramas : _______________________
Potong kuku :________________________ Potong kuku :________________________

c) Alat bantu :
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d) Rekreasi dan aktivitas sehari-hari dan keluhan
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e) Olah raga :
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f) Kekuatan
otot:......................................................................................................................
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g. Pola Istirahat Tidur
Di rumah Di rumah sakit
Waktu tidur : Siang ______________ Waktu tidur : Siang ________________
:Malam______________ :Malam________________
Jumlah jam : ___________________ Jumlah jam tidur : _____________________
tidur
Masalah di RS
:.................................................................................................................................
Merasa segar setelah tidur
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FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

h. Pola Kognitif –Persepsi

Status
mental:........................................................................................................................
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Bicara:........................................................................................................................
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Bahasa sehari-hari :
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Kemampuan membaca :
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Kemampuan berkomunikasi:
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Kemampuan memahami :
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Tingkat
Ansietas:.....................................................................................................................
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Pendengaran:
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Penglihatan:
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Vertigo:.......................................................................................................................
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Ketidaknyamanan/Nyeri:
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Deskripsi :
P:...................................................................................................................
Q:..................................................................................................................
R:...................................................................................................................
S:...................................................................................................................
T :..................................................................................................................

FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

Penatalaksanaan
nyeri:...........................................................................................................................
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i. Pola Peran Hubungan
Pekerjaan :
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Status Pekerjaan:
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Sistem pendukung:
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Masalah keluarga berkenaan dengan perawatan dirumahsakit:
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Kegiatan sosial :
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Lain-lain:
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j. Pola Seksualitas/Reproduksi
Tanggal Menstruasi Akhir(TMA) :........................................................................
Masalah
Menstruasi:.................................................................................................................
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Pap Smear Terakhir:
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Pemeriksaan Payudara/Testis Mandiri
Bulanan:.....................................................................................................................
............Masalah Seksual berhubungan dengan penyakit:
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FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

k. Pola Persepsi Diri/ Konsep Diri

a) Body image/gambaran diri:
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b) Role/peran:..........................................................................................................
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c) Identity/identitas diri:
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d) Self esteem/harga diri:
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e) Self ideal/ideal diri:
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l. Pola Koping-Toleransi Stres
a) Masalah selama di rumah sakit (penyakit, finansial, perawatan diri)
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b) Kehilangan/perubahan besar di masa lalu:
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c) Hal yang dilakukan saat ada masalah:
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d) Penggunaan obat untuk menghilangkan stress:

FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

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e) Keadaan emosi dalam sehari-hari:
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m. Pola Keyakinan Nilai

Agama:
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Pantangan Keagamaan:
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Pengaruh agama dalam kehidupan:
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Permintaan kunjungan rohaniawan pada saat
ini:...............................................................................................................................
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n. Pemeriksaan Fisik
Gambaran
Tanda Vital Suhu : ...................... Lokasi : ................
Nadi : ............... Irama : ......................Pulsasi................
TD : .......................... Lokasi : ................................
RR : ......................... Irama : ....................................
Tinggi badan
Berat badan sebelum masuk RS : ................., rumah sakit :.............
LILA
Kepala :

FAUZIAH ELITA APZA, S.Kep │17123691

Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

Rambut
Mata
Hidung
Mulut
Telinga
Leher
Trakea
JVP
Tiroid
Nodus Limfe
Dada I
Paru P
P
A
Jantung I
P
P
A
Abdomen I
P
P
A
Ekstremitas Kekuatan otot
Muskuloskeletal/Sendi Inspeksi
Palpasi
Vaskular Perifer
Integumen Inspeksi
Palpasi
Neurologi
Status mental/GCS
Saraf cranial
Reflek fisiologi
Reflek patologis

FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

Payudara

Genitalia
Rectal

o. Pemeriksaan Penunjang
Diagnostik
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Laboratorium
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p. Terapi
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FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

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2. DIAGNOSA KEPERAWATAN
1) ....................................................................................................................................
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2) ....................................................................................................................................
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3) ....................................................................................................................................
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4) ....................................................................................................................................
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FAUZIAH ELITA APZA, S.Kep │17123691

 Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018
3. INTERVENSI KEPERAWATAN
NO. DIAGNOSA KEPERAWATAN NOC NIC

FAUZIAH ELITA APZA, S.Kep │17123691

Praktek Profesi Ners
STIKes MERCUBAKTIJAYA Padang
2017/ 2018

FAUZIAH ELITA APZA, S.Kep │17123691