Prosdok Revisi Ke 4
Prosdok Revisi Ke 4
IDENTITAS
1. Nama Pasien : Tn.A
2. Umur : 57
3. Suku/ Bangsa : Jawa/Indonsia
4. Agama : Islam
5. Pendidikan : S1
6. Pekerjaan : PNS
7. Alamat : Yogyakarta
8. Sumber Biaya : BPJS NONPBI
KELUHAN UTAMA
1. Keluhan utama :
Pasien mengeluh susah untuk memulai tidur.
5. Lain-lain:
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RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis :
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- Genogram :
PERILAKU YANG MEMPENGARUHI KESEHATAN
Perilaku sebelum sakit yang mempengaruhi kesehatan:
Alkohol ya tidak keterangan
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Merokok ya tidak
keterangan
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Obat ya tidak
keterangan…..............................................................
Olah raga ya tidak
keterangan…..........................................................
Jenis................................................ Flow..............lpm
j. Penggunaan WSD:
- Jenis : .................................................................................................................................................................
- Jumlah cairan : ..................................................................................................................................................
- Undulasi :...................................................................................................................................................
- Tekanan : ..................................................................................................................................................
k. Tracheostomy: ya tidak
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l. Lain-lain:
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f. Kemampuan berkemih:
Spontan Alat bantu, sebutkan: .................................................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
g. Produksi urine : 300 cc/hari
Warna : kuning
Bau : khas amonia
h. Kandung kemih : Membesar ya tidak
i. Nyeri tekan ya tidak
j. Intake cairan oral : 250 cc/hari parenteral :
cc/hari
k. Balance cairan:
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k. Lain-lain:
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6. Sistem pencernaan (B5) Masalah Keperawatan :
a. TB :170 cm BB :65kg.......................
b. IMT :22,5 ........... Interpretasi :................................
8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Aurcicula
MAE
Membran
Tymphani
Rinne
Weber
Swabach
b. Tes Audiometri
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PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah
TERAPI
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Malang, 2018
(
)
ANALISIS DATA
Hari/
DATA ETIOLOGI MASALAH
Tgl/ Jam
DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN
TANGGAL: .................................
1.
2.
3.
4.
5.
6.
RENCANA INTERVENSI
Hari/
No.
Tgl/ Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
Dx
Shift