ASUHAN KEPERAWATAN

PADA TN. M DENGAN GANGGUAN PEMENUHAN KEBUTUHAN NUTRISI

DI RUANG TERATAI RSUD DR. SOERATNO GEMOLONG

Tgl/jam MRS : 24 oktober 2016

Tanggal/jam pengkajian : 25 oktober 2016 / jam 15.10 wib
Metode pengkajian : Autoanamnesa dan alloanamnesa
Diagnosa medis : Dispepsia
No. registrasi : 060549

A. PENGKAJIAN
I. BIODATA
1. Identitas Klien
Nama klien : Tn. M
Jenis Kelamin : Laki-laki
Alamat : Tulosari rt.8 karangwaru, plupuh, sragen
Umur : 65th
Agama : Islam
Status Perkawinan : Menikah
Pendidikan : SLTP
Pekerjaan : Swasta
2. Identitas penanggung jawab
Penanggung Jawab
Nama : Tn. S
Jenis Kelamin : Laki-laki
Umur : 30 tahun
Pendidikan : SLTA
Pekerjaan : Swasta
Alamat : Tulosari, karangwaru, plupuh, sragen
Hubungan dng Pasien : Anak kandung
B. Riwayat Kesehatan Sekarang
1. Keluhan Utama : Mual, muntah-muntah lebih dari 5x, perut sakit, badan terasa lemes
2. Riwayat Penyakir Sekarang :
Muntah-muntah sejak 1hari yang lalu, 1 hari lebih dari 5x muntah saat makan
3. Riwayat penyakit dahulu :
1 minggu yang lalu klien sakit sama seperti ini
4. Riwayat Penyakit Keluarga :

5. Genogram
Keterangan :
/ : Laki-laki / Perempuan
/ : Meninggal Laki-laki/ Meninggal Perempuan
: Garis Pernikahan
: Garis Keturunan
: Klien
..................... : Tinggal serumah
C. Pengkajian Pemenuhan Kebutuhan Dasar Manusia Menurut Gordon (11 Pola)
1. Pola persepsi dan pemeliharaan kesehatan
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2. Pola Aktivitas dan latihan (Sebelum dan Selama Sakit)
Penilaian
No Aktivitas
0 1 2 3 4
1 Kemampuan melakukan ROM
2 Kemampuan mobilitas ditempat tidur
3 Kemampuan makan dan minum
4 Kemampuan toileting
5 Kemampuan mandi
6 Kemampuan berpindah
7 Kemampuan berpakaian
Keterangan :
0 : Mandiri
1 : Dengan alat bantu
2 : Dibantu orang lain
3: Dengan bantuan alat dan orang lain
4. Tergantung total
3. Pola istirahat dan Tidur

2. Pola nutrisi
Sebelum di rawat : ...................................................................................................................
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Selama di rawat : ......................................................................................................................
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3. Pola eliminasi
Sebelum di rawat: ....................................................................................................................
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Selama di rawat: .......................................................................................................................

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4.
5. Tidur dan istirahat
Sebelum di rawat: ....................................................................................................................
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Selama di rawat:........................................................................................................................
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6. Sensori, persepsi dan kognitif
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7. Konsep diri
 a. Identitas diri : .......................................................................................................................
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b. Gambaran diri : ....................................................................................................................
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c. Ideal diri : .............................................................................................................................

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d. Harga diri : ...........................................................................................................................

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e. Peran diri : ............................................................................................................................
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8. Seksual dan reproduksi
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 9. Pola peran hubungan
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10. Manajemen koping stress
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11. Sistem nilai dan keyakinan
Sebelum di rawat: ....................................................................................................................
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Selama di rawat: .......................................................................................................................

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D. Pemeriksaan Fisik
1. Tingkat kesadaran :
BB= sekarang Kg, sebelum sakit kg, TB = cm,
0
2. TTV :S C, N x/mnt, RR x/mnt, TD mmHg
3. Kepala : .................................................................................................................
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4. Mata, telinga, hidung : ..............................................................................................................
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5. Mulut : .................................................................................................................
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6. Leher : .................................................................................................................
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7. Dada/thoraks
Inspeksi : .................................................................................................................
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Palpasi : .................................................................................................................
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Perkusi : .................................................................................................................
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Auskultasi : .................................................................................................................
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8. Abdomen
Inspeksi : .................................................................................................................
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Auskultasi : .................................................................................................................
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 Palpasi : .................................................................................................................
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Perkusi : .................................................................................................................
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9. Genetalia : .................................................................................................................
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10. Ekstremitas
Atas : .................................................................................................................
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Bawah : .................................................................................................................
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11. Kulit : .................................................................................................................
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Pemeriksaan Penunjang
Pemeriksaan EKG =
Pemeriksaan Rongen =

• Therapy
 Tanggal : Tanggal : Tanggal :

H. Pemeriksaan Penunjang

Pemeriksaan darah rutin Tanggal : ................................................................................................

Pemeriksaan Hasil Rujukan Normal Satuan

• Hemoglobin 12.00-16.00 g/dl
 • Hematokrit 42.00-52.00 %
• Lekosit 5-10 x10^3uL
• Trombosit 150-300 x10^3uL
• Eritrosit 4.00-5.00 x10^3uL
• MPV 6.5-12.00 fL
• PDW 9.0-17.0
• MCV 82.0-92.0 fL
• MCH 27.0-31.0 pg
• MCHC 32.0-37.0 g/dl
• Limfosit % 25.0-40.0 %
• Monosit % 3.0-9.0 %
• Eosinofil % 0.5-5.0 %
• Basofil % 0.0-1.0 %
• Limfosit # 1.25.4.0 x10^3uL
• Monosit # 0.30-1.00 x10^3uL
• Eosinofil # 0.02-0.50 x10^3uL
• Basofil # 0.0-10.0 x10^3uL
• Gran % 50.0-70.0 %
• Gran # 2.50-7.00 x10^3uL
• GDS

• ANALISIS DATA
Data Diagnosa Etiologi
• DIAGNOSA KEPERAWATAN
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