Sekolah Tinggi Ilmu Kesehatan Kusuma Husada Surakarta

FORMAT ASUHAN KEPERAWATAN

ASUHAN KEPERAWATAN
PADA Ny/Tn ....... DENGAN GANGGUAN PEMENUHAN KEBUTUHAN .........................
DI RUANG ...................... RSUD SOEHADI PRIJONEGORO KAB. SRAGEN

Tgl/Jam MRS : .................................................

Tgl/Jam Pengkajian : .................................................
Metode Pengkajian : .................................................
Diagnosa Medis : .................................................
No. Registrasi : .................................................

A. PENGKAJIAN
I. BIODATA
1. Identitas Klien
Nama Klien : ................................................
Jenis Kelamin : ................................................
Alamat : ................................................
Umur : ................................................
Agama : ................................................
Status Perkawinan : ................................................
Pendidikan : ................................................
Pekerjaan : ................................................

2. Identitas Penanggung Jawab

Nama Klien : ................................................
Jenis Kelamin : ................................................
Alamat : ................................................
Umur : ................................................
Agama : ................................................
Status Perkawinan : ................................................
Pendidikan : ................................................
Pekerjaan : ................................................

II. RIWAYAT KESEHATAN

1. Keluhan Utama
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2. Riwayat Penyakit Sekarang
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3. Riwayat Penyakit Dahulu

Program Studi Profesi Ners Angkatan VIII TA 2018/2019

 Sekolah Tinggi Ilmu Kesehatan Kusuma Husada Surakarta

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4. Riwayat Kesehatan Keluarga
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5. Genogram

Keterangan :

III.PENGKAJIAN KEBUTUHAN DASAR HENDERSON

1. Oksigenasi
Sesak napas : Tidak ( )
Iya ( )
Frekuensi : konstan/intermitten
Kapan terjadi : ........................................
Kemungkinan Faktor Pencetus :
.............................................................................
Faktor yang memperberat :
.............................................................................
Faktor yang meringankan :
.............................................................................
Batuk : Tidak ( ) / Iya ( )
Sputum : Tidak ( ) / Iya ( ), warna : ............................
Nyeri dada : Tidak ( ) / Iya ( )
Hal yang dilakukan untuk meringankan nyeri dada :
..........................................................................................................................................
Riwayat Penyakit : Asma ( )
Tubercolosis (TB) ( )
Chest Surgery/Trauma Dada ( )
Paparan dengan penderita TB ( )
Riwayat merokok ( )
2. Nutrisi
Frekuensi makan : .................................................................................

Program Studi Profesi Ners Angkatan VIII TA 2018/2019

 Sekolah Tinggi Ilmu Kesehatan Kusuma Husada Surakarta

BB/TB : .................................................................................
BB dalam 1 bulan terakhir : Tetap ( )
Meningkat ( ) : ......... Kg, alasan : ...................
Menurun ( ) : ......... Kg, alasan : ....................
Jenis makanan : .................................................................................
Makanan yang disukai : .................................................................................
Makanan yang pantang : .................................................................................
Alergi : .................................................................................
Nafsu makan : Baik ( )
Kurang ( ), alasan : ..........................
Masalah pencernaan : Mual ( )
Muntah ( )
Kesulitan menelan ( )
Sariawan ( )
Riwayat operasi/trauma GI : .................................................................................
Diit RS : .................................................................................
Habis ( )
1/2 Porsi ( )
¾ Porsi ( )
Tidak Habis ( ), alasan : ..........................
Kebutuhan pemenuhan ADL makan : mandiri/tergantung/dengan bantuan

3. Cairan, Elektrolit dan Asam Basa

Frekuensi minum : ................................... Konsumsi air/hari : ............. ltr/hari
Turgor kulit : .............................................................................................
Support IV Line : Iya/Tidak, jenis : .................................................................
Dosis : .............................................................................................

4. Eliminasi Bowel
Frekuensi : ............................ Penggunaan pencahar ............................
Waktu : pagi/siang/sore/malam
Warna : .................. darah : .................... konsistensi : ....................
Gangguan eliminasi bowel : Konstipasi ( )
Diare ( )
Inkontinensia bowel ( )
Kebutuhan pemenuhan ADL Bowel : mandiri/tergantung/dengan bantuan

5. Eliminasi Bladder
Frekuensi : ................................ Penggunaan pencahar ....................................
Warna : ..................................... darah ..........................................................

Program Studi Profesi Ners Angkatan VIII TA 2018/2019

 Sekolah Tinggi Ilmu Kesehatan Kusuma Husada Surakarta

Gangguan eliminasi bladder : Nyeri saat BAK ( )

Burning Sensation ( )
Bladder terasa penuh setelah BAK ( )
Riwayat Dahulu : Penyakit Ginjal ( )
Batu Ginjal ( )
Injuri/trauma ( )
Penggunaan kateter : Iya/tidak
Kebutuhan pemenuhan ADL Bladder : mandiri/tergantung/dengan bantuan

6. Aktivitas dan Latihan

Pekerjaan : .........................................................................................................
Olahraga Rutin : .........................................................................................................
Alat Bantu : Walker ( )
Kruk ( )
Kursi roda ( )
Tongkat ( )
Terapi : Traksi ( ) di : ..........................................................
Gips ( ) di : ..........................................................
Kemampuan melakukan ROM : pasif/aktif
Kemampuan ambulasi : mandiri/tergantung/bantuan

7. Tidur dan Istirahat

Lama tidur : ....................................................... Tidur siang : ya/tidak
Kesulitan tidur di RS : ya/tidak
Alasan : .............................................................................................
Kesulitan tidur : Menjelang tidur ( )
Mudah/sering terbangun ( )
Merasa tidak segar saat bangun ( )

8. Kenyamanan dan Nyeri

Nyeri : ya/tidak, Skala Nyeri (1-10) : ...................................................................
Paliatif/Provokatif : .............................................................................................
Quality : .............................................................................................
Region : .............................................................................................
Severity : .............................................................................................
Time : .............................................................................................
Ambulasi di tempat tidur : mandiri/tergantung/dengan bantuan

9. Sensori, Persepsi dan Kognitif

Gangguan Penglihatan : ya/tidak
Gangguan Pendengaran : ya/tidak
Gangguan Penciuman : ya/tidak

Program Studi Profesi Ners Angkatan VIII TA 2018/2019

 Sekolah Tinggi Ilmu Kesehatan Kusuma Husada Surakarta

Gangguan Sensasi Taktil : ya/tidak

Gangguan Pengecapan : ya/tidak
Riwayat Penyakit : eye surgery ( )
Otitis media ( )
Luka sulit sembuh ( )
Persepsi klien terhadap penyakitnya :
..........................................................................................................................................
..........................................................................................................................................
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Respon klien mencari solusi untuk masalah kesehatannya :
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10. Komunikasi
Hubungan klien dengan keluarga dan sekitarnya :
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Cara klien menyatakan emosi, kebutuhan, dan pendapat :
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11. Aspek Spiritual dan Dukungan Sosial

Kepercayaan klien dan aspek ibadah :
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Dukungan keluarga terhadap klien :
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12. Kebutuhan Rekreasi

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IV.PEMERIKSAAN FISIK
1. Keadaan Umum : baik/cukup/lemah
a. Kesadaran : .............................................................................
b. Tanda-Tanda Vital
Tekanan Darah : .............. mmHg

Program Studi Profesi Ners Angkatan VIII TA 2018/2019

 Sekolah Tinggi Ilmu Kesehatan Kusuma Husada Surakarta

Nadi : Frekuensi : .............. x/menit

Irama : .....................................................
Kekuatan : .....................................................
Pernapasan : Frekuensi : .............. x/menit
Irama : .....................................................
Suhu : ............... oC
2. Pemeriksaan Head To Toe
a. Kepala
1) Bentuk dan ukuran kepala : .................................................................................
2) Pertumbuhan rambut : .................................................................................
3) Kulit kepala : .................................................................................
b. Muka
1) Mata
a) Kebersihan : .........................................................
b) Fungsi penglihatan : .........................................................
c) Palpebra : .........................................................
d) Konjungtiva : .........................................................
e) Sklera : .........................................................
f) Pupil : .........................................................
g) Diameter ki/ka : .........................................................
h) Reflek terhadap cahaya : .........................................................
i) Penggunaan alat bantu penglihatan : .........................................................
2) Hidung
a) Fungsi penghidu : .................................................................................
b) Sekret : .................................................................................
c) Nyeri sinus : .................................................................................
d) Polip : .................................................................................
e) Napas Cuping hidung : .................................................................................
3) Mulut
a) Kemampuan bicara : .................................................................................
b) Keadaan bibir : .................................................................................
c) Selaput mukosa : .................................................................................
d) Warna lidah : .................................................................................
e) Keadaan gigi : .................................................................................
f) Bau napas : .................................................................................
g) Dahak : .................................................................................
4) Gigi
a) Jumlah : .................................................................................
b) Kebersihan : .................................................................................
c) Masalah : .................................................................................
5) Telinga
a) Fungsi pendengaran : .................................................................................

Program Studi Profesi Ners Angkatan VIII TA 2018/2019

 Sekolah Tinggi Ilmu Kesehatan Kusuma Husada Surakarta

b) Bentuk : .................................................................................
c) Kebersihan : .................................................................................
d) Serumen : .................................................................................
e) Nyeri telinga : .................................................................................
c. Leher
a) Bentuk : .................................................................................
b) Pembesaran tyroid : .................................................................................
c) Kalenjar getah bening : .................................................................................
d) Nyeri waktu menelan : .................................................................................
e) JVP : .................................................................................
d. Dada (Thorax)
6) Paru-paru
 Inspeksi : .................................................................................
 Palpasi : .................................................................................
 Perkusi : .................................................................................
 Auskultasi : .................................................................................
7) Jantung
 Inspeksi : .................................................................................
 Palpasi : .................................................................................
 Perkusi : .................................................................................
 Auskultasi : .................................................................................
e. Abdomen
 Inspeksi : .................................................................................
 Palpasi : .................................................................................
 Perkusi : .................................................................................
 Auskultasi : .................................................................................
f. Genetalia : .............................................................................................
g. Anus dan rektum : .............................................................................................
h. Ekstremitas
8) Atas
 Kekuatan otot kanan dan kiri : .....................................................................
 ROM kanan dan kiri : .....................................................................
 Perubahan bentuk tulang : .....................................................................
 Pergerakan sendi bahu : .....................................................................
 Perabaan akral : .....................................................................
 Pitting edema : .....................................................................
 Terpasang infus : .....................................................................
9) Bawah
 Kekuatan otot kanan dan kiri : .....................................................................
 ROM kanan dan kiri : .....................................................................
 Perubahan bentuk tulang : .....................................................................

Program Studi Profesi Ners Angkatan VIII TA 2018/2019

 Sekolah Tinggi Ilmu Kesehatan Kusuma Husada Surakarta

 Pergerakan sendi bahu : .....................................................................

 Perabaan akral : .....................................................................
 Pitting edema : .....................................................................
 Terpasang infus : .....................................................................
i. Integumen : .........................................................................................................

V. PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium
Tanggal Pemeriksaan : ..............................................
Jenis Pemeriksaan Nilai Normal Satuan Hasil Ket. Hasil

2. Pemeriksaan Diagnostik
Tanggal Pemeriksaan : ...............................................
Jenis Pemeriksaan Hasil Pemeriksaan

VI.TERAPI MEDIS
Hari/ Golongan &
Jenis Terapi Dosis Fungsi
Tanggal Kandungan
Cairan IV :

Program Studi Profesi Ners Angkatan VIII TA 2018/2019

 Sekolah Tinggi Ilmu Kesehatan Kusuma Husada Surakarta

Obat Peroral :

Obat Parenteral :

Obat Topikal :

Program Studi Profesi Ners Angkatan VIII TA 2018/2019