ASUHAN KEPERAWATAN PADA DENGAN

DIAGNOSA MEDIS
DI RUANG MELATI 2 RSUD Dr. MOEWARDI

Tgl/Jam masuk RS :
Tanggal/Jam Pengkajian :
Metode pengkajian :
Diagnosa Medis :
No. Registrasi :

PENGKAJIAN
I. BIODATA
1. Identitas Klien
Nama Klien :
Alamat :
Umur :
Agama :
Status Perkawinan :
Pendidikan :
Pekerjaan :
2. Identitas Penanggung Jawab
Nama :
Umur :
Pendidikan :
Pekerjaan :
Alamat :
Hubungan dengan Klien :
II. RIWAYAT KEPERAWATAN
1. Keluhan Utama
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2. Riwayat Penyakit Sekarang
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3. Riwayat Penyakit Dahulu
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4. Riwayat Kesehatan Keluarga
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5. Riwayat Kesehatan Lingkungan
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Genogram:
III. PEMERIKSAAN FISIK
1. Keadaan/Penampilan Umum
a. Kesadaran :
b. Tanda-Tanda Vital
1) Tekanan Darah :
2) Nadi
- Frekuensi :...............................................................................
- Irama : ..............................................................................
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- Kekuatan : ...............................................................................
3) Pernafasan
- Frekuensi :...............................................................................
- Irama :...............................................................................
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4) Suhu : ..............................................................................
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2. Kepala
a. Bentuk Kepala :
b. Kulit Kepala :
c. Rambut :
3. Muka
a. Mata
1) Palpebra : ..............................................................................
2) Konjungtiva : ...............................................................................
3) Sclera :...............................................................................
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4) Pupil : ..............................................................................
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5) Diameter pupil ki/ka : ...........................................................
6) Reflek terhadap cahaya : ..............................................................
7) Penggunaan alat bantu penglihatan : ............................................
 b. Hidung : .......................................................................................
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c. Mulut : .......................................................................................
d. Telinga :........................................................................................
4. Leher
a. Kelenjar tyroid :....................................................................................
b. Kelenjar limfe : ....................................................................................
c. JVP : .....................................................................................
5. Dada (Thorax)
a. Paru-paru
- Inspeksi : .....................................................................................
- Palpasi : .....................................................................................
- Perkusi : .....................................................................................
- Auskultasi : .....................................................................................
b. Jantung
- Inspeksi : .....................................................................................
- Palpasi : .....................................................................................
- Perkusi : .....................................................................................
- Auskultasi : .....................................................................................
6. Abdomen
a. Inspeksi : .....................................................................................
b. Auskultasi : .....................................................................................
c. Perkusi : .....................................................................................
d. Palpasi : .....................................................................................
7. Genetalia : ............................................................................................

8. Rektum : ............................................................................................
9. Ekstremitas
a. Atas
Kanan Kiri
Kekuatan otot
Rentang gerak
Akral
Edema
CRT
Keluhan
 b. Bawah
Kanan Kiri
Kekuatan otot
Rentang gerak
Akral
Edema
CRT
Keluhan

IV. PENGKAJIAN POLA KESEHATAN FUNGSIONAL

1. Pola Persepsi dan Pemeliharaan Kesehatan
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2. Pola Nutrisi/Metabolik
a. Pengkajian Nutrisi ABCD
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b. Pengkajian pola nutrisi
Sebelum Sakit Saat Sakit
Frekuensi
Jenis
Porsi
Keluhan

3. Pola Eliminasi
a. BAB
Sebelum Sakit Saat Sakit
Frekuensi
Konsistensi
Warna
Penggunaan Pencahar

Keluhan
b. BAK
Sebelum Sakit Saat Sakit
Frekuensi
Jumlah Urine
Warna
Pancaran
Perasaan Setelah Berkemih

Total Produksi Urin

Keluhan
 c. Analisa Keseimbangan Cairan Selama Perawatan
Intake Output Analisa
a. Minuman cc a. Urine cc Intake cc
b. Makanan cc b. Feses cc Output: cc
c. Cairan IV cc c. Muntah cc
d. IWL cc
Total cc Total cc Balance cc

4. Pola Aktifitas dan Latihan

Kemampuan Perawatan Diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas ditempat tidur
Berpindah
Ambulasi/ROM

Ket:
0: Mandiri, 1: dengan alat bantu, 2: dibantu orang lain, 3: dibantu orang
lain dan alat; 4: tergantung total

5. Pola Istirahat Tidur

Sebelum Sakit Saat Sakit
Jumlah tidur siang
Jumlah tidur malam
Penggunaan obat tidur

Gangguan tidur
Perasaan waktu bangun

Kebiasaan sebelum
tidur
6. Pola Kognitif – Perseptual
a. Status mental
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b. Kemampuan penginderaan
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c. Pengkajian nyeri
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7. Pola Persepsi Konsep Diri
a. Gambaran diri/ Citra tubuh
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b. Ideal diri
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c. Harga diri
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d. Peran diri
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e. Identitas diri
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8. Pola Hubungan Peran

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9. Pola Seksualitas Reproduksi
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10. Pola Mekanisme Koping
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11. Pola Nilai dan Keyakinan
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V. PEMERIKSAAN PENUNJANG

Hari/Tgl/ Jenis Nilai Satuan Hasil Keterangan

Jam Pemeriksaan Normal Hasil
Hari/Tgl/ Jenis Nilai Satuan Hasil Keterangan
Jam Pemeriksaan Normal Hasil
VI. TERAPI MEDIS

Hari/Tgl/ Jenis Terapi Dosis Golongan & Fungsi &

Jam Kandungan Farmakologi
Hari/Tgl/ Jenis Terapi Dosis Golongan & Fungsi &
Jam Kandungan Farmakologi
VII.ANALISA DATA
Nama : No. CM :
Umur : Diagnosa Medis :

No Hari/Tgl/ Data Fokus Problem Etiologi Ttd

Jam
No Hari/Tgl/ Data Fokus Problem Etiologi Ttd
Jam
No Hari/Tgl/ Data Fokus Problem Etiologi Ttd
Jam
VIII. PRIORITAS DIAGNOSA KEPERAWATAN
1. .........................................................................................................................

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2. .........................................................................................................................

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3. .........................................................................................................................

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IX. RENCANA KEPERAWATAN

Nama : No. CM :
Umur : Diagnosa Medis :

Hari / No. Tujuan dan Intervensi Ttd

Tgl Dx Kriteria Hasil

Hari / No. Tujuan dan Intervensi Ttd

Tgl Dx Kriteria Hasil
Hari / No. Tujuan dan Intervensi Ttd
Tgl Dx Kriteria Hasil
Hari / No. Tujuan dan Intervensi Ttd
Tgl Dx Kriteria Hasil
X. TINDAKAN KEPERAWATAN/IMPLEMENTASI
Nama : No. CM :
Umur : Diagnosa Medis :

Hari/Tgl No. Implementasi Respon Ttd

/Jam Dx
Hari/Tgl No. Implementasi Respon Ttd
/Jam Dx
Hari/Tgl No. Implementasi Respon Ttd
/Jam Dx
Hari/Tgl No. Implementasi Respon Ttd
/Jam Dx
Hari/Tgl No. Implementasi Respon Ttd
/Jam Dx
Hari/Tgl No. Implementasi Respon Ttd
/Jam Dx
Hari/Tgl No. Implementasi Respon Ttd
/Jam Dx
Hari/Tgl No. Implementasi Respon Ttd
/Jam Dx
Hari/Tgl No. Implementasi Respon Ttd
/Jam Dx
XI. CATATAN KEPERAWATAN
Nama : No. CM :
Umur : Diagnosa Medis :

No Hari/Tgl Evaluasi Ttd

Dx /Jam
No Hari/Tgl Evaluasi Ttd
Dx /Jam
No Hari/Tgl Evaluasi Ttd
Dx /Jam
No Hari/Tgl Evaluasi Ttd
Dx /Jam
No Hari/Tgl Evaluasi Ttd
Dx /Jam