FAKULTAS KEPERAWATAN
UNIVERSITAS AIRLANGGA
IDENTITAS
1. Nama Pasien :
2. Umur:
3. Suku/ Bangsa :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :
8. Sumber Biaya :
KELUHAN UTAMA
1. Keluhan utama:………………………………………………………………………………………
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5. Lain-lain:
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- Jenis : …………………........................................................................
- Genogram :
2. Sistem Pernafasan
a. RR:................................
b. Keluhan: sesak nyeri waktu nafas orthopnea
Batuk produktif tidak produktif
Sekret:…….. Konsistensi :......................
Warna:.......... Bau :..................................
c. Penggunaan otot bantu nafas:
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d. PCH: ya tidak
e. Irama nafas teratur tidak teratur
f. Friction rub:...................................................................................................................................
g. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot
h. Suara nafas Vesikuler Bronko vesikuler
Tracheal Bronkhial Masalah Keperawatan :
Ronki Wheezing
Crackles
i. Alat bantu napas ya tidak
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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4. Sistem Persyarafan
a. S : Masalah Keperawatan :
b. GCS : ..................................................
c. Refleks fisiologis patella triceps biceps
d. Refleks patologis babinsky brudzinsky kernig
e. Keluhan pusing ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
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N12 : normal tidak Ket.: ……..............................................................
5. Sistem perkemihan
Masalah Keperawatan
a. Kebersihan genetalia: Bersih Kotor
b. Sekret: Ada Tidak
c. Ulkus: Ada Tidak
d. Kebersihan meatus uretra: Bersih Kotor
e. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
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f. Kemampuan berkemih:
Spontan Alat bantu, sebutkan: .......................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
g. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
h. Kandung kemih : Membesar ya tidak
i. Nyeri tekan ya tidak
j. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
k. Balance cairan:
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o. Lain-lain:
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6. Sistem pencernaan
a. TB :............... BB :................................ Masalah Keperawatan :
b. IMT :............... Interpretasi :................................
c. LOLA :...............
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Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
j. Peristaltik:.............. x/menit
k. BAB: ......................x/hari Terakhir tanggal : ..............
l. Konsistensi: keras lunak cair lendir/darah
m. Diet: padat lunak cair
n. Diet Khusus:
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o. Nafsu makan: baik menurun Frekuensi:.......x/hari
p. Porsi makan: habis tidak Keterangan:.......................
q. Lain-lain:
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7. Sistem penglihatan
a. Pengkajian segmen anterior dan posterior: Masalah Keperawatan :
OD OS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO
OD OS
Aurcicula
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MAE
Membran
Tymhani
Rinne
Weber
Swabach
b. Tes Audiometri:
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9. Sistem muskuloskeletal
a. Pergerakan sendi: bebas terbatas
b. Kekuatan otot:
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Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
n. ROM : ................................................
o. POD : ................................................
p. Cardinal Sign : ................................................
q. Lain-lain:
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b. Warna:..............................................
c. Pitting edema: +/- grade:................
d. Ekskoriasis: ya tidak
Masalah Keperawatan :
e. Psoriasis: ya tidak
f. Pruritus: ya tidak
g. Urtikaria: ya tidak
h. Lain-lain:
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- Riwayat luka sebelumnya : ya tidak
Jika ya:
- Tahun :...................................
- Jenis Luka :...................................
- Lokasi :...................................
- Riwayat amputasi sebelumnya : ya tidak
Jika ya:
Jika ya:
- Tahun :...................................
- Lokasi :...................................
f. ABI:...................................
g. Lain-lain:
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e. Lain-lain:
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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
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TERAPI
(………………………)
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PROGRAM STUDI PROFESI NERS
FAKULTAS KEPERAWATAN
UNIVERSITAS AIRLANGGA
ANALISIS DATA
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PROGRAM STUDI PROFESI NERS
FAKULTAS KEPERAWATAN
UNIVERSITAS AIRLANGGA
TANGGAL: .................................
1.
2.
3.
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5.
6.
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RENCANA INTERVENSI
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IMPLEMENTASI DAN EVALUASI KEPERAWATAN
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