IDENTITAS
1. Nama Pasien : An. A
2. Umur : 6 bulan 8 hari
3. Suku/ Bangsa : Jawa/Indonesia
4. Agama : Islam
5. Pendidikan :-
6. Pekerjaan :-
7. Alamat : Surabaya
8. Sumber Biaya : Orang Tua
KELUHAN UTAMA
1. Keluhan utama:diare
RIWAYAT PENYAKIT SEKARANG
1. Riwayat Penyakit Sekarang:
Diare dirasakan sejak 3 hari yang lalu. Mula-mula intensitas BAB kurang, dan sejak 2 hari yang
lalu diare semakin parah diserta dengan demam, terdapat bercak-bercak terasa gatal pada kulit,
diare diikuti dengan batuk, sesak dan klien tidak mau menyusu. Dengan alasan tersebut orang tua
klien membawa klien ke RS untuk di periksa.
5. Lain-lain:
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RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis :Ibu An.A positif HIV
- Genogram :
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 : ………….. 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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k. Lain-lain:
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6. Sistem pencernaan (B5) Masalah Keperawatan :
a. TB :............... BB :................................
b. IMT :............... 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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Surabaya, ……………..20...
(……………………………)
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)
Dx
Shift