ASUHAN KEPERAWATAN PADA Nn.

F DENGAN DIAGNOSA MEDIS TB PARU

MENGGUNAKAN TEORI KEPERAWATAN HENDERSON
DI IRNA PARU RUANG ISOLASI I

I. PENGKAJIAN
1.    Identitas
a.      Identitas Pasien
Nama : Nn.F
Umur                                    :
Agama                      :
Jenis Kelamin                       :
Status                        :
Pendidikan                :
Pekerjaan                  :
Suku Bangsa             :Indonesia
Alamat                      :
Tanggal Masuk         :
Tanggal Pengkajian   :
No. Register              :
Diagnosa Medis        :

b.      Identitas Penanggung Jawab

Nama                                    : ............................................................................................
Umur                                    : .............................................................................................
Hub. Dengan Pasien : ...........................................................................................
Pekerjaan                  : .............................................................................................
Alamat                      : ..............................................................................................

2.    Status Kesehatan
a.      Status Kesehatan Saat Ini
1)      Keluhan Utama (Saat MRS dan saat ini)
Saat MRS :..........................................................................................................
Saat ini     : ..........................................................................................................

2)      Upaya yang dilakukan untuk mengatasinya

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b.      Satus Kesehatan Masa Lalu

1)      Penyakit yang pernah dialami
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Pernah dirawat
...........................................................................................................................
Alergi
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2)      Kebiasaan (merokok/kopi/alkohol dll)
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3)      Riwayat Penyakit Keluarga

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4)      Diagnosa Medis dan therapy
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3.    Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)

a.       Pola Bernapas
   Sebelum sakit       
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   Saat sakit  
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b.      Pola makan-minum
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
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c.       Pola Eliminasi
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
...........................................................................................................................

d.      Pola aktivitas dan latihan
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
...........................................................................................................................
e.       Pola istirahat dan tidur
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
...........................................................................................................................
f.       Pola Berpakaian
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
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g.       Pola rasa nyaman
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
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h.      Pola Aman
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
i.        Pola Kebersihan Diri
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
...........................................................................................................................
j.        Pola Komunikasi
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
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k.      Pola Beribadah
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
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l.        Pola Produktifitas
   Sebelum sakit        :
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   Saat sakit               :
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m.    Pola Rekreasi
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
                  ...........................................................................................................................
n.      Pola Kebutuhan Belajar
   Sebelum sakit        :
...........................................................................................................................
   Saat sakit               :
               ...........................................................................................................................
4.    Pengkajian Fisik
a.       Keadaan umum :
Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma
GCS  : verbal:……….Psikomotor:……….Mata :……………..
b.      Tanda-tanda Vital : Nadi =  ………, Suhu = …………., TD =………, RR =………
c.       Keadaan fisik
1)      Kepala  dan leher            :
........................................................................................................................................
2)      Dada :
   Paru
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   Jantung
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3)      Payudara dan ketiak :
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4)      Abdomen            :
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5)      Genetalia            :
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6)      Integumen :
7)      Ekstremitas         :
   Atas
................................................................................................................................
   Bawah
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8)      Neurologis          :
   Status mental dan emosi :
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   Pengkajian saraf kranial :
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   Pemeriksaan refleks :
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d.      Pemeriksaan Penunjang
1)      Data laboratorium yang berhubungan
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2)      Pemeriksaan radiologi
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3)      Hasil konsultasi
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4)      Pemeriksaan penunjang diagnostic lain
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5.    ANALISA DATA
DATA INTERPRETASI MASALAH
(Sesuai dengan patofisiologi)

II. DAFTAR  DIAGNOSA KEPERAWATAN /MASALAH KOLABORATIF

BERDASARKAN PRIORITAS
 TANGGAL / JAM TANGGAL
NO DIAGNOSA KEPERAWATAN Ttd
DITEMUKAN TERATASI

A. RENCANA TINDAKAN  KEPERAWATAN

Rencana Perawatan Tt
Hari/ No
Tujuan dan Kriteria
Tgl Dx Intervensi Rasional
Hasil

B. IMPLEMENTASI KEPERAWATAN

Hari/ Ttd
No Dx Tindakan Keperawatan Evaluasi proses
Tgl/Jam
      

C. Evaluasi Keperawatan
Hari/Tgl
No No Dx Evaluasi TTd
jam