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ASUHAN KEPERAWATAN PADA PASIEN Ne. MEDENGAN DIAGNOSA MEDIS ...DUSPEPSA DIRUANGAN G 9404, WTF KAMAR © RSUD Prof. Dr. H. Aloei Saboe KOTA GORONTALO, |. PENGKAJIAN Agama Cleat Jenis Kelamin er em) Status Potlee teenikek Pendidikan Stup Pekerjaan Mash Sekolah Suku Bangsa Gorantals Alamat Dembe 2 ‘Tanggal Masuk r/dfronr, et: Tanggal Pengkajian : 2/0 (dear No. Register F-01-4) Diagnosa Medis Hp) ispepesct cuter oaeeen sete eee SCORN b. Identitas Penanggung Jawab Nama Ny. Ast Alamat_ I pilo Umur 4y Tahun Agama (am Jens Kelamin Jecenfian ‘Status Menikah Pendidikan to Pekerjaan : Ie 2. Status Kesehatan a. Status Keschatan Saat Ini 1) Keluhan Utama (Saat MRS dan saat ini) Saat MRS Teuntat leit OSS SUSE es ein Ney uly Ugh dan, Mya Gea ygen Shale nyu’ F (sedan Saat ini a Soak Rasen, ns erga eng Sat Ine PAGom tudn Mant Muntal- Aauntel. Fretuene’” tx Pager juga mahh (ueraretban Oyen Ululad’ Tongan thale nyse & (ei Be = Yo ke Th = lsoce ‘Upaya yang dilakukan untuk mengatasinya Sebelum Matte 15, asin ditmurth bdvacganyes Persbas ketene Posktete Peeawed Urbane elgg Vetlingse Feclone . Satus Kesehatan Masa Lalu 1) Penyakit yang pernah dialami ee Velurege Danin Mengatakan. Pasien Perna MAS Alergi fae Mak memities Fiwagat ater: bad olenspun Kebiasaan (merokok/kopi/alkohol dll) Gite Hale Mende leehiaceacn Ieee, Tap ade, pasaan —Ninuor hep Riwayat Penyakit Keluarga ee fuengataber ada Yang Memes riwa wyatt” Dim Diagnosa Medis dan thea lax Vang nla, Potion porno i diego th Jonyalnt : | Therapy Yang Azdapedben 25 Re WP RL de tPe WW). Ondenrontron Jetomp fv Wy, Ranching — 2K, Onp/iv Gacralpar Yer x2 cth/pe 3. Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spritual) a. Pola Bemapas Sebelum sakit Jasin Adal Yema tenagluk Stak rakes foal bh Bruna i Saat sakit Saat dity: fag jugn Hak Mengeluh ge eee Pola Makan-Minum Sebelum sakit Qe Rawin tremitis Lebintaan Maken - Melanay Sons Pinata. Seats Soak Eikay: Varin tenga talcan tifak cla ean an BX Murtah WMiewsn bios Aric Subile Pola Eliminasi Sebelum sokit yale Mormal , bah 1 2efhan Saat sakit Die perma, Dan Uefa, Nolet ‘erp Pola AKtvis dan Laan Panes Mmm pu Mlababan alchvtay Ceourn tnabin Sepak Mandi Malan Reiaune seam Saat Hibay Pete Hepa Os linda Untale Verpalenvan Sebelum sakit Pola Istirahat dan Tidur Sebelum sakit Jasin mengatulcan Bapat Uwitiraat (dw bengas : Saat sakit fore Sting Rrhaquen bertne Pps Yong Season Yasin Pola Berpakaian Sebelum sakit Yasin Rapat Varpakarnn Steura Manbir’ Sastst = Pabien vianpock diy Danke Feluarge Satan feat oun Pola Rasa Aman dan Nyaman Saeene sen bak (reataloun n Saat sakit Saat Bikey patien meratatan myer Tui Soperk fae bebe, a non Veh) Pola Kebersihan Dit Scbelum sakit Saat irumah Pasiin mreunpr wrembreshiban in Feava Wandin Sts bay Bk baate Leen i. Pola Komunikasi Seeimssit: baien Baas Ditkemunitnn’ henge bahase egg Saat sakit Prin than dimale Verbemaniba Senge ee j. Pola Beribadah Sem sy ati ew tht ee Speen st Dera nto Keseonbbrmnye . Pola Produktifitas Sebelum sakit ta back SRE tet tegaan if Ivor 1. Pola Rekreasi Sebetumsakit: Dagon Veretrean’ & Seka an Kdaange. © Ming BA in tebe Nee Poa Kaban Ba ee ee Sebo ait ee wr ett et Sag fet foug Werefcbabicor Tre Suny Mengalans Pert yorg Rider Saat sakit Ss py ne ieee Rectery anyge 4, Pengkajian Fisk a. Keadaan umum: (gaat ngkat Kesadaran [Komposmetis JApats/ Somnolen / Sopor/K GCS + Verbal: Psikomotor: ( ‘Mata: 4 b, Tanda-tanda Vital: Nadi= 9 Suhu= Soa TD= ling RR= Lex/ra . Keadaan fisik 1) Kepala dan Jeher 2) Dada Pana redtuk: hanks Gmcns , Nia + otot Mths Gemnapeter , Crore Porta loner, “Rate abe drove ee > Jenn : (agensites beat” “Reka Sas is aed DOA baat laste x x Low 3) Payudara dan ketiak badute Vayudors Vimetn’s Lin’ chin lemes date ode Payer bole avile 4) Abdomen pees. omhk Gimehn dan pwlak oda Tee tapae feat’ /Arrenit fe fats eb, engl, aden rien teton es 5) Genta Qusien Vdete Versebta ustule ae 6) Integumen (eaist fate beth 7) Ekstremitas = Teepea pote tye Lit > | + Bawah Cimeetas Kates Bae Sen (tomers 8) Neurologis + Status mental dan emosi ak Gee FY Me ve beacloon Une lero + Pengkajian saraf cranial tidate Pileey’ « Femaiisanietex = day Biba 4, Pemeriksagn Penunjang 1) Data laboratorium yang berhubungan Wh tg g/d, thot 421 fut, Hemratotent 3, ‘h, font Bib riba fut, Theombayt 231 ribs fu 2) Pemeriksaan radiologi 3) Hasil konsultasi 4) Pemeriksaan penunjang diagnostic lain | woc Ospeprer vege ~S Mspephir drqanik. Dispepsm Feagiinal c v ca (op lan Allcaha} ress 1 v eran Reaper Meataia. {al ee £ i : J Ga aa 1 Predut’ Uer Vogedislatas Uespeton, a gue Poeglapaen Dei Mace ed Mies K vu > He Ponte ae Wnt, eAIAP Nuifee ras v acter is Kedar gan Vela v Care Nyor Abt = —> terbohan pada Kesehatan v efit Pengetann [ume DATASUBIEKTIFGg © [| DATAOREMTING cost] NY ey Alew’ fu Joma jx User Mengatatean ke: pos Mens Rytn ula hat Pad To: Wo fw ,N: Mesum Yerut Vagicn as bec, Me oe/m (sheen eo fli Hpk | fiero” SSC*dYC Re belie = LM tengatata” Merore ign tampon — yes! female KLASIFIKASI DATA 7 Pe Bite Malina dan tinue | ry arms Wlang bal tye’ terbake Uh hak’ LT Byen didacrat Yerut [Wagpen ay Ls Sata 5 (fedorg) (TE ee Birsecoin “p10 Bend = lien “tumpeh Meriyyat lesan = lee 2 Wrengateiion |. Perg” Malan tamporke oe Bas wakan, anise | Hien Oo Lelie [= th: Gly Mt: Ay |-Ty = scm | | ener Fyteiy Peryabrys ANALISA DATA PTIOLOGL Dupeprie vi _ Pipa fergie! eR Se A Respen musaia | ; = = ay Vasodilatas: bathe aster i Produ Het Filambuug Meniraead i = Het fortofe dlouyan 7 Moukaye ofatto [pt te 5 Uedoug) v IT: Wye Sratatcan S10 mot | en | 2 re ge Nutas = basse nate Open — Dipti organi ~ 2 iy eras (tress [ - v - Perens - We kas [ene me ane (7T- be. Sanyet hana vases) | [Preteens [nase L = Parse oe Fentil —_ Produkt Hot Blan Ribak 5 botritea (eningket = bh = Yo leg uv = = Igo chm am Went ANALISA DATA NO DATA MASALAH ETIOLOGL S| Anne Fosites Dipepeie« ae Wega Ua Geracn Comes” toalog Viper fgg Pen yolerta ry. 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