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RIWAYAT KESEHATAN SEBELUMNYA ANG ThA mmetaiar —aypangn waPmibik:, PMMBEK'S NATE” ce meme Pemoiet onto 4 (HK srg. lel... RIWAYAT KE! Aneke “TA MaPrgptalen Eee od, EAU. 8ON9, pee Peake Yory cana Emme TRXA E._ PEMERIKSAAN FISIK Tanda-tanda vital TD :.84/b0. 100 M4 Suhu :3925 38 Nadi :. 769/e"6 Pernafasan : 2.6%/n1 Tinggi Badan :!¢9. Berat Badan :.49. 9 GCS. EA VS ane e(gendePtanpa rambutkotor mudah rontok/gaial-gatal Lain-lain Masalah keperawatan :H2©, 0%, "again, Erprrauasen, 2.Mata : Ikterik/midriasis/pakai kacamata/contact lens/gangguan penglihatan Lain-lain :443k. 949... maraton, Masalah keperawatan 3.Hidung : perdarahansinusitis/gangguan penciuman/malformasi/terpasang NCT Lain-lain Masalah keperawatan 4.Mulut Kotor/bau/terpasang ETT/Gudel/perdarahan/lidah kotor/gangguan _pengecapan Lain-lain Masalah keperawatan :tie&.. 08, asian, Empracats 5.Gigi : Gigi palswkotor/kawat gigi/karies/tidak ada gigi 39 Lain-lain Masalah keperawatan 6.Telinga : Perdarahan/terpasang alat bantu dengar/infeksi/gangguan pendengaran Lain-lain meres Masalah keperawvatan (,..% I. Leher —_: Pembesaran KGB/kaku kuduk/terpasang trakeostomi/ JVP Lain-lain Masalah Keperawatan {46% 5 ache gh amine, Ast Wonte, mopar ©), PUL Dada : inspeks Jie _t9reiay,Peomoeraotrn Palpasi Perkusi ssftctth Vopeea, freee, ‘Auskultasi £220... NSFP. feo pale, tees wore. Masalah Keperawatan IV. Tangan : Utuh/ eae pln ferill/clubbing finger/dingin/fraktur/edema Lain-lain :....- Masalah Keperawatan Y. Abdomen te olatcenpe, Sober, Inspeksi : ben's Adee, defeloeet....nged,, kf Palpasi 40 Perkusi <2" ae Auskultasi erro. use ©)... tsr/tom Masalah Keperawatan v 1. Genitalia; Perdarahan(ferpasang 9 ( katetertrauma/malformasi/menstruasi/infekst Lain-lain : ' Masalah keperawatan VIL. Kaki:Fraktur/edema/malformasi/luka/infeks /keganasan ‘sianosis/dingin Lain-lain 09h. trea Masalah keperawatan : tt... homers VILL Punggung Lordosis/kiposis/skoliosis/luka/dekubitus/infeksi Lain-lain :... Masalah keperawatan : 8 ots, Merdes, Hasi! Pemeriksaan Laboratorium dan Diagnostik HB: 9.2 g/atlry-te) AWompee 4: 108-1093 / ue EISEN neeeeeeeee Parent > 3.05 10 (4.9; bi) Winetes« 26654.0.42%232.8) “PUM 37,0 mula (12 6-426) Kerman 5 19, Sd (0180, 2130) aoe A FOES thanat * Cor 2 doom bots Rome, Piting open Feneumenia Medikasi/ obat-obatan yang diberikan saat ini 41 ~ ks2 2x geomy Diagnosa keperawatan if wPRWn Pekanbaru.2§2!0222%. Mahasiswa Awie Aeniaoy 42 ANALISA DATA Nama Pasien 1/0-A No. Rekam Medis = DxMedis :Cx0 Ruang Rawat orange MASALAH NO. DATA ETIOLOGI ATA Ber ve Perro eer Prreconcn Hemediinonce| Rec, f.doe ORPENE Ds: Pasian mmryataees cosets a3 on ee , bo) PEE gay, a ee t [PO:-Parien tamere Lemon Tee dormer pereuee Ferm, 2A LE erring - KULY he page [MV 10: 84/p0 mmng AD? 20 X/emne 5. 370% 2e: 2ex/mne Ur Pom 2A ETF in, Vag most HD 23:2 faraen: €.34 homeert. tne ntroct - 5.05 emote: 263 Ineor atriny mycy 07st 24? ANALISA DATA Nama Pasien 11 A No. Rekam Medis Dx Medis ceo Ruang Rawat eenongya NO. DATA ETIOLOGI MASALAH KEPERAWATAN DSATAA mengacacon msn cD Rares Me agen aunt Fite] o hentet mac Meme a 7TH A mongatorer tidoe ¥ hee PPoeWeR again mot borer aeann v 0. teins + ae 4 me mort tomre lemon, © MOR TUA Foye me ges + bob brLiKe pucet = MeOH Laer reg “Tom tome vite, -10 98/65 maby +h: 936/imn1 10:22 oftans ore Ur A MefIL “ermine: 199 ay jg) Roser Nama Pasien <1. FORMAT ENCANA ASUHAN KEPERAWATAN Nama Mahasiswa rAgie APRIADY ee ™ ee No. M.R. ae fees wo] ness [Tuan tea Hast | __ Interven epeavtn : tidak erecve Risks Perper coma laren vettornn ante | ire rte morte tar Cate Om nitrogen Tat Een Ere eeomacntom 324 Jom rarajemen cairo lourervas 1 Prmemiter gtoter denaidres! moniter Were leek enter hent ermerieraon, Aowcereter en | mtenker Ser nimedirone Teraeniee otek \ntauy -oteck Crile nba ci erotnen : [Sere coin Inbar veme Eslacerag: [Fehr ernment ume FORMAT ENCANA ASUHAN KEPERAWATAN Nama Pasien inn, Nama Mahasiswa ARIE are/Aoy Ruang See NIM semmecer. No. MLR. Ke Diagnosa 7 keperswatan | TeSuan & Kriteria Hasil Intervensi Keperawatan b [roses SAM a Fen Unk MOMAMAM MAL Perratee Hou 15. | entities mgtamin mac 2G Jota de hee . Minti ma prea women MAUL CFTPEGEREE deren e den Grate ean Soren triton net FrRinonat) Fert teen [Pare oie mea, Fort Legeaga. Me mate] Preis meal Cinie. bee ipfRben speal p Linnea! Kee ons p) fy ee Feros / hilangben Ie Pete Pro mace OMe Introd dian tar Go coer ONMER EOF Membre molt ass Kavos Pombene, Oct | CATATAN PERKEMBANGAN Nama klien NA Diagnosa medis — : (r Ruang rawat f venongy, Tanda Waktu Dia ; (Totten) ||” xkenermristan Implementasi Evaluasi (SOAP) tangan te] toa [aim Portus Prapmanner glot™ PAR game TE w Poe. Vane certs] 'Srare Neat teres Leimatn rammeniee tert 0 laden Jor erckran con (BL VE Papmoniter hae. encrer tne WR Pemoricewan (aiaretenal, “FH EAE Plater maPmOnAeM tutor 2 | memetncme iv PorSeis 9 mmoles Wet es whet © | ean a Dx/mne NOM on Ompan rpm: 99 By el. Wertman: 1.99 ma/dl Hie S124 eMart PnP bee coin, POL rakeavinn lace et 854 Erembeait : tot trite 3.05 mrinom | once Brier) IPE try mye i) WAPI PM ome at coe Mine [Ot § Go Ce /e, yu, Bi rerits prev: Ware pe pterte loetain, bervtivey renee Pheer ne ae Lenten enone es L CATATAN PERKEMBANGAN Nama Klien AINA Diagnosa medis —: cro Ruang rawat Semon, Tanda ae pemwes sl juasi (SOAP) tangan Caviam) | _Keperawatan epenen Ecoles atl | 247 20n [ARIA Brsue Frannie ake |p parih mania i Core Aide eerbae] marure Need Ue Tee eee le ewiin encnie et Pepmoniter Mae. ~ Frrtiron cm CO vc mb) Prmericenas \abuvieh ~ bor Forty pa ae apie 4 feo ire Celene tmrdincmne es [itv 5 10:99 Jes shy WARY AMPS dx, HR: 6 2 ofan oust Fe: 20 %/nn MONOMER Onpun SO Steve EA I °9 YM O/AL ee Petns 13 y eNeies Seis Vis gg tateavinn “treet 844 FTFom bea: 108 naviene Baasice IMEUE ontrss Yg V2 bP [vacton LAMP clelm cece hey UA + Looe CC /24 Jue A: Pests perce Feb Bee BEE LeLge, Untece Ps Norte Faber Pres CATATAN PERKEMBANGAN Nama klien mwa Diagnosa medis —: cr Ruang rawat —: vray Wek Tanda Catriam) eet Implementast Evaluasi (SOAP) tangan | 3 DRI Perfor Pranmenner etter Pore tide eeckne| b'draee mammtoniee bone leak rapmoniter Wat Prmericewss (alee armenian tober : Mimgdinounie JS PPHCOLE I ALalE® doen eure MMM bErKN Op pan MP OEE coinn retravenn, Corn stount en pW A rnoeioe alm reo terme Lelia Jor-Prcien domo Pv rete oer eet IY TD a4 /6r tombe 1: baph/rmnt si ee ve. 2h4/men yrrem 97 mofAl erwin L399 mel, Bab oe pprimome © 30866 infar acoria tect Slo urine Boe Ce /2qd0% A.ceaks porPux pon tke Chew belgie bret. es Lotien intervene CATATAN PERKEMBANGAN Nama Klien r1N.A Diagnosa medis — : CFO Ruang rawat |: vereweys "Tanda creed | noes Implementas! Evalvasi (SOAP) tengan oe hacer, 5. Parn~ MmPrgototan Torn fi mProdonu ia PeieRON, mv dvmnden gee Frriouizors Fotetor Ling Fr. Pengeeon J Loren /hiletigkons Vraear 9Fryr ees meet dn tide uy cong [ Po En sepiy roteceies Hg, - Sob 6 Ponta, Out mpmenitee muclFroca | Mra istinne| Masel Sock hence meen e reps) vive wereaney den Waele EP tetas OTN A fomPre Lome Se ee cane Fv pct = BP torn md te hv FTE? Ofer mg 99 fate PR 22x Jimi Sahat leon: 99 m/e Feretinins 1, Pa fly AP Reve Worle, bereden Po INNene Pret ab lle CATATAN PERKEMBANGAN Nama klien 171N.A Diagnosa medis — :cto Ruang rawat 1 Kereneys Waktu Diagnosa Tanda (al/am) ieee Implementasi Evaluasi (SOAP) tangan 27 1a Trausen MORO Fina PPtEReN, Ave duran don Canoes FPrteL com Fotetor Lins Hon Pengrcoy mee J Krone (hitengbon, Eralea. venytioy Prot | PRO ae iste Pete oy come mapmenitar muccltrneand SiR MAPegEte EO rua Act Maker - MeFAy WekEN birteny 4 PMMA AO Hin. A em ee: 2G xm UII 7 miml 199 s/o PE Mauctn sepLomy ttrotogy Poe | MARS! CATATAN PERKEMBANGAN Nama Klien Diagnosa medis Ruang rawat —: veranys da Waktu Diagnosa Tan (Tgl/Jam) Keperawatan Implementasi Evaluasi (SOAP) tangan 2 ee durin don Lngeet Ferouiccrs Fotetor L ters. moo Rem Kurang) /islorighon, Kretaan oPryrnoe Pro etn spy comap Paes “Arm eorain Be Oot PAOOdoms mes Perabo | mPhase tue PEO e) Pome, © Pomen MPmgpRaR Awol mpmeniber save rateg _ morn THA bei A Moen semaen Ling | -TA.A dome Upmen TW 1D “96 /se mre wy 2dox/mon 6 eve gn 2ie/nes vrown 297 ths, teretinn 1,99 mo fA Ai nov ePlen tering es i nkeryme! di (ouaieen NAMA NIM LOGBOOK PRAKTIK PROFESL NERS, FAKULTAS KEPERAWATAN UNIVERSITAS RIAU 2022/2023 [ARIE AFeINOT tennooe HARVTANGGAL — as/iaen. STASEBLOK RUANGAN wane \ernanan [No-) WaKTU KEGIATAN, PARAT MAIASISWA, a | PRESEPTOR KLINIK 08 30 cg.00 2930 te0e Woo 12.06 13.00 mendgonb CoA InEYE ina dengan cotton mpontorien, Boer Th ag ko fY0NS Tee OOK UME a een FeMeM {nores marble Prrauee Luke th Crom dpnoees dim. Lute Erdos Kates /Poyguny. base eos eadeas Prod, Pane rmbt Lota, Pa tho dngon doshorn dm. Luka PA ED KOKO Yooper Pegqug (we Epeden Lee tome, PtP ore eecen b0eitn ont a Peooct~e, inguT PAL Pcien TAM tone Gory Sao none pea RS PRS, a pen ce LOGBOOK PRAKTIK PROFESI NERS VAKULTAS KEPERAWATAN UNTVERSIPAS RIAE 2022/2023 NAMA ‘acie. netinor NIM cemees HARVTANGGAL —24fvzeu STASE/BLOK oe RUANGAN vga NO.| WAKTU KEGIATAN ranas | MATIASISWA | eg.oe | (oe tere Warm emreortO Ces SAlinn Porcen EAL Unt APL Hee Port gary hewe name tat EP SPL Parte HOM Okt ee oh Paron. reson acm, ede den pemen © Pacion Tro te mmentir Conn, Bowmen 4D hon ee { w NAMA NIM HARI/TANGGAL STASE/BLOK RUANGAN LOGBOOK PRAKTIK PROPESI NERS VAKULTAS KEPERAWATAN UNIVERSITAS REAE 2022/2023 pete AareiAoy NO. | WARTU (aioe 2yi/2022 ne reign ~KEGIATAN PARAP ] MAHASISWA | PRESEPTOR | KLINIK eco 03.60 29-26 lto-ve fa ase 00 V0. ley Pacer PPraGoAL ON INFOF ekg hrateis Ps sAlsrn pasion MrEMPrRsiCReN MYA Cot Yary Okan Aimy Pak pin O30 my Memento ober 1m) irae Peak, Pacem nye Mean Ceram | Pacem na dergin Ri emgoey tae Lae, hectare Saghere dim enh, rake, MACs om lrmetomges Intag mn Pasi en meee af Pm aee a, ‘

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