PROGRAM STUDI PROFESI NERS

FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
PENGKAJIAN ASUHAN KEPERAWATAN

Nama : Pnedidikan :
Tanggal Lahir : No Register :
Agama : Dx Medis :
Jenis Kelamin : Tanggal MRS :
Pekerjaan : Tanggal Pengkajian :
Suku : Alamat :

1. Diagnosa medis

2. Keluhan utama

3. Riwayat penyakit sekrang

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4. Riwayat penyakit terdahulu
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Riwayat alergi
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5. Riwayat penyakit keluarga
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B1 Airway Kardiovaskuler
 Kesulitan bernafas Askultasi  Suara Jantung
 Batuk  Vasikuler  S1-S2 tunggal
 berdahak’  Bronchovasikuler  Mur-mur
 tidak berdahak  Bronchial  Edema
Inspeksi  Suara nafas tambahan  Kulit basah
 Jalan nafas  Ronchi  Sesak saat/setelah
 Paten  Wheezing beraktivitas
 Sumbatan  Stridor  Gambaran EKG
 Bentuk dada  Rales  Normal
 Normal chest  Snoring  Aritmia
 Barell chest  Lain-lain...............  Infark
 Pigon chest  RR............................  Konduksi abnormal
 Retaksi dada  Pola nafas  iskemia
 Pernafasan cuping hidung  Takipnea
 Nyeri dada  Bradipnea
Perkusi  Apnea
 Sonor  dispnea
 Hipersonor
 Redup

B2 Blood Sirkulasi Balance cairan

 Nadi................x/menit  Akral  Intake cairan...............cc
 Tekanan darah........mmHg  Hangat  Output cairan..............cc
 MAP.................................  Dingin  Balance cairan............cc
 Suhu..............................C  Pucat  Dehidrasi
 CRT  Edema
Hematologi  < 2 detik
 Peredarah dari................  >2 detik
 Jumlah darah.................cc  Konjungtiva anemis
 petekie  Turgor kulit......... detik

B3 Brain/Persyarafan Persepsi sensori

 GCS: E.......V.......M........  Pupil  Gangguan indra
 Tingkat kesadaran  Isokor  Kognitif
 Composmentis  Unisokor  Orientasi penuh
 Apatis  Midriasis  Bingung
 Somnolen  Unrespon  Motorik
 Sopor  Miosis  Mandiri
 Coma  Refleks  Pasrsial
 Kejang  Normal  Total
 Kaku kuduk  Abnormal Istirhat-Tidur
 tremor  parese  Nyenyak
 Gangguan tidur
B4 Bladder/Perkemihan
 BAK.....................x/hari  Bau  Urin menetes
 Normal  Khas  Distensi kandung kemih
  Kateter  Amoniak  Terdapat urin residu
 Warna urine  Keton  Urine menetes
 Kuning jernih  UP.......................cc/  Sensasi kandung kemih
 Kuning pekat hari penuh
 Merah  Pancaran Urin  BAB.....................x/hari
 Piuria (putih)  Kuat  Normal
 lemah  Colonstomy
B5 Bowel/pencernaan
Inspeksi  Kembung Perkusi
 Bibir  Konstipasi  Timpani
 Lembab  BAB : Sudah / belum  Hipertimpani
 Kering  BAB kering Skrining Gizi
 Sariawan  BAB diare  BB.........................Kg
 Gusi bengkak  BAB melena  TB.........................Kg
 Lidah: bersih / kotor  Askultasi  IMT.........................
 Anoreksia  Bising usus .......x/menit Nutrisi
 Mual Palpasi  Jenis diet
 Muntah  Nyeri area :  ........................................
 Muntah darah  Mc Burney  Alaergi makanan
 Gigi berlubang  Ulu hati  .......................................
 Asites spider nevi  Supra pubis  Pantangan makanan
 Gangguan menelan  Lain-lain...................  .....................................

B6 Bone/Muskuloskeletal
 Sendi : bebas / kontraktur  Integumen/perawtan  Kulit epidermis
 Radang / nyeri diri  Eritema
 Tulang  Rambut  Laserasi
 Terbuka  Bersih  Maserasi
 Tertutup  Kotor  Bulla (melepuh)
 Area fraktur.....................  Ketombe  Abrasi
 Tindakan  Kutu  Kulit dermis
 Oprasi  Rontok  Insisi pembedahan
 Gips  Hidung  Ulkus dekubitus
 Reposisi  Bersih  Luka bakar......... (1-100%)
 Lain-lain...................  Kotor  ADL
 Tonus otot  Polip  Mandiri
 Tumor  Parsial
 Perdarahan  Total
 Mulut : bersih/kotor
 Kulitb : ersih/kotor

 Edema ektermitas
 CRT ekstermitas........detik
B7 Psikologis
  Ketakutan pada sesuatu  Pasif  Bicara sendiri
yang tidak jelas  Malu  Bicara kasar
 Sedih  Ingin pulang  Menarik diri
 Menjerit cemas  Berduka  Kontak mata negatif
 Gelisah  Kehilangan  Implusivitas
 Marah  Depresi  Isos
 Merontak  Panik  Menunduk
 Menolak tindakan  Rendah diri  Sulit berbicara
B8 Sosial Spiritialitas
Sosial Spiritual  Bingung terhadap hidup
 Peran hubungan  Tingkat kepercayaan  Takut kematian
 Terganggu  Yakin  Keputusasaan
 Tidak terganggu  Ragu-ragu  Merasa kekosongan
Lingkungan  Kegiatan ibadah spiritual
 Sehat  Mandiri
 Tidak sehat  Dibantu
 Tidak melakukan
B9 Behavior and Community
 Peran terganggu  Cultire value  Adat istiadat kesehatan
 Minum alkohol  Tradisi  ...........................................
 Narkoba  .........................................  ..........................................
 Lingkungan yang tidak  ........................................
sehat
B10 Blood examinatiion
 PROGRAM STUDI PROFESI NERS
FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
PENGKAJIAN ASUHAN KEPERAWATAN

DAFTAR DIAGNOSA

No. Tanggal/Jam Dx Keperawatan Paraf

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FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
PENGKAJIAN ASUHAN KEPERAWATAN

INTERVENSI KEPERAWATAN

No. Diagnosa Tujuan dan Kriteria hasil Intervensi

 PROGRAM STUDI PROFESI NERS
FAKULTAS KEPERAWATAN
UNIVERSITAS JEMBER
PENGKAJIAN ASUHAN KEPERAWATAN

IMPLEMENTASI

Tanggal / Jam No DX Implementasi Paraf