ASUHAN KEPERAWATAN MAHASISWA/I PRAKTEK

AKADEMI KEPERAWATAN KESDAM ISKANDAR MUDA LHOKSEUMAWE

Nama Mahasiswa : MUHAMMAD AZIZI MERO

NIM : 13404221060

PENGKAJIAN

Ruang :
No. Kamar/TT :

1. Biodata
Nama :
Umur :
Jenis kelamin :
Agama :
Alamat :
Pekerjaan :
Status perkawinan :

2. Riwayat kesehatn
Riwayat Kesehatan Sekarang
1.Riwayat Penyakit Saat Ini :
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2.Keluhan Utama :
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 3.Riwayat Kesehatan Yang Lalu :
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4.Riwayat kesehatan keluarga

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3. Pola aktifitas sehari-hari (di rumah & di rumah sakit )

No. Kebiasaan Di Rumah Di Rumah Sakit
1. Makan

2. Minum

3. Eliminasi BAB
 4. Eliminasi BAK

5. Istirahat/Tidur

6. Personal hygiene

7. Aktifitas/Latihan
Olahraga
Lain-lain

Pemeriksaan Fisik :
a. Keadaan/Penampilan/Kesan Umum Pasien
Pasien tampak ...............................................................................................................................
Kulit dan keadaan tubuh...............................................................................................................
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b. Tanda-tanda vital
Tekanan Darah : Suhu :
Denyut Nadi : Respirasi/RR :

TB/BB :
Status Nutrisi :
c. Pemeriksaan Kepala dan Leher
Kepala : ...........................................................................................................................
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Rambut : ...........................................................................................................................
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Wajah : ...........................................................................................................................
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Hidung : ...........................................................................................................................
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Telinga : ...........................................................................................................................
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Mulut &
Faring : ...........................................................................................................................
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Leher : ...........................................................................................................................
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d. Pemeriksaan Integumen/Kulit dan Kuku

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e. Pemeriksaan Payudara dan Ketiak
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f. Pemeriksaan Sistem Pernapasan

Inspeksi : ...........................................................................................................................
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Auskultasi : ...........................................................................................................................
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Perkusi : ...........................................................................................................................
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Palpasi : ...........................................................................................................................
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g. Pemeriksaan Sistem Kardivaskuler

Inspeksi : ...........................................................................................................................
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 Auskultasi : ...........................................................................................................................
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Palpasi : ...........................................................................................................................
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Perkusi : ...........................................................................................................................
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h. Pemeriksaan Abdomen
Inspeksi : ...........................................................................................................................
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Auskultasi : ...........................................................................................................................
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Palpasi : ...........................................................................................................................
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Perkusi : ...........................................................................................................................
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i. Pemeriksaa Genetalia
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j. Pemeriksaan Muskuloskeletal/Ekstremitas
Kekuatan Otot : ...........................................................................................................................
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k. Pemeriksaan Neurologi
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l. Penatalaksanaan/Terapi
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m. Pemeriksaan Penunjang Medis

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 ANALISA DATA

DATA PENUNJANG ETIOLOGI MASALAH

 ANALISA DATA

DATA PENUNJANG ETIOLOGI MASALAH

 DAFTAR DIAGNOSA KEPERAWATAN

TGL TGL
NO. DIAGNOSA KEPERAWATAN TT
MUNCUL TERATASI
 RENCANA ASUHAN KEPERAWATAN

DIAGNOSA
NO. TUJUAN INTERVENSI IMPLENTASI EVALUASI
KEPERAWATAN
 RENCANA ASUHAN KEPERAWATAN

DIAGNOSA
NO. TUJUAN INTERVENSI IPLEMENTASI EVALUASI
KEPERAWATAN