KEGIATAN HARIAN (ADL) MAHASISWA PROFESI NERS

UNIVERSITAS JAMBI TAHUN 2024

Nama Mahasiswa :
NIM/Kelompok :
Ruangan :
Hari/Tanggal :

WAKTU KEGIATAN

Jambi, 2024

Pembimbing akademik Pembimbing lapangan Mahasiswa

(……………………….) (……………………….) (……………………….)

PROFESI NERS – PSIK – UNJA - 2024

 RENCANA KEGIATAN HARIAN KEPALA RUANGAN
Tanggal :
Nama Karu :
Nama Perawat :
Ruangan :
Jumlah Pasien :
Jumlah Perawat :

Waktu Kegiatan Keterangan

Jambi, 2024
Kepala Ruangan

(………………………………..)
PROFESI NERS – PSIK – UNJA - 2024
 RENCANA KEGIATAN HARIAN KETUA TIM
Nama Katim :
Nama Perawat :
Ruangan :
Tanggal :
Nama Psien :

Waktu Kegiatan Keterangan

Jambi, 2024
Ketua TIM

(………………………………..)
PROFESI NERS – PSIK – UNJA - 2024
 RENCANA KEGIATAN HARIAN
PERAWAT PELAKSANA
Nama Perawat :
Ruangan :
Tanggal :
Nama Psien :

Waktu Kegiatan Keterangan

Jambi, 2024
Perawat Pelaksana

(………………………………..)
PROFESI NERS – PSIK – UNJA - 2024
 UNIVERSITAS JAMBI
FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN
PROGRAM STUDI PROFESI NERS

ASUHAN KEPERAWATAN

Unit : ............... Tanggal Masuk : ..............

Ruang/Kamar : ............... Tanggal Pengkajian : ...............

I. Pengkajian
A. Identitas Klien
1. Klien
Nama Klien : ...................................................
Umur : ................................................... Tahun
Jenis kelamin : ...................................................
Status marital : ................................................... Menikah/belum menikah
Agama : ...................................................
Suku bangsa : ...................................................
Bahasa yang digunakan : ................................................... Indonesia/Daerah/Asing
Pendidikan : ...................................................
Pekerjaan : ...................................................
Alamat Rumah : ...................................................

2. Penanggung Jawab
Nama : ....................................................
Alamat rumah : ....................................................
Hubungan dengan klien : .....................................................

B. Data Medik
Diagnosa Medik
 Saat Masuk : ...........................
 Saat pengkajian : ...........................

PROFESI NERS – PSIK – UNJA - 2024

C. Alasan Masuk Rumah Sakit
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Keluhan utama saat pengkajian:
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D. Riwayat Kesehatan Saat Ini : (Paliatif Quality Regio Skala Time)
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E. Riwayat Kesehatan Masa Lalu :
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F. Riwayat Kesehatan Keluarga
1. Susunan anggota keluarga
Genogram ( 3 Generasi) :

PROFESI NERS – PSIK – UNJA - 2024

G. Kebiasaan Sehari-Hari
1. Nutrisi – Cairan
a. Keadaan sebelum sakit
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b. Keadaan sejak sakit

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2. Eliminasi
a. Keadaan sebelum sakit :
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b. Keadaan sejak sakit :
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3. Aktivitas – Latihan
a. Keadaan sebelum sakit
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b. Keadaan sejak sakit
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PROFESI NERS – PSIK – UNJA - 2024

 .......................................................................................................
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4. Tidur – Istirahat
a. Keadaan sebelum sakit
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b. Keadaan sejak sakit
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H. Aspek Sosial
a. Ekspresi efek dan emosi
Senang Sedih Menangis
Cemas Marah Diam
Takut Lain……………………….

b. Hubungan dengan keluarga

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I. Data Spritual
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J. Pemeriksaan Fisik
1. Keadaan sakit : Klien tampak sakit ringan/sedang/berat/tidak tampak
sakit
Alasan .......................................................................................................
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PROFESI NERS – PSIK – UNJA - 2024

2. Tanda- tanda Vital
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3. Antropometri
a. Lingkar lengan atas : …………. cm
b. Lipat kulit triceps : …………. cm
c. TB : …………. cm
d. BB : …………. kg
e. IMT (Indeks Masa Tubuh) : …………. kg/m2
Kesimpulan : ........................................................................................
4. Kepala
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5. Mata/penglihatan
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6. Hidung/penciuman
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7. Telinga/pendengaran
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8. Mulut/Pengecapan
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PROFESI NERS – PSIK – UNJA - 2024
9. Leher
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10. Dada/Pernapasan
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11. Kardiovaskuler/Sirkulasi
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12. Abdomen/ Pencernaan
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13. Muskuloskletal
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14. Genitourinaria
Laki – laki

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PROFESI NERS – PSIK – UNJA - 2024

 Perempuan

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15. Keadaan Neurologi
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16. Integumen/ kulit

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17. Pola Persepsi dan Konsep Diri
a. Pola Persepsi
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b. Konsep Diri:
Gambaran Diri
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PROFESI NERS – PSIK – UNJA - 2024

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Harga Diri
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Ideal Diri
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Peran Diri
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Identitas Diri
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PROFESI NERS – PSIK – UNJA - 2024

 18. Mekanisme Koping
Kemampuan Mengendalikan Stress
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Sumber Pendukung
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19. Pemeriksaan Refleks

Refleks Fisiologis
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Refleks Patologis
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PROFESI NERS – PSIK – UNJA - 2024

K. Pemeriksaan Diagnostik
1. Laboratorium:
a. Darah :

b. Faeces :

c. Urine :

d. Sputum :

e. Lain – lain :

2. Radiologi :

3. EKG :

4. EEG :

5. USG :

6. Pemeriksaan lainnya:

L. Program Terapi
1. Obat-obatan :

2. Diet :

3. Fisioterapi :

Mahasiswa

( )
PROFESI NERS – PSIK – UNJA - 2024
II. Analisa Data
Nama Pasien :
Usia :

No Data Penyebab Masalah

PROFESI NERS – PSIK – UNJA - 2024

III. Diagnosa Keperawatan
No Tanggal Diagnosa Keperawatan Paraf
Ditegakkan

PROFESI NERS – PSIK – UNJA - 2024

IV. Rencana Asuhan Keperawatan
Nama Pasien :
Usia :

No Diagnosa Tujuan/ Intervensi Keperawatan Paraf

Keperawatan Kriteria
Hasil

PROFESI NERS – PSIK – UNJA - 2024

V. Implementasi dan Evaluasi
Nama
Pasien :
Usia :
Hari/Tanggal :

No Hari/tanggal Dx.Kep Implementasi Evaluasi Paraf

Jam

PROFESI NERS – PSIK – UNJA - 2024