ASUHAN KEPERAWATAN

PADA PASIEN GANGGUAN

KOMUNIKASI VERBAL DENGAN
DIAGNOSA MEDIS STROKE

DI RUANG MAWAR
RSUD Dr.H.ABDUL MOELOEK PROVINSI
LAMPUNG

http://www.free-powerpoint-templates-design.com
Welcome!!
01 DAVID ANDREANSYAH

02 DINI NOVITRI

03 ELSA YUNIAR

04 RAHMA SARI HSB

05 SITI ZULAIKHA

NATSYA ZHAFIRA AJRINA

06 PUTRI
 TGL PENGKAJIAN : 26 MARET 2019
JAM PENGKAJIAN : 100.00 WIB
RUANG/KELAS : MAWAR/IIB

NO.REGISTER : 02.15.01.201900008856.001
TGL.MRS : 20 MARET 2019
 .
IDENTITAS

1.Identitas Pasien 2. Identitas Penanggung Jawab

Nama : Ny.S Nama : Suad
Umur : 65 Tahun Umur : 65 Tahun
Jenis Kelamin : Perempuan Jenis Kelamin: Laki-Laki
Agama : Islam Agama : Islam
Pendidikan : SMP Pekerjaan : Pekerja Swasta (PT)
Pekerjaan : Ibu Rumah Tangga Alamat : Jl.Tupai GG.Manggis,
Go.Darah : O No.73, Kedaton
Alamat : Jl.Tupai Hubungan dengan Klien : Suami
Gg.Manggis, No.73, Kedaton
 KELUHAN UTAMA
.

Saat Masuk
Demam
Rumah Sakit

Saat
Pengkajian Saat dilkukan pengkajian keluarga
klien mengatakan nyeri pada dada
karena memiliki riwayat penyakit
jantung coroner, nyeri terasa apabila
DIAGNOSA Stroke melakukan aktivitas yang berlebihan
MEDIS HT(Hipertensi) seperti ditusuk-tusuk pada bagian
jantung dengan skala nyeri 5 dari
1-10 (nyeri sedang).
 RIWAYAT KESEHATAN

1. Riwayat Kesehatan yang .

Lalu Keluarga pasien mengatakan bahwa

pasien memiliki riwayat hipertensi,
vertigo dan jantung coroner sejak
4 tahun yang lalu

Pasien dan keluarganya datang ke 2. Riwayat Kesehatan

RSUD Dr.H.Abdul Moeloek pada tanggal Sekarang
16 Maret 2019, sebelumnya pasien rujukan dari
rumah sakit DKT. Dengan keluhan demam sejak
4 hari yang lalu disertai dengan lemas, mual,
pusing, nafsu makan menurun, gelisah serta
pasien tidak bisa tidur 3 hari yang lalu.
Lanjutan ...
.

Keluarga pasien mengatakan bahwa

3. Riwayat Kesehatan Keluarga keluarganya tidak ada yang menderita
penyakit
yang sifatnya diturunkan atau menular.
 RIWAYAT POLA PEMELIHARAAN
1. Pola Aktivitas Sehari-hari
ADL Di Rumah
Pola pemenuhan kebutuhan Keluarga pasien biasa makan 3xsehari.
nutrisi dan cairan Pasien tidak ada pantangan atau alergi
terhadap makanan apapun. Klien
minum 3-8 gelas sehari
Pola Eliminasi Kelurga pasien mengatakan pasien
BAK ≤ 4-5x/hari tergantung banyakan
nya minum pasien, warna kuning
normal, berbau khas, dn tidak ada
masalah saat buang air kecil.
Pasien BAB 1-2x/hari, warna feses
normal, tidak ada masalah pada saat
BAB
Di Rumah Sakit
Keluarga pasien mengatakan pasien sulit
menelan sehingga dipasangkan selang
NGT untuk memenuhi kebutuhan nutrisi
pasien.
Kelurga pasien mengatakan proses BAK
tidak bisa dilakukan karena pasien tidak
bisa bangun tetapi,hanya berbaring
ditempat tidur, sehingga paien
dipasangkan selang urine (kateter) untuk
mempermudah proses pengeluaran urine
Pasien tidak BAB sama sekali.
Lanjutan ...
ADL Di Rumah
. Di Rumah Sakit

Pola Istirahat Tidur .

Keluarga pasien mengatakan pasien
tidur ≤7-8jam/perhari, tidak ada
gangguan pola tidur.
Keluarga pasien mengatakan pasien tidak
bisa tidur sejak 4 hari yang lalu, sejak
pertama kali masuk RSAM, dengan
gangguan gelisah. Upaya mengatasi nya
dipaksakan untuk tidur.

Pola Kebersihan Diri (PH) Kelurga pasien mengatakan pasien Kelurga pasien mengatakan pasien tidak
mandi 2x/hari mencuci rambut, gosok mandi hanya di lap-lap bagian tubuh
gigi 2x/hari, dan mengganti baju pasien menggunakan kain dan berganti
dengan keadaan kuku bersih dan pendek. pakaian dengan keadaan kuku bersih dan
pendek.

Aktivitas Lain Kelurga pasien mengatakan pasien Kelurga pasien mengatakan bahwa pasien
melakukan aktivitas di rumah dan hanya dapat berbaring di tempat tidur dan
bersosialisasi dengan baik pada semua aktivitasnya dibantu oleh kelurga
lingkungan disekitar rumah. pasien.
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