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ASUHAN KEPERAWATAN PADA ................DENGAN ...................................................................

DI RUANG .......................................... RSU TIDAR MAGELANG

Tanggal pengkajian : ...................................................

Tanggal masuk : ...................................................Ruangan : ...................................................

I. PENGKAJIAN

A. Identitas

1. Identitas Klien

Nama : .............................................................

No. RM : .............................................................

Umur : .............................................................

Jenis kelamin : .............................................................

Agama : .............................................................

Pendidikan : .............................................................Pekerjaan : .............................................................

Suku : .............................................................

Bahasa : .............................................................

Alamat : .............................................................

Pembiaaan kesehatan : .............................................................

!. Identitas Penanggung Jawa

Nama : .............................................................

Umur : .............................................................

Pendidikan : .............................................................

Pekerjaan : ............................................................."ubungan dengan klien : .............................................................

Suku : .............................................................

Bahasa : .............................................................

Alamat : .............................................................

No. telepon : .............................................................

!. Kelu"an Uta#a

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$. Riwa%at Kese"atan Se&a'ang

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D. Riwa%at Pen%a&it Da"ulu

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E. Riwa%at Kese"atan Kelua'ga#. Ri$aat penakit dalam keluarga:........................................................................................................................................................

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!. %enogram

Kete'angan ga#a' (: perempuan

: laki&laki

: laki&laki meninggal

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: perempuan meninggal

: klien

: tinggal serumah

: garis pernikahan

: garis keturunan

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). Keadaan U#u#

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G. Ting&at Kesada'an...............................................................................................................................................................

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H. Tanda*tanda +ital

Suhu Nadi Perna'asan Tekanan (arah

I. Pengu&u'an Ant',-,#et'i

#. Berat badan : ............... kg!. Tinggi badan : ............... )m

*. +ndeks Masa Tubuh ,+MT- :

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J. Pe#e'i&saan )isi& Head t, T,e

1. Pe#e'i&saan Ke-alaInspeksi:

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Palpasi:

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. Pe#e'i&saan Mata

Inspeksi:

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Palpasi:......................................................................................................................................................

/. Pe#e'i&saan Hidung

Inspeksi:

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......................................................................................................................................................Palpasi:

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0. Pe#e'i&saan Mulut

Inspeksi :......................................................................................................................................................

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Paplasi :

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. Pe#e'i&saan Telinga

Inspeksi:......................................................................................................................................................

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Palpasi:......................................................................................................................................................

2. Pe#e'i&saan Le"e'

Inspeksi :

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Palpasi: ........................................................................................................................................

..............3. Pe#e'i&saan dada dan -a'u

Inspeksi:

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Perkusi :......................................................................................................................................................

Palpasi:

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Auskultasi: ...................................................................................................................................

...................4. Pe#e'i&saan Jantung

Inspeksi:

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Palpasi:......................................................................................................................................................

Perkusi:......................................................................................................................................................

Auskultasi :......................................................................................................................................................

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5. Pe#e'i&saan Pa%uda'a dan A&sila

Inspeksi :

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Palpasi:

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16. Pe#e'i&saan Ad,#en

Inspeksi :......................................................................................................................................................

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......................................................................................................................................................Auskultasi :......................................................................................................................................................

Perkusi :......................................................................................................................................................

Palpasi : ......................................................................................................................................

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11. Pe#e'i&saan Genetalia

Inspeksi :......................................................................................................................................................

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Palpasi : ......................................................................................................................................

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1. Pe#e'i&saan Re&tu# dan Anus

Inspeksi :

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Palpasi :

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1/. Pe#e'i&saan E&st'e#itas .

a. kstermitas Atas:

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................................................................................................................................................b. kstermitas Ba$ah:

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/ekuatan otot:

10. Pe#e'i&saan &ulit dan &u&u

Inspeksi :......................................................................................................................................................

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Palpasi :......................................................................................................................................................

K. Peng&a7ian Keutu"an Dasa'

1. Keutu"an 8&sigenasi

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. Keutu"an Nut'isi dan $ai'an

a. Keutu"an Nut'isi

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N,. Pe#anding Seelu# sa&it Saat di&a7i

#. 0rekuensi makanan

!. Jumlah makanan

*. Jenis makanan

1. Alergi makanan

2. Na'su makan

3.

/eluhan ,mual4

muntah4 kembung4

anoreksia-

5.Makanan

Pantangan

. Keutu"an 9ai'an

#- Balan)e )airan ,hitung jumlah dan jenis )airan masuk dan keluar- :

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!- (iuresis :

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.........................................................................................................................................*- Rute )airan masuk ,oral4 parenteral4 enteral4 dsb- :

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1- Jenis )airan :

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2- /eluhan :

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/. Keutu"an Eli#inasi

a. !A!

N,. Pe#anding Seelu# sa&it Saat di&a7i

#. 0rekuensi

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!. 6arna

*. Bau

1. /onsistensi

. !AK

N,. Pe#anding Seelu# sa&it Saat di&a7i

#. 0rekuensi

!. 6arna

*. Bau

1. Perasaan0. Keutu"an Te'#,'egulasi

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. Keutu"an A&ti:itas dan Lati"an

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Tael Ting&at Ke#andi'ian(

/emampuan Pera$atan (iri 7 # ! * 1

Makan8minum

Toileting

Berpakaian

Mobilitas di tempat tidur

Berpindah

/eterangan :

7 9 mandiri * 9 dibantu orang lain dan alat

# 9 dengan alat bantu 1 9 tergantung total

! 9 dibantu orang lain

2. Keutu"an Se&sualitas

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3. Keutu"an Psi&,s,sial ;St'ess K,-ing dan K,nse- Di'iJAMD@ KEP

INTER+ENSITTD

TUJUAN TINDAKAN

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N8TGL

>JAMD@ KEP

INTER+ENSITTD

TUJUAN TINDAKAN

+. IMPLEMENTASI

N8 D@.KEP TGL >JAM IMPLEMENTASI RESP8N TTD

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N8 D@.KEP TGL >JAM IMPLEMENTASI RESP8N TTD

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+I. E+ALUASI

;Pe'&e#angan setia- "a'i dala# entu& S8APJAM D@ KEP E+ALUASI TTD

N8 TGL>JAM D@ KEP E+ALUASI TTD

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PEM!AHASAN(

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