Politeknik Kesehatan Rs Dr.soepraoen malang

7/23/2019 Politeknik Kesehatan Rs Dr.soepraoen malang

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POLITEKNIK KESEHATAN RS dr.SOEPRAOEN

PROGRAM STUDI KEPERAWATAN

FORMAT PENGKAJIAN

RUANG PERAWATAN ANAK

I. Biodata

A. Identitas Klien

1. Naa!Naa "an##ilan $ %%%%%%%%%%%%%%%%%%%%%%%%%%

&. Te"at t#l la'ir!(sia $ %%%%%%%%%%%%%%%%%%%%%%%%%%

). *enis +elain $ %%%%%%%%%%%%%%%%%%%%%%%%%%

,. A # a a $ %%%%%%%%%%%%%%%%%%%%%%%%%%

-. Pendidi+an $ %%%%%%%%%%%%%%%%%%%%%%%%%%

. Alaat $ %%%%%%%%%%%%%%%%%%%%%%%%%%

/. T#l as(+ $ ...................................... 0a ............2

3. T#l "en#+aian $ %%%%%%%%%%%%%%%%%%%%%%%%%%

4. Dia#nosa edi+ $ %%%%%%%%%%%%%%%%%%%%%%%%%%

15. Ren6ana tera"i $ %%%%%%%%%%%%%%%%%%%%%%%%%%

B. Identitas Oran# t(a

1. A7a'

a. N a a $ %%%%%%%%%%%%%%%%%%%%%%%%%%

8. U s i a $ %%%%%%%%%%%%%%%%%%%%%%%%%%

6. Pendidi+an $ %%%%%%%%%%%%%%%%%%%%%%%%%%

d.Pe+eraan!s(8erPen#'asilan $ %%%%%%%%%%%%%%%%%%%%%%%

e. A # a a $ %%%%%%%%%%%%%%%%%%%%%%%%%%

9. Alaat $ %%%%%%%%%%%%%%%%%%%%%%%%%%

&. I8(

a. N a a $ %%%%%%%%%%%%%%%%%%%%%%%%%%

8. U s i a $ %%%%%%%%%%%%%%%%%%%%%%%%%%

6. Pendidi+an $ %%%%%%%%%%%%%%%%%%%%%%%%%%

d.Pe+eraan!S(8er"en#'asilan$ %%%%%%%%%%%%%%%%%%%%%%%

e. A#aa $ %%%%%%%%%%%%%%%%%%%%%%%%%%

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9. Alaat $ %%%%%%%%%%%%%%%%%%%%%%%%%

:. Identitas Sa(dara Kand(n#

No N A M A U S I A HUBUNGAN STATUS KESEHATAN

II. Ri;a7at Kese'atan

A. Ri;a7at Kese'atan Se+aran# $

Kel('an Utaa $ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

Ri;a7at Kel('an Utaa $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Kel('an Pada Saat Pen#+aian $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%

B. Ri;a7at Kese'atan Lal( 0+'(s(s (nt(+ ana+ (sia 5 < - ta'(n2

1. Prenatal 6are

a. I8( eeri+sa+an +e'ailann7a setia" in##( di%%%%%%%%.

Kel('an selaa 'ail 7an# dirasa+an ole' i8(= ta"i ole' do+ter

dian(r+an(nt(+ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

8. Ri;a7at ter+ena radiasi $ %%%%%%%%%%%%%%%.

6. Ri;a7at 8erat 8adan selaa 'ail $ %%%%%%%%%%%%%..

e. Ri;a7at I(nisasi TT $ %%%%%%%%%%%%%%%..

9. Golon#an dara' i8( %%%%.. Golon#an dara' a7a' %%%%..

&. Natal

a= Te"at ela'ir+an $ %%%%%%%%%%%%%%%%.

8. *enis "ersalinan $ %%%%%%%%%%%%%%%%%.

6. Penolon# "ersalinan $ %%%%%%%%%%%%%%%%

e. Ko"li+asi 7an# dialai ole' i8( "ada saat ela'ir+an dan setela'

ela'ir+an $ ....................................................................................................

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). Post natal

a. Kondisi 8a7i $ %%%% APGAR %%%%%%%

8. Ana+ "ada saat la'ir tida+ en#alai $ %%%%%%%%%%%

0Unt(+ se(a Usia2

> Klien "erna' en#alai "en7a+it $ %%%"ada ((r $ %%%%% di8eri+an

o8at ole' $ %%%%%%%%%%%%%%%%..

>Ri;a7at +e6ela+aan $ %%%%%%%%%%%%%%%%..

> Ri;a7at en#+ons(si o8at?o8atan 8er8a'a7a tan"a an(ran do+ter dan

en##(na+an @at!s(8tansi +iia 7an# 8er8a'a7a $ %%%%%%%%%%.

>Per+e8an#an ana+ di8andin# sa(dara?sa(daran7a $ ...................

:. Ri;a7at Kese'atan Kel(ar#a

> Geno#ra

Ket $

I. Ri;a7at I(nisasi 0i(nisasi len#+a"2

NO *enis i(nisasiWa+t(

"e8erianre+(ensi

Rea+si setela'

"e8erianre+(ensi

1. B:G

&. DPT 0I=II=III2

).Polio

0I=II=III=I2

,. :a"a+

-. He"atitis

. Ri;a7at T(8(' Ke8an#

A. Pert(8('an isi+

1. Berat 8adan $ %%%%%%+#

&. Tin##i 8adan $%%%%%. 6.

). Wa+t( t(8(' #i#i %%%%%%#i#i Tan##al %% *(la'

#i#i ...................... 8(a'.

B. Per+e8an#an Tia" ta'a"

Usia ana+ saat

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1. Ber#(lin# $ %%%%% 8(lan

&. D(d(+ $ %%%%% 8(lan

). Meran#+a+ $ %%%%% 8(lan

,. Berdiri $ %%%%% ta'(n-. Beralan $ %%%%% ta'(n

. Sen7( +e"ada oran# lain "ertaa +ali $ %%% ta'(n

/. Bi6ara "ertaa +ali $ %%%%ta'(n den#an en7e8(t+an $

%%%%%

3. Ber"a+aian tan"a 8ant(an $ %%%%%

4. DDST $.........................................

I. Ri;a7at N(trisi

A. Pe8erian ASI

........................................................................................................................

B. Pe8erian s(s( 9or(la

1. Alasan "e8erian $ %%%%%%%%%%%%%%%%%%%%%%%

&. *(la' "e8erian $ %%%%%%%%%%%%%%%%%%%%%%%

). :ara "e8erian $ %%%%%%%%%%%%%%%%%%%%%%%Pola "er(8a'an n(trisi tia" ta'a" (sia sa"ai n(trisi saat ini

Usia Jenis Nutrisi Lama Pemberian

II. Ri;a7at Psi+ososial

> Ana+ tin##al 8ersaa $

...........................................................................................

> Lin#+(n#an 8erada di $ ................................................

>R(a' de+at den#an $ ......................... te"at 8erain ..................................

+aar +lien $ ................................................

> R(a' ada tan##a $ ................................................

> H(8(n#an antar an##ota +el(ar#a $ ................................................

> Pen#as(' ana+ $ ................................................

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III. Ri;a7at S"irit(al

> S(""ort siste dala +el(ar#a $ ................................................

> Ke#iatan +ea#aaan $ ................................................

IC. Rea+si Hos"italisasi

A. Pen#alaan +el(ar#a tentan# sa+it dan ra;at ina"

? I8( e8a;a ana+n7a +e RS +arena $ ................................................

? A"a+a' do+ter en6erita+an tentan# +ondisi ana+ $ ...........................

? Perasaan oran# t(a saat ini $ ................................................

? Oran# t(a selal( 8er+(n(n# +e RS $ ..........................................

? an# a+an tin##al den#an ana+ $ ................................................

B. Pea'aan ana+ tentan# sa+it dan ra;at ina"...................................

C. A+tiitas se'ari?'ari

A. N(trisi

Kondisi Se8el( Sa+it Saat Sa+it

1. Selera a+an

B. :airan


1. *enis in(an

&. re+(ensi in(

). Ke8(t('an 6airan

,. :ara "een('an

:. Eliinasi 0BABFBAK2


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1. Te"at "e8(an#an

&. re+(ensi 0;a+t(2

). Konsistensi

,. Kes(litan

-. O8at "en6a'ar

D. Istira'at tid(r


1. *a tid(r

- Sian#

- Mala

&. Pola tid(r

). Ke8iasaan se8el(

tid(r

,. Kes(litan tid(r

E. Ola' Ra#aKondisi Se8el( Sa+it Saat Sa+it

1. Pro#ra ola' ra#a

&. *enis dan 9re+(ensi

). Kondisi setela' ola'

ra#a

. Personal H7#iene


1. Mandi

? :ara

? re+(ensi

? Alat andi

&. :(6i ra8(t

? re+(ensi

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? :ara

). G(ntin# +(+(

? re+(ensi

? :ara

,. Goso+ #i#i

? re+(ensi

? :ara

G. A+ti9itas!Mo8ilitas isi+


1. Ke#iatan se'ari?'ari

&. Pen#at(ran ad;al

'arian

). Pen##(naan alat Bant(

a+ti9itas

,. Kes(litan "er#era+an

t(8('

H. Re+reasi


1. Perasaan saat

se+ola'

&. Wa+t( l(an#

). Perasaan setela're+reasi

,. Wa+t( sen##an# +l#

-. Ke#iatan 'ari li8(rCI. Peeri+saan isi+

1. Keadaan (($

&. Kesadaran $

). Tanda < tanda ital $

a. Te+anan dara' $ ..................................... H#8. Den7(t nadi $ ..................................... ! enit

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6. S('( $ ..................................... o:

d. Perna"asan $ ..................................... ! enit

,. Berat Badan $Tin##i Badan$ ..................................

-. Ke"ala

Ins"e+si

Keadaan ra8(t F H7#iene +e"ala $a. Warna ra8(t $

8. Pen7e8aran $

6. M(da' ronto+ $

d. Ke8ersi'an ra8(t $

Pal"asi

Benolan $ ada ! tida+ ada $

N7eri te+an $ ada ! tida+ ada $

Te+st(r ra8(t $ +asar!'al(s $

. M(+a

Ins"e+si

a. Sietris ! tida+ $

8. Bent(+ ;aa' $

6. Gera+an a8noral $

d. E+s"resi ;aa' $

Pal"asi

N7eri te+an ! tida+ $

Data lain $

/. Mata

Ins"e+sia. Pel"e8ra $ Edea ! tida+

Radan# ! tida+

8. S6lera $ I6ter(s ! tida+

6. :on(n#tia $ Radan# ! tida+

Aneis ! tida+

d. P("il $ ? Iso+or ! aniso+or

? M7osis ! idriasis

? Re9le+s "("il ter'ada" 6a'a7a $ ..................

e. Posisi ata $

Sietris ! tida+ $9. Gera+an 8ola ata $

#. Pen(t("an +elo"a+ ata $

'. Keadaan 8(l( ata $

i. Keadaan is(s $

. Pen#li'atan $ ? Ka8(r ! tida+

? Di"lo"ia ! tida+

Pal"asi

Te+anan 8ola ata $

Data lain $

3. Hid(n# F Sin(s

Ins"e+si

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a. Posisi 'id(n# $

8. Bent(+ 'id(n# $

6. Keadaan se"t($

d. Se6ret ! 6airan $

Data lain $

4. Telin#

Ins"e+si

a. Posisi telin#a $

8. U+(ran ! 8ent(+ telin#a $

6. A(ri+el $

d. L(8an# telin#a $ Bersi' ! ser(en ! nana'

e. Pea+aian alat 8ant( $

Pal"asi

N7eri te+an ! tida+

Peeri+saan (i "enden#aran

a. Rinne $

8. We8er $

6. S;a8a6' $

Peeri+saan esti8(ler $

Data lain $

15. M(l(t

Ins"e+sia. Gi#i

- Keadaan #i#i $

- Karan# #i#i ! +aries $

- Pea+aian #i#i "als( $

8. G(si

Mera' ! radan# ! tida+ $

Kotor ! tida+ $

6. Bi8ir

- :ianosis ! "(6at ! tida+ $

-Basa' ! +erin# ! "e6a' $

- M(l(t 8er8a( ! tida+ $

- Kea"(an 8i6ara $

- Data lain$

11. Ten##oro+an

a. Warna (+osa $ N7eri te+an$

8. N7eri enelan $

1&. Le'er

Ins"e+si

Kelenar t'7roid $ Me8esar ! tida+

Pal"asi

a. Kelenar t'7roid $ Tera8a ! tida+

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8. Ka+( +(d(+ ! tida+ $

6. Kelenar li9e $ Me8esar ata( tida+

Data lain $

1). T'ora dan "erna"asana. Bent(+ dada $ Iraa "erna9asan$

8. Pen#e8an#an di ;a+t( 8erna"as $

6. Ti"e "erna"asan $

Data lain $

Pal"asi

a. o+al 9reit(s $

8. Massa ! n7eri $

A(s+(ltas

a. S(ara na9as $ esi+(ler ! Bron6'ial ! Bron6'oesi+(ler

8. S(ara ta8a'an $ Ron6'i ! W'ee@in# ! Rales

Per+(si

Red(" ! "e+a+ ! '7"ersonor ! t7"ani

Data lain $

1,. *ant(n#

Pal"asi

I6t(s 6ordis $

Per+(si

Pe8esaran ant(n# $

A(s+(ltasi

a. B* I $

8. B* II $

6. B* III $

d. B(n7i ant(n# ta8a'an $

Data lain $

1-. A8doen

Ins"e+si

a. Me8(n6it $8. Ada l(+a ! tida+ $

Pal"asi

a. He"ar $

8. Lien $

6. N7eri te+an $

A(s+(ltasi

Peristalti+ $

Per+(si

a. T7"ani $

8. Red(" $

Data lain $

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1. Genitalia dan An(s $

1/. E+streitas

E+streitas atasa. Motori+

- Per#era+an +anan ! +iri $

- Per#era+an a8noral $

- Ke+(atan otot +anan ! +iri $

- Ton(s otot +anan ! +iri $

- Koordinasi #era+ $

8. Re9le+s

- Bi6e"s +anan ! +iri $

- Tri6e"s +anan ! +iri $

6. Sensori

- N7eri $

- Ran#san# s('( $

- Rasa ra8a $

E+streitas 8a;a'

a. Motori+

- Ga7a 8eralan $

- Ke+(atan +anan ! +iri $

- Ton(s otot +anan ! +iri $

8. Re9le+s- KPR +anan ! +iri $

- APR +anan ! +iri $

- Ba8ins+7 +anan ! +iri $

- N7eri $

- Ran#san# s('( $

- Rasa ra8a $

Data lain $

13. Stat(s Ne(rolo#i.

Sara9 < sara9 6raniala. Ner(s I 0Ol9a6tori(s2 $ "en#'id( $

8. Ner(s II 0O"ti6(s2 $ Pen#li'atan $

6. Ner(s III= I= I 0O6(lootori(s= Tro6'learis= A8d(6ens2

- Konstri+si "("il $

- Gera+an +elo"a+ ata $

- Per#era+an 8ola ata $

- Per#era+an ata +e 8a;a' F dala$

d. Ner(s 0Tri#ein(s2

- Sensi8ilitas ! sensori $

- Re9le+s da#( $

- Re9le+s 6ornea $

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e. Ner(s II 0a6ialis2

- Gera+an ii+ $

- Pen#e6a"an & ! ) lida' 8a#ian de"an$

9. Ner(s III 0A6(sti6(s2

(n#si "enden#aran $

#. Ner(s IC dan C 0Gloso"'arin#e(s dan a#(s2- Re9le+s enelan $

- Re9le+s (nta' $

- Pen#e6a"an 1!) lida' 8a#ian 8ela+an# $

- S(ara $

'. Ner(s CI 0Assesori(s2

- Mealin#+an +e"ala +e +iri dan +e +anan $

- Men#an#+at 8a'( $

i. Ner(s CII 0H7"o#loss(s2

- Deiasi lida' $

Tanda < tanda "eran#san#an sela"(t ota+

a. Ka+( +(d(+ $

8. Kerni# Si#n $

6. Re9le+s Br(d@ins+i $

d. Re9le+s Lase#( $

Data lain $

CI. Peeri+saan Tin#+at Per+e8an#an 05 < Ta'(n 2

Den#an en##(na+an DDST

1. Motori+ +asar

&. Motori+ 'al(s

). Ba'asa

,. Personal so6ial

CII. Test Dia#nosti+

La8oratori( oto Rot#en= :T S6an= MRI= USG= EEG= E:G

CIII. Tera"i saat ini 0dit(lis den#an rin6i2

ANALISA ATA

NAMA PASIEN $

UMUR $

NO. REGISTER $

NO TANGGAL ATA PENUNJANG MASALAH KEMUKINAN

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13/71

! "JAM PEN#EBAB

AFTAR IAGNOSA KEPERAWATAN

NAMA PASIEN $

UMUR $NO. REGUSTER $

13


14/71

NO

!

TGL

MUN$UL

IAGNOSA KEPERAWATAN TGL

TERATASI

T!T

14


15/71

INTER%ENSI

NAMA PASIEN $

NO. REGISTER $

UMUR $DC MEDIS $

NO IAGNOSA

KEPERAWATAN

PEREN$ANAAN

TUJUAN & KH INTER%ENSI RA


16/71


17/71

$ATATAN KEPERAWATAN

NAMA PASIEN $

UMUR $

NO. REGISTER $

NO

!

TGL! NO!'

KEP.

JAM TINAKAN

KEPERAWATAN

E%ALUASI T!T

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18/71

FORMAT $ATATAN PERKEMBANGAN

NAMA PASIEN $

UMUR $

DC. MEDIS $

NO! '!

KEP

TANGGAL

"

JAM

$ATATAN PERKEMBANGAN TT!

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FORMAT ASKEP MATERNITAS ASUHAN KEPERAWATAN

PAA N(! !!!!!!! ENGAN !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

I RUANG!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

PENGKAJIAN

I. ANAMNESA

1. BIODATA

Naa $ ............................................................

U(r $ ............................................................

Pe+eraan $ ............................................................

Stat(s $ ............................................................

A#aa $ ............................................................

Alaat $ ............................................................Naa s(ai $ ............................................................

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20/71

Pe+eraan $ ............................................................

Alaat $ ............................................................

Dia'nosa edis $ ............................................................

&. KELUHAN UTAMA

........................................................................................................................................). RIWAAT KESEHATAN

a. Ri;a7at Pen7a+it Saat Ini

.................................................................................................................................................

.................................................................................................................................................

.................................................................................................................................................

.................................................................................................................................................

...........................................................

8. Ri;a7at Kese'atan Masa Lal(

.................................................................................................................................................

.................................................................................................................................................

.............................................

6. Ri;a7at Kese'atan Kel(ar#a

.................................................................................................................................................

.................................................................................................................................................

....................................................

,. RIWAAT PERKAWINAN

a. Stat(s "er+a;inan $ ........................................

8. U(r "ertaa +ali +a;in $ ........................................

6. Bera"a +ali +a;in $ ........................................

d. Bera"a +ali +a;in 7an# se+aran# $ ........................................

-. RIWAAT OBSTETRI

a. Menar6'e $ ........................................

8. Haid terat(r ! tida+ si+l(s $ ........................................6. Laa 'aid $ ........................................

d. Kel('an $ .........................................

e. Si9at dan 8an7a+n7a dara' $ .........................................

9. Aenorea $ .........................................

#. HPHT $ .........................................

'. Ta+siran "ersalinan $ ........................................

. RIWAAT KEHAMILAN= PERSALINAN= NIAS ANG LALU

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21/71

a. Ri;a7at +e'ailan 7an# lal(

NoAna)

)e

Jenis )e*u+an

TM I, II,

III

)e+ami*an bera)+ir -A, I, P, A, S, H" M.

8. Ri;a7at "ersalinan 7an# 8ar(

No Persa*inan )e BBL $ara *a+ir Hi/u0"Mati

Peno*on1 Umurse)aran1

Ke*ainan

6. Ri;a7at ni9as 7an# lal(

No Ana) )e Ke*u+an saat ni2as Pemberian ASI

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22/71

/. RIWAAT KEHAMILAN= PERSALINAN DAN NIAS SAAT INI

a. Ri;a7at +e'ailan se+aran#

TGL UK LEOPOL

I & I%

BJA TENS

I " BB

ALBUMIN OEEM"

REFLEK

TBJ LAIN&

LAIN

-TT.

TERAPI

STATUS PRAESENS

Keadaan (( $ ...........................................................................

TB ! BB $ ...........................................................................

Stat(s #i@i $ ...........................................................................

Kelainan 8ent(+ $ ...........................................................................

TT $ TD .............................. Nadi .....................................

S('( .......................... RR .....................................

Ke"ala $ ........................................................................Le'er $ ...........................................................................

T'ora+s $ ..........................................................................

P(lo $ ..........................................................................

:or $ ..........................................................................

Maae $ .........................................................................

A8doen $ .........................................................................

He"ar $ .........................................................................Lien $ .........................................................................

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23/71

Lain? lain $ .........................................................................

Genito(rinar7 $ ........................................................................

E+streitas $ ........................................................................

Len#an $ ........................................................................

Ka+i $ Oede ...................... Re9le+s ..............

To(6'er $ *a.................................Ole'................................

Indi+asi $ ...............................................................

(la! a#ina $ ...............................................................

Pe8(+aan $ ...............................................................

E99i6eent $ ...............................................................

Ket(8an $ ...............................................................

Hod#e $ ..............................................................

Lain? lain! +eadaan l(ar 8iasa $ ....................................................

a+tor resi+o $ ..................................................................................................Kesi"(lan $ G.............. P............... A............... den#an UK ........................

8. Ri;a7at "ersalinan se+aran# 0diisi 1i+a i8( "art( ata( ni9as2

MRS tan##al $ ..................................................................................................

Di+iri ole' $ ..................................................................................................

Peeri+saan "ertaa ole' $ $ .......................................................................................

Per(laan 'is $ Hari! tan##al $ ........................................... *a........................

Ket(8an "e6a' $ ................................................. Warna $ ..................................

Lain? lain $ ..................................................................................................

STATUS PRAESENS

Keadaan (( $ ..................................................................................................

TB ! BB $ ..................................................................................................

Stat(s #i@i $ ..................................................................................................

Kelainan 8ent(+ $ ..................................................................................................

TT $ TD .................................. Nadi .....................................

S('( .............................. RR .....................................

Ke"ala $ ..................................................................................................

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24/71

Le'er $ ..................................................................................................

T'ora+s $ ..................................................................................................

P(lo $ ..................................................................................................

:or $ ..................................................................................................

Maae $ ..................................................................................................

A8doen $ ..................................................................................................

He"ar $ ..................................................................................................

Lien $ ..................................................................................................

Lain? lain $ ..................................................................................................

Genito(rinar7 $ ..................................................................................................

E+streitas $ ..................................................................................................

Len#an $ ..................................................................................................

Ka+i $ Oede ......................................... Re9le+s .............................

STATUS OBSTETRI

Pal"asi $ ..................................................................................................

TU $ ..................................................................................................

D** $ ..................................................................................................

Leta+ ana+ $ ..................................................................................................

Lain? lain $ ..................................................................................................

To(6'er $ *a................................. Ole'.................................................

Indi+asi $ ..................................................................................................

(la! a#ina $ ..................................................................................................

Pe8(+aan $ ..................................................................................................

E99i6eent $ ..................................................................................................

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25/71

Ket(8an $ ..................................................................................................

Hod#e $ ..................................................................................................

Lain? lain! +eadaan l(ar 8iasa $ .........................................................................................

Part(s di"i"in ole' $ .................................Den#an "en#a;asan...............................

Di8ant( $ ..................................................................................................

KALA I

T1*"

3am

Pembu)aa

n

Fre)uens

i His

Lama

His

Kuat"

ti/a)

JJ Keteran1an

KALA II

TGL"

JAM

Lama His JJ Keteran1an

KU

i8( $................................................

J

"erdara'an $ ....................................

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26/71

E"isiotoi!

tida+ $ ................................

Tinda+an

lain $ ....................................

KALA III

T1*" 3am His Keteran1an

Plasenta $ Len#+a"! Tida+ U+(ran $ .............................................................................

Insertiae $ ......................................................... Me8ran $ .............................................

Keadaan l(ar 8iasa $ .................................................................................................................

Keadaan U & a "ost "art( $ ..............................................................................................

Tanda? tanda ital $ TD .................................. Nadi .....................................

S('( .............................. RR .....................................

Perine( $ ..................................................................................................

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27/71

Keadaan l(ar 8iasa! lain? lain $ ..................................................................................................

BAI

La'ir a $......................................... La+i? la+i! "ere"(an ........... Hid("! Mati

Panan# 8adan $ ....................... BBL ..................... LK ................... LD..........................

APGAR S6ore $ ..............................................................................................................

Tanda? tanda ital $ Nadi ............................ S('( ........................ RR ............................

:a"(t s(66endane( $ ..............................................................................................................

:e"'al 'eato $ ..............................................................................................................

An(s $ ada ! tida+

Kelainan! lain? lain $ ...........................................................................................................

6. Ri;a7at Ni9as Se+aran#

KALA I%

T1*"

3am

TFU Kontra)s

i

Lo4+ea Keteran1a

n

Tera0i

3. RIWAAT KB

KB 7an# se8el(n7a $ ..................................................................................................

Kel('an $ ..................................................................................................

Ren6ana KB 7an# a+an datan# $ ...................................................................................

4. RIWAAT PSIKOSOSIAL SPIRITUAL

Konse" diri

27


28/71

.......................................................................................................................................................

...............................................................................................................................

Sosial

.......................................................................................................................................................

.......................................................................................................................................................

.......................................................................................................................................................

................................................................................

S"irit(al

.......................................................................................................................................................

.......................................................................................................................................................

.......................................................................................................................................................

................................................................................

15. POLA AKTIITAS SEHARI? HARI

Ma+an $ ..................................................................................................

Di r(a' $ ..................................................................................................

Di RS $ ..................................................................................................

Min( $ ..................................................................................................

Di r(a' $ ..................................................................................................Di RS $ ..................................................................................................

Eliinasi $ ..................................................................................................

Di r(a' $ ..................................................................................................

Di RS $ ..................................................................................................

Istira'at ! tid(r

$ ..................................................................................................

Di r(a' $ ..................................................................................................

Di RS $ ..................................................................................................

A+tiitas $ ..................................................................................................Di r(a' $ ..................................................................................................

Di RS $ ..................................................................................................

II. PEMERIKSAAN PENUN*ANG

........................................................................................................................................

........................................................................................................................................

........................................................................................................................................

........................................................................................................................................

28


29/71

........................................................................................................................................

........................................................................................................................................

III. OBSERASI BAI

T1*" 3am

)ea/aan umum

-TT%, re2*e)s

0rimiti2.

berat

ba/an

BAK"

BABMinum

Lain&

*ain

PEMERIKSAAN PENUN*ANG

29


30/71

TERAPI

ANALISA ATA

Naa Pasien $ ............................................................. No re#ister $ ...........................

Dia#nosa Medis $ ............................................................ U(r $ ...........................

N

o

Tan##al!

a

Data Pen(nan# MASALAH PENEBAB

30


31/71



Dia#nosa Medis $ ............................................................ U(r $ ...........................

N

o

Tan##al

(n6(l

Dia#nosa +e"era;atan tan##al

teratasi

TTD

31


32/71

$ATATAN KEPERAWATAN


Dia#nosa Medis $ ............................................................ U(r $ ...........................

N

o

T1* no

/5

)e0

Ja

m

Tin/a)an

)e0era6atan

e7a*uasi 0roses TT

32


33/71

FORMAT $ATATAN PERKEMBANGAN

NAMA PASIEN $

UMUR $DC. MEDIS $

NO! '!

KEP

TANGGAL

"

JAM


33


34/71



ASUHAN KEPERAWATAN PAA Tn!"N(!"S/r! 888888!

ENGAN 8888888888888!!!I RUANG88888888888!!

RUMAH SAKIT 8888888888888888888

A. PENGKA*IAN

1. Bio/ata Ole'$ %%%%%%. T+!St$ %%.. NIM$ %%...

Naa $ %%%%%%%% T#l. MRS$%%%%%%. *a %..%%.%

U(r $ %%%%%%% .. T#l. Pen#+aian$ %%%%*a %%%%..*enis +elain $ %%%%%%%%

34

KEPERAWATAN

MEDIKAL BEDAH


35/71

A#aa $ %%%%%%%%

Alaat $ %%%%%%%%

Pendidi+an $ %%%%%%%%

Pe+eraan $ %%%%%%%%

Stat(s "er+a;inan $ %%%%%%%%

Dia#nosa edis $ %%%%%%%%

No. re#ister $ %%%%%%%%

Ke*uar1a (an1 mu/a+ /i+ubun1i9

Naa $ %%%%%%%%

Pe+eraan $ %%%%%%%%

Alaat $ %%%%%%%%

H(8(n#an Kel(ar#a $ %%%%%%%%

&. Ke*u+an Utama

a. Alasan as(+ r(a' sa+it $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

8. Kel('an saat "en#+aian $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

:! Ri6a(at 0en(a)it se)aran1 9

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%

;! Ri6a(at 0en(a)it masa *a*u 9

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

35


36/71

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Pen7a+it 'erediter dala +el(ar#a$ ada ! tida+ .*i+a ada= se8(t+an $ %%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Ri;a7at "en7a+it en(lar dala +el(ar#a$ ada ! tida+.

*i+a ada= se8(t+an $ %%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

=! Ri6a(at Psi)ososia* S0iritu* 9

a. Konse" diri

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%

8. Sosial%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

6. S"irit(al

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

>! Po*a A)ti2itas Se+ari&+ari -/i rum+ ? /i RS . 9

N

o

KEBIASAAN DIRUMAH DIRUMAH SAKIT

1. Ma+an

36


37/71

&. Min(

). Eliinasi BA.B

,. Eliinasi BAK

-. Istira'at!tid(r

. A+ti9itas!lati'an!

Ola'ra#a

Lain?lain

Pemeri)saan 2isi) 9

a. Keadaan U( Pasien$

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%

8. Tanda?tanda ital $

S('( t(8(' $ Res"irasi $

Den7(t nadi $ TB ! BB $

Tensi dara' $

37


38/71

Stat(s n(trisi $

6. Peeri+saan Ke"ala dan Le'er $

Ke"ala $ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

. %%%%%%%%%%%%%%%%%%%%%%%%%%%%..

Ra8(t $ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

Waa' $ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Mata $ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

Hid(n#$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Telin#a $ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

M(l(t F $ %%%%%%%%%%%%%%%%%%%%%%%%%...%%%.

arin# %%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%...

Le'er $ %%%%%%%%%%%%%%%%%%%%%%%%%%%%...

%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

%%%%%%%%%%%%%%%%%%%%%%%%%%%%..d. Peeri+saan Inte#(en!+(lit dan +(+( $

38


39/71

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

e. Peeri+saan Pa7(dara dan Ketia+

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

9. Peeri+saan T'ora+!Dada $

T'ora $ 0Ins"e+si2%%%%%%%%%%%%%%%%%%%%%%%...

%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%

Par( $ 0Ins"e+si=Per+(si=Pal"asi=A(s+(ltasi2%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%*ant(n# $ 0Ins"e+si= Per+(si= Pal"asi= A(s+(ltasi2%%%%%%%%%%%..

%%%%%%%%%%%%%%%%%%%%%%%%%%%..

%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%

#. Peeri+saan A8doen0Ins"e+si= Per+(si= Pal"asi= A(s+(ltasi2

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

'. Peeri+saan +elain dan daera' se+itarn7a 08ila di"erl(+an2

Genetalia $%%%%%%%%%%%%.............................................................%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

An(s $ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

39


40/71

i Peeri+saan M(s+(los+eletal 0E+streitas2 $%%%%%%%%%%%%%%%%%..

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%

. Peeri+saan Ne(rolo#i $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

+. Peeri+saan Stat(s ental $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

l. Peeri+saan Pen(nan# edis $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

. Penatala+sanan ! Tera"i $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Malan#= %%%%%%.

Pera;at

Ttd dan naa teran#

ANALISA ATA

NAMA PASIEN $

UMUR $

NO. REGISTER $

ATA PENUNJANG MASALAH KEMUNGKINAN PEN#EBAB

40


41/71


NAMA PASIEN $

UMUR $

NO. REGISTER $

NO TGL! IAGNOSA KEPERAWATAN TGL! T!T

41


42/71

! MUN$UL TERATASI

42


43/71

REN$ANA ASUHAN KEPERAWATAN

NAMA PASIEN$

UMUR $

NO. REG $NO! IAGNOSA

KEPERAWATAN

TUJUAN REN$ANA KEPERAWATAN RASION

43


44/71

$ATATAN KEPERAWATAN

NAMA PASIEN$

UMUR $

NO. REGISTER $

NO! TGL! NO '!

KEP

JAM TINDAKAN KEPERAWATAN E%ALUA

44


45/71

POLITEKNIK KESEHATAN RS Dr. SOEPRAOEN


ORMAT :ATATAN PRKEMBANGAN

NAMA PASIEN$

UMUR $

DC. MEDIS $

NO! '!

KEP

TANGGAL"

JAM


S $

O $

A $

P $

I $

E $

R $

45


46/71

FORMAT ASKEP GERONTIK

Kasus 9

Tem0at 9

Tan11a* Pen1)a3ian 9Wa)tu 9

I! PENGKAJIAN

A. ATA BIOGRAFI

Naa $

*enis +elain $

Golon#an dara' $

Te"at F tan##al la'ir $

Pendidi+an tera+'ir $A#aa $

Stat(s "er+a;inan $

Tin##i 8adan!8erat 8adan $

Pena"ilan $

Alaat $

Oran# 7an# (da' di'(8(n#i $

Alaat F tele"on $

B! Ri6a(at Ke*uar1a

Geno#ra $

$! Ri6a(at Pe)er3aan

Pe+eraan saat ini $

Alaat "e+eraan $

Bera"a ara+ dari r(a' $ ?

Alat trans"ortasi $ ?

Pe+eraan se8el(n7a $

Bera"a ara+ dari r(a' $Alat tran"oertasi $

S(8er?s(8er "enda"atan dan +e6(+("an ter'ada" +e8(t('an $ .

! Ri6a(at Lin1)un1an Hi/u0

T7"e te"at tin##al $

+aar $

Kondisi te"at tin##al $

*(la' oran# 7an# tin##al dala sat( r(a' $

Deraat "riasi $Tetan##a terde+at $

Alaat dan tele"on $

46


47/71

E! Ri6a(at Re)reasi

Ho88i!inat $

Kean##otaan dala or#anisasi $

Li8(ran!"eralanan $

F! Sistem Pen/u)un1

Pera;at!8idan!do+ter!9isiot'era"i $ ?

*ara+ dari r(a' $?

R(a' Sa+it $? ara+n7a +

Klini+ $? ara+n7a +

Pela7anan +ee'atan di r(a' $

Ma+anan 7an# di'antar+an $?

Pera;atan se'ari?'ari 7an# dila+(+an +el(ar#a $ .

Lain?lain $

G! is)ri0si )e)+ususan

Ke8iasaan rit(al $

an# lainn7a $

H! Status Kese+atan

Pen7a+it!asala' +ese'atan saat ini

Stat(s +ese'atan (( selaa lia ta'(n 7an# lal( $

Kel('an (taa $ .

Pro7o)ati7e"Pa*iati7e=

@ua*it("@uantit(

Re1ion,

Se7erit( s4a*e

Time

Mero)o)"minum )o0i"a*4o+o*

Su)a ma)an asin, ma)an manis, tin11i 0urin, atau ma)anan ber*ema)

Obat&obatan

NO NAMA OBAT DOSIS KET

1

47


48/71

Stat(s i(nisasi $ ?

Aler#i $ ?

1 O8at?o8atan $ ?

& Ma+anan $ ?) a+tor lin#+(n#an $ ?

Pen7a+it 7an# diderita $

Alat Bant(

I! A)ti7itas Hi/u0 Se+ari&+ari

In/e)s Kat= S+ore A 0

O)si1enasi= $airan /an e)*e)tro*it,

Nutrisi,

E*iminasi=

A)ti7itas,

Istira+at /an ti/ur= .

Persona* +(1iene,

Se)sua*,

Re)reasi,

Psi)o*o1is,

Perse"si +lien=

Konse" diri=

Eosi=

Ada"tasi

48


49/71

Me+anise "erta'anan diri

J! Tin3auan Sistem

Keadaan (( $Tin#+at +esadaran $

G:S $

Tanda?tanda ital $

1. Ke"ala $

&. Mata?Telin#a?Hid(n# $

a2 Pen#li'atan=

82 Penden#aran=

62 Hid(n#= "e8a(

). Le'er

,. Dada dan "(n##(n# $

a2 Par(?"ar(=

82 *ant(n#= tensi 1,5!45 H#= Nadi 5 Kali!enit +(ar= re#(ler= s('( a+ral

'an#at.

-. A8doen dan "in##an# $

a2 Siste Pen6ernaan= Stat(s

82 Siste Geneta(rinari(e=

. E+treitas atas dan 8a;a'=

/. Siste i(ne $

3. Genetalia $

4. Re"rod(+si $

15. Persara9an $

11. Pen#e6a"an $

K! PENILAIAN STATUS MENTAL

1. S'ort Porte8le Mental Stat(s (estionaire 0 SPMS 2

&. Mini ? Mental State Ea 0 MMSE 2

). Inentaris De"resi Be6+

,. APGAR Kel(ar#a

49


50/71

L! ata Penun3an1

1. La8oratori $

&. Radiolo#i $

). EKG $

,. USG $

-. :T? S6an $

. O8at?o8atan $

50


51/71

51


52/71

52


53/71

53


54/71

II. ANALISA DATA

N

O

ATA -SIGN"S#MPTOM. INTERPRETA

SI

-ETIOLOGI.

MASALAH

-PROBLEM.

54


55/71

III. PRIORITAS MASALAH

. PROSES KEPERAWATAN

NO

'!

KEPE&

RAWAT

AN

REN$ANA KEPERAWATANIMPLEMENT

ASI

E%ALUA

SI

TUJUAN"KRITERIA INTER%ENSI RASIONAL

: ; < = >

1. 1. .

55


56/71

56


57/71

POLITEKNIK KESEHATAN RS dr SOEPRAOEN


PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

Naa a'asis;a $%%%%%%%%%%%%%%%%%Ni $%%%%%%%%%%%%%%%%%

R(an# ra;at $%%%%. Tan##al!MRS $%%%%%

I IDENTITAS KLIEN

Naa $%%%%%%%.0L!P2 U(r $%%.T'n Noor :M $%%%%..

II ALASAN MASUK

III. AKTOR PRESDISPOSISI

1. Perna' en#alai #an#(an i;a di asa lal(

&. Pen#o8at se8el( n7a $

). Tra(a$

*elas+an $

Masala' +e"era;atan $

,. An##ota 7an# #an##(an i;a $%%%%%%%%%%%%%%%%%

Bila ada

H(8(n#an +el(ar#a

Geala

Ri;a7at "en#o8atan


-. Pen#alaan asalal( 7an# tida+ en7enan#+an $

I%! PEMERIKSAAN FISIK

1. Tanda ital $ TD $%%%.. N $%%% S $%%% P $%%%%..

&. Berat 8adan $%%%%%. Tin##i 8adan $%%%%.

). Kel('an 9isi+ $%%%%%%%%%%%%%%%%%%%%%%%%%%.

*elas+an $

57


58/71


%! PSIKOSOSIAL

1. Geno#ra $

*elas+an $


&. Konse" diri

a. Identitas diri $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

8. Peran $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

6. Ideal diri

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%.. d Har#a diri

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.


). H(8(n#an sosial

a. Oran# 7an# 8erarti $

%%%%%%%%%%%%%%%

8. Peran serta dala +e#iatan +elo"o+ $ %.........................................................................................................

6. Ha8atan dala 8er'(8(n#an den#an oran# lain $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%


,. S"irit(al

a. Nilai dan +e7a+inan $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

8. Ke#iatan i8ada' $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

58


59/71


%I! STATUS MENTAL

1. Pena"ilan $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%Masala' +e"era;atan $

& Pe8i6araan $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%


&. A+ti9itas otori+ $

%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%..

%%%%%%%%%%%%


). A9e+ dan eosi $

a. A9e+

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%


8. Ala "erasaan 0eosi2 $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%.


,. Intera+si selaa ;a;an6ara $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%


-. Perse"si sensori+ $

A"a+a' ada #an##(an $%%%%%%%%%%%%%%%%%%%%%

Hal(sinasi $%%%%%%%%%%%%%%%%%%%%%%%%%.

59


60/71

Ill(si $%%%%%%%%%%%%%%%%%%%%%%%%%%%.


. Proses "i+ir $

a. "roses "i+ir 0Ar(s dala 8ent(+ "i+ir2 $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%


8. Isi "i+ir $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%.


. Tin#+at +esadaran

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Ada+a' #an##(an orientasi $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%.


/. Meori $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%


3. Tin#+at +onsentrasi dan 8er'it(n# $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%.


4. Kea"(an "enilaian $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.


15. Da7a tili+ dari $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

60


61/71


%II! KEBUTUHAN PEREN$ANAN PULANG

1. Kea"(an +lien een('i +e8(t('an $

Kea"(an een('i +e8(t('an A TIDAK

1. a+anan

&..+eaanan

). +ese'atan

,. "a+aian

-. trans"ortasi

. te"at tin##al

/. +e(an#an

lain?lain $%%%%%.


%%%%%%%%%%..

%%%%%%%%%%%

&. Ke#iatan 'id(" se'ari?'ari 0ADL2 $

a. Pera;at diri $

Ke#iatan 'id(" se'ari?'ari 0 ADL 2 Bant(an total Bant(an inial

Mandi

Ke8ersi'an

Ma+anBAK!BAB

Ganti"a+aian

Masala' +e"era;atn $

%%%%%%%%%%..

%%%%%%%%%%%

8.N(trisi $

A"a anda "(as den#an "ola a+an anda

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

A"a+a' anda a+an eisa'+an diri

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.. re+(ensi a+an $%%%%%%%%%%%%%%%%%%%%%%%%

Berat 8adan $%%%%%%%%%%%%%%%%%%%%%%%%.


6. Tid(r

Masala' tid(r $

%%%%%%%%%%..

Ke8iasaan tid(r $

%%%%%%%%%%%

A"a ada 7an# e"er(da' (nt(+ tid(r $

61


62/71


%%%%%%%%%%%%.

). Kea"(an +lien dala 'al?'al 8eri+(t ini $

Men#antisi"asi +e'id("an se'ari?'ari $

Me8(at +e"(t(san 8erdasar+an +ein#inan sendiri$

Mela+(+an "eeri+saan 9isi+ $Masala' +e"era;atan $

,.. Klien eili+i s7ste "end(+(n#.

Kel(ar#a $

Tera"is $

Lain?lain $


%%%%%%%%%%%%

-. +lien eni+ati saat 8e+era = +e#iatan "rod(+ti9 ata( 'o8i

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..


%III! MEKANISME KOPING

Ada"ti9 Malada"ti9

1

&

)

,-

1

&

)

,-


%%%%%%%%%%%%%

I'! MASALAH PSIKOSOSIAL AN LINGKUNGAN

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%


%%%%%%%%%%..

'! PENGETAHUAN KURANG TENTANG

A"a+a' +lien e"(n7ai asala' 7an# 8er+aitan den#an "en#eta'(an 7an#

+(ran#

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.


%%%%%%%%%%%.

%%%%%%%%%%%

'I! ASPEK MEIS

Dia#nosa edi+ $

62


63/71

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

Tera"i +e"era;atan $

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%


'II! AFTAR MASALAH KEPERAWATAN

1. %%%%%%%%%%%%%%%%%

&. ....................................................................

). %%%%%%%%%%%%%%%%.

,. %%%%%%%%%%%%%%%%

-. %%%%%%%%%%%%%%%%

. %%%%%%%%%%%%%%%%

'III! AFTAR IAGNOSA KEPERAWATAN

1. %%%%%%%%%%%%%%%%%%%%%%%.

&. %%%%%%%%%%%%%%%%%%%%%%%.

). %%%%%%%%%%%%%%%%%%%%%%%.

,. %%%%%%%%%%%%%%%%%%%%%%%..

-. %%%%%%%%%%%%%%%%%%%%%%%%

. %%%%%%%%%%%%%%%%%%%%%%%%.

63


64/71

REN$ANA KEPERAWATAN

NAMA PASIEN $ %%%%%%%%%% NO :M $ %%%%%

*ENIS KELAMIN $ %%%%%%%%%.. DIAGNOSA $ %%%%%RUANGAN $ %%%%%%%%%. UNIT KESWA $ %%%%%

N

o

Tan##al

!a

Dia#nosa

+e"era;atan

T((an dan tinda+an +e"era;atan T

T

D

64


65/71

POLITEKNIK KESEHATAN RS dr SOEPRAOEN

PROGRAM STDI KEPERAWATAN

FORMAT PENGKAJIAN KEPERAWATAN KOMUNITAS

I. DATA DEMOGRAFI

A. Struktur Keluarga

N!"! KK #

"$r #

%&'() K&*!"(' #

A+!"! #

P&'d(d(,!' #

P&,&r!!' #

S$,$. B!'+)! #

B. Daftar Anggota Keluarga

N

/

N!"!. "$r %&'()

K&*!"(

'

H$

K*+

A+!

"!

P&'d P&, K&!d ()(, K&

L P S&!

S!,(

. Data Ekono!"

! P&'+!)(*!' r!!-r!! &r$*!' # d!*!" 1 KK

1 R 10000002 R 1000000-3000000 3 R

3000000

A!,! ,&*$!r+! "&'!$'+ #

1 :! 2 T(d!,

II. #INGKUNGAN FISIK

A. Peru!a$an

! S!$) K&&"(*(,!' #

1 S&;! 2 N$"!'+ 3 M(*(, )&'d(r(

%&'() R$"!

1 P&r"!'&' 2 S&"( &r"!'&' 3 T(d!, &r"!'&'


66/71

1 T!'! 2 P!!' 3 T&+&* 4 S&"&'

d Ad! &'d&*! d( )&(! ,!"!r

1 :! 2 T(d!,

& K&&r)(!' r$"!

1 B!(, 2 =$,$ 3 K$r!'+

> Ad! &'d&*! d( )&(! r$"!

1 :! 2 T(d!,

+ %(,! :!? !!,! d($,! )&(! !r(

1 :! 2 T(d!,

@&'(*!)( r$"!

1 10 d!r( *$!) *!'!( 2 10 d!r( *$!) *!'!(

( P&'

1 T&r!'+ 2 R&"!'+-r&"!'+ 3 G&*!

%!r!, r$"! d&'+!' &!'++!

1 B&r)!$ 2 D&,! 3 T&r()!, H!*!"!' d( )&,(!r r$"!

1 Ad! 2 T(d!,

* %(,! !d! ? */,!)('!

1 D( d&!' 2 D()!"('+ 3 D( &*!,!'+

" P&"!'>!!!' &,!r!'+!'

1 K&$' 2 K/*!" 3 K!'d!'+

' B&r!! *$!) r$"!CCC"2

B. Su!%er A"r

! S$"&r !(r $'$, "!)!, d!' "('$"

1 PAM 2 S$"$r 3 A(r "('&r!*

%(,! d( PAM? )$"$r

1 D("!)!, 2 T(d!,

K/'d()( &"! &'!"$'+!' !(r

1 T&r$,! 2 T&r$$

+ K/'d()( !(r d!*!" &'!"$'+!'

1 B&r;!r'! 2 B&r!$ 3 B&r!)!

4 T(d!, &r!)!. &r;!r'!

Ad! &'(, d!*!" &'!"$'+!' !(r

1 :! 2 T(d!,

. Pe!%uangan Sa!&a$! D("!'! ,&*$!r+! "&"$!'+ )!"!

1 S$'+!( 2 D(("$' 3 D(!,!r

66


67/71

4 S&"!r!'+ &"! 5 L!('-*!('? )&$,!'CCC

P&'!"$'+!' )!"! )&"&'!r!

1 Ad! 2 T(d!, !d!. &r)&r!,!'

! K&&"(*(,!' ,!'d!'+ &'!,

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Politeknik Kesehatan Rs Dr.soepraoen malang

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