Standar Asuhan Keperawatan Medikal Bedah
7
STANDAR ASUHAN KEPERAWATAN MEDIKAL BEDAH STIKES HANGTUAH SURABAYA ASUHAN KEPERAWATAN pada KLIEN TB PARU A. Pengertian TB Paru merupakan penyakit infeksi yang disebabkan oleh Mycobacterium Tubercullosa. B. Asuhan Keperawatan PENGKAJIAN 1. Identitas Nama : Umur : Jenis Kelamin : Status : Agama : Suku/Bangsa : Bahasa : Pendidikan : Pekerjaan : Alamat : Penanggung Jawab : Askes/ Astek/ Jamsostek/ Sendiri 2. Riwayat Sakit dan Kesehatan a. Keluhan Utama : .............................................. ...................................................... .. ...................................................... ...................................................... ...................... b. Riwayat Penyakit Sekarang :............................................ ......................................... ...................................................... ...................................................... ...................................................... ...................................................... ...................................................... ......................................................
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Transcript of Standar Asuhan Keperawatan Medikal Bedah
STANDAR ASUHAN KEPERAWATAN MEDIKAL BEDAH
STIKES HANGTUAH SURABAYA
ASUHAN KEPERAWATAN pada KLIEN TB PARU
A. Pengertian TB Paru merupakan penyakit infeksi yang disebabkan oleh Mycobacterium Tubercullosa.
B. Asuhan KeperawatanPENGKAJIAN1. Identitas
Nama :Umur :Jenis Kelamin :Status :Agama :Suku/Bangsa :Bahasa :Pendidikan :Pekerjaan :Alamat :Penanggung Jawab : Askes/ Astek/ Jamsostek/ Sendiri
2. Riwayat Sakit dan Kesehatana. Keluhan Utama : ......................................................................................................
..................................................................................................................................b. Riwayat Penyakit Sekarang :.....................................................................................
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..................................................................................................................................c. Riwayat Penyakit Dahulu :........................................................................................
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..................................................................................................................................d. Riwayat Kesehatan Keluarga :..................................................................................
.................................................................................................................................Genogram :
e. Riwayat alergi : ..........................................................................................................................................................................................................................................
3. Review Of Systema. Tanda-tanda Vital
Suhu : ................°C Nadi :.................x/menit Tekanan darah :.................mmHg Respiratory rate :.................x/menit TB :.................cm BB :.................kg
b. Sistem Pernapasan (Breath)Bentuk dada : Pergerakan :Otot bantu napas : jika ada, jelaskan:
Irama napas : kelainan :Suara napas :Sesak napas : Batuk : ( )ya ( )tidakSputum : warna :Kemampuan aktivitas :
c. Sistem Kardiovaskuler (Blood)
d. Sistem Persarafan (Brain)........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
e. Sistem Perkemihan (Bladder)........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
f. Sistem Pencernaan (Bowel)Inspeksi :..............................................................................................................................................................................................................................................Palpasi :...............................................................................................................................................................................................................................................Perkusi :...............................................................................................................................................................................................................................................Auskultasi :...............................................................................................................................................................................................................................................
g. Sistem Muskuloskeletal (Bone)......................................................................................................................................................................................................................................................................................................................................................................................................
4. Pemeriksaan Penunjanga. Laboratorium
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b. Photo......................................................................................................................................................................................................................................................................................................................................................................................................
c. Lain - lain......................................................................................................................................................................................................................................................................................................................................................................................................
ANALISA DATANama Klien :Umur :
No DATA (Simptom) PENYEBAB (Etiologi) MASALAH (Problem)
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