Professional Documents
Culture Documents
DENGAN
DI RUANG.
TANGGAL PENGKAJIAN :
A. PENGKAJIAN
1. IDENTITAS
a. Identitas klien
Nama
: ............................................................................................................
Umur
; ............................................................................................................
Jenis Kelamin
: ............................................................................................................
Pekerjaan
: ............................................................................................................
Alamat
: ............................................................................................................
............................................................................................................
Pendidikan
: ............................................................................................................
Agama
: ............................................................................................................
Suku bangsa
: ............................................................................................................
Tanggal Masuk RS
: ............................................................................................................
No. CM
: ............................................................................................................
Dx Medis
: ............................................................................................................
Tanggal Pengkajian
: ............................................................................................................
Umur
: ............................................................................................................
Jenis Kelamin
: ............................................................................................................
Pekerjaan
: ............................................................................................................
Alamat
: ............................................................................................................
............................................................................................................
Pendidikan
: ............................................................................................................
Agama
: ............................................................................................................
2. RIWAYAT KESEHATAN
a. Keluhan Utama
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b. Riwayat Kesehatan Sekarang
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c. Riwayat Kesehatan Dahulu
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d. Riwayat Kesehatan Keluarga
1. Riwayat penyakit menurun/ menular
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2. Genogram
e. Riwayat Alergi
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3. RIWAYAT PERSALINAN DAN KELAHIRAN YANG LALU
NO. Tahun
Tipe
persalinan
Penolong
Jenis
BB
Keadaan
Masalah post
kelamin
lahir
kesehatan
partum
berapa lama :
Siklus
hari
b. Riwayat KB
Jenis
Lama menggunakan
Keluhan
c. Riwayat ginekologi
: (ya/ tidak)
b. Status obstetric
c. HPHT
: .. taksiran partus :
..
d. Mengikuti kelas prenatal
: ya/ tidak
e. Kunjungan ANCke
:
:
Jenis
sehat
sakit
Sebelumt dirawa
Selama dirawat
Pola makan
Jenis
Porsi
Frekuensi
Diet khusus
Makanan disukai
Kesulitan menelan
Gigi palsu
Napsu makan
Pola minum
Jenis
Frekuensi
Jumlah
Pantangan
Minuman yang disukai
c. Pola eliminasi
No
1
Jenis
BAB
Frekuensi
Warna
Masalah
2
BAK
Frekuensi
Jumlah
Warna
Masalah
d. Pola aktivitas sehari hari
Sehat
No
Jenis
1
2
3
4
5
6
7
8
9
10
Mandi
Berpakaian
Eliminasi
Mobilisasi di tempat tidur
Berpindah
Berjalan
Berbelanja
Memasak
Naik tangga
Pemeliharaan rumah
Selama dirawat
3
Ket:
0 : Mandiri
1 : Alat bantu
2 : Dibantu orang lain
3 : dibantu orang lain alat
4 : tergantung / tidak mampu
: .........................................................................................................
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Bahasa
: .........................................................................................................
.........................................................................................................
Kemampuan membaca
: .........................................................................................................
.........................................................................................................
Jenis
Sebelumt dirawat
Selama dirawat
Tidur siang
Lama tidur
Keluhan
Tidur malam
Lama tidur
Keluhan
: .........................................................................................................
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Harga diri
: .........................................................................................................
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Identitas diri
: .........................................................................................................
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Peran diri
: .........................................................................................................
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R:
GCS:
N:
E:
S:
V:
BB/ TB :
M:
3. KEPALA
a. Inspeksi dan palpasi kepala
1) Bentuk dan kesimetrisan :
2) Lesi/ luka, bersih
:
b. Inspeksi dan palpasi rambut
1) Warna
:
2) Tekstur
:
3) Penyebaran :
4) Kebersihan :
c. Pemeriksaan muka :
1) Inspeksi
( warna kulit dan kesimetrrisan)
STIKes Karsa Husada Garut
:
:
:
:
b. Gigi
Jumlah
Warna
:
:
STIKes Karsa Husada Garut
c.
d.
e.
f.
g.
h.
Kondisi
Lidah
Warna
Tekstur
Mukosa
Kondisi
Pergerakan
Fungsi lidah
Reflek menelan
Keluhan
Gusi
Warna
Keluhan
Inspeksi palatum dan uvula
Inspeksi tonsil
Inspeksi faringeal
Tes rasa
:
:
:
:
:
:
:
:
:
:
:
:
:
:
: mengecap rasa
5. Pemeriksaan leher
a. Leher : hiperekstensi/ tidak, ada masa/ tidak
b. Pembesaran kelenjar tyroid : ada/ tidak
c. JVP
:
6. Pemeriksaan dada
a. Thoraks
i. Inspeksi
1. Pernafasan : dada/ perut frekuensi :
2. Kontur dada: simetris/ tidak
3. Klavikula
:
sternum :
4. Spina :
scapula:
ii. Palpasi
1. Nyeri atau tidak
2. Tulang vertebrae spina : kaku/ tidak
3. Lengkung iga : lentur/ tidak
4. Gerak dada: simetris/ tidak
5. Taktil fremitus : simetris/tidak
6. Fibrasi : lemah/ tidak
iii. Perkusi thoraks
1. Thoraks posterior
: resonan, hipersonan, tymfani
iv. Auskultasi
1. Trachea, bronchus : (vesikuler, bronchial, tracheal)
2. Bunyi napas tambahan : (rales ronchi, wheezing, friksi pleura)
b. Dada
i. Jantung
Bunyi
:
Irama
:
STIKes Karsa Husada Garut
Frekuensi
ii. Payudara
Inspeksi
Palpasi
:
:
:
7. Abdomen
a. Inspeksi
b. Kesimetrisan :
c. Warna kulit :
d. Lesi:
e. Striae :
f. Linea :
g. Leopold I:
h. Leopold II:
i. Leopold III:
j. Leopold IV:
k. TFU:
l. Bising usus :
m. Hepar : nyeri/ tidak
n. Limpa
o. Ginjal kanan kiri : nyeri/ tidak
8. Genitalia
a. Hematoma : ada/ tidak ada
b. Bengkak
: ada/ tidak ada
c. Perdarahan : ada/ tidak ada
d. Varises
: ada/ tidak ada
9. Anus
a. Hemoroid : ada/ tidak ada
10. Ekstremitas
i. Ekstremitas Atas
Bentuk
:
Pergerakan
:
Refleks
:
Keadaan
:
Edema
:
Turgor
:
Kekuatan otot
j. Ekstremitas Bawah
k. Bentuk
l. Pergerakan
:
:
STIKes Karsa Husada Garut
m.
n.
o.
p.
q.
r.
Refleks
Keadaan
Edema
Turgor
:
:
:
:
Kekuatan otot
8. PEMERIKSAAN PENUNJANG
No Lab
Nama
Umur
Alamat
No
1
:
:
:
:
Nama Test
Hematologi
Darah Rutin
Hemoglobin
Hematokrit
Leukosit
Trombosit
Eritrosit
Laju Endap Darah
Morfologi darah tepi
Eritrosit
Leukosit
Trombosit
Kesan
Kimia Klinik
AST/SGOT
ALT/SGPT
Ureum
Kreatinin
Protein total
Albumin
Glukosa sewaktu
Glukosa puasa
Kolesterol total
Natrium
Kalium
Imunologi
HbsAg
Anti Dengue Igg
Anti Dengue IgM
No Cm
Ruangan
Jenis Kelamin
Tanggal
Hasil
:
:
:
:
Unit
Nilai Normal
g/dL
%
/mm3
/mm3
juta/mm3
/mm3
13.0-18.0
40-52
3.800-10.000
150.000-440.000
3.5-6.5
u/L
u/L
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
Mg/dL
s/d 37
40
15-50
15-50
0.7-1.2
6.6-8.7
3.5-5
<140
70-110
135-145
3.6-5.5
9.
Widal
Lainnya
TERAPI :
B. ANALISA DATA
No
Data
Etiologi
Problem
No
Data
Etiologi
Problem
C. DIAGNOSA KEPERAWATAN
1.
2.
3.
4.
5.
Rencana keperawatan
Tujuan dan Kriteria Hasil
Intervensi
D. IMPLEMENTASI
Tgl/Jam
No DP
Implementasi
Evaluasi
Paraf
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F. EVALUASI
Tgl/Jam
No DP
Evaluasi
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Paraf
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G. CATATAN PERKEMBANGAN
No
Tanggal
Dp
Catatan Perkembangan
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Pelaksana
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