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TGL/PARAF TGL/PARAF CI NILAI RATA-

NILAI NILAI
CI KLINIK AKADEMIK RATA

1. Pengkajian
a. Identitas Klien
Nama : ..................................................................................
Umur : ..................................................................................
Jenis Kelamin : ..................................................................................
Agama : ..................................................................................
Pendidikan : ..................................................................................
Pekerjaan : ..................................................................................
Suku/ Bangsa : ..................................................................................
Tanggal Masuk RS : ..................................................................................
Tanggal Pengkajian : ..................................................................................
No. Medrec : ..................................................................................
Diagnosa Medis : ..................................................................................
Alamat : ..................................................................................
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b. Identitas penangung jawab

Nama : ..................................................................................
Umur : ..................................................................................
Jenis kelamin : ..................................................................................
Pendidikan : ..................................................................................
Pekerjaan : ..................................................................................
Hubungan dengan klien : ..................................................................................
Alamat : ..................................................................................
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2. Riwayat Kesehatan
a. Keluhan utama
1) Keluhan Utama Saat Masuk RS :
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2) Keluhan Utama Saat Pengkajian:
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b. Riwayat Kesehatan Sekarang :
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c. Riwayat Kesehatan Dahulu
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3. Pola Aktivitas Sehari-hari
No Jenis aktivitas Di Rumah Di Rumah Sakit
1. Nutrisi
A. Makan
 Jenis ....................................................... .......................................................
 Frekuen ....................................................... .......................................................
si ....................................................... .......................................................
 Porsi ....................................................... .......................................................
 Keluhan
B. Minum ....................................................... .......................................................
 Jenis ....................................................... .......................................................
 Jumlah ....................................................... .......................................................
(cc/ hari)
 Keluhan
2. Eliminasi
A. BAK
 Frekuen ....................................................... .......................................................
si ....................................................... .......................................................
 Warna ....................................................... .......................................................
 Keluhan
B. BAB ....................................................... .......................................................
 Frekuen ....................................................... .......................................................
si ....................................................... .......................................................
 Warna ....................................................... .......................................................
 Konsiste
nsi
 Keluhan
3. Istirahat Tidur
A. Siang
 Jam ....................................................... .......................................................
B. Malam
 Jam ....................................................... .......................................................
4. Personal Hygiene
A. Mandi ....................................................... .......................................................
B. Keramas ....................................................... .......................................................
C. Gosok Gigi ....................................................... .......................................................
 5. Aktivitas ...................................................... .......................................................
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4. Pengkajian Fisik
a. Kesadaran Umum :
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b. GCS : E: ....................... M:...........................
V:...........................
c. Orientasi :
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d. Tanda-tanda Vital : TD : ............................ N :
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RR : ............................ S : ..................................
e. Pemeriksaan Fisik
1) Sistem Pernapasan
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2) Sistem Kardiovaskuler
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3) Sistem Pencernaan
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4) Sistem Endokrin
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5) Sistem Perkemihan
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6) Sistem Integumen
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7) Sistem Muskuloskeletal
Ekstrimitas atas
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Ekstrimitas bawah
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8) Sistem Persarafan
Tes Fungsi Kranial
a) Nervus Olfaktorius
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b) Nervus Optikus
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c) Nervus okulomotorius, Trochlearis, Abdusen

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d) Nervus Trigeminus
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e) Nervus Fasialis
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f) Nervus Akustikus
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g) Nervus Glosofaringeus dan Vagus

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h) Nervus assesorius
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i) Nervus Hipoglosus
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5. Data Psikologis
a. Status Emosi
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b. Pola Koping
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c. Pola Komunikasi
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d. Konsep Diri
1) Gambaran Diri
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2) Identitas Diri
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3) Peran
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4) Ideal Diri
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5) Harga Diri
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e. Data Sosial
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 f. Data Spiritual

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6. Data Penunjang
Pemeriksaan Hasil Nilai Normal
7. Terapi Medis

8. Analisa Data

No Data Kemungkinan Penyebab & Dampak Masalah

9. Diagnosa Keperawatan
10. Intervensi Keperawatan
11. Implementasi Dan Evaluasi
No Tgl/ Implementasi Evaluasi Paraf
Dx Jam
12. CATATAN PERKEMBANGAN
Tgl/Jam DP Catatan perkembangan Paraf
 ASUHAN KEPERAWATAN
PADA____DENGAN GANGGUAN SISTEM SYARAF___________
DI RUANG SYARAF GEDUNG KEMUNING LT 5
RSUP. dr. HASAN SADIKIN BANDUNG
 Oleh :
Hilda Nur Fitri
NPM: 214112045

PROGRAM STUDI PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN JENDERAL
ACHMAD YANI
CIMAHI
2012