ASUHAN KEPERAWATAN MEDIKAL BEDAH Nama Mahasiswa:__________________________ NIM:_______________ A. PENGKAJIAN Tanggal : ________________________________________________________ Jam : ________________________________________________________ 1.Identitas klien Nama : ________________________________________________________ Umur : ________________________________________________________ Jenis kelamin : Perempuan/ Laki-laki Pendidikan: ________________________________________________________ Pekerjaan : ________________________________________________________ Alamat : ________________________________________________________
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
ASUHAN KEPERAWATAN MEDIKAL BEDAHNama Mahasiswa:__________________________NIM:_______________
A. PENGKAJIANTanggal: ________________________________________________________Jam: ________________________________________________________1. Identitas klienNama: ________________________________________________________Umur: ________________________________________________________Jenis kelamin: Perempuan/ Laki-lakiPendidikan: ________________________________________________________Pekerjaan: ________________________________________________________Alamat: ________________________________________________________Tgl. masuk RS: ______________________________________________________No RM: ________________________________________________________Dx. Medis: _______________________________________________________
2. Riwayat kesehatanKeluhan utama:__________________________________________________________________________________________________________________________________________
Riwayat penyakit sekarang:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Riwayat penyakit dahulu:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Riwayat penyakit keluarga:_______________________________________________________________________________________________________________________________________________________________________________________________________________
3. Pola Kesehatan Fungsional :a. Pola persepsi kesehatan-manajemen kesehatan_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________b. Pola nutrisi-metabolik_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
c. Pola eliminasi_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
d. Pola aktivitas latihan_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Kemampuan perawatan diri01234
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi / ROM
Keterangan: 0= mandiri; 1= dengan alat bantu; 2= dibantu orang lain; 3= dibantu orang lain dan alat; 4= tergantung total
e. Pola istirahat tidur_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
f. Pola persepsi kognitif_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________g. Pola persepsi diri-konsep diri_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
h. Pola peran hubungan_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
i. Pola seksualitas reproduksi_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
j. Pola koping-toleransi stres_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
k. Pola nilai kepercayaan_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. Pemeriksaan Fisika. Keadaan umum: ______________________________________________________________________________________________________________________________________________________________________________________________b. Tanda Vital:________________________________________________________c. TB/BB:____________________________________________________________d. KepalaBentuk: ________________________________________________________Rambut: ________________________________________________________Wajah: ________________________________________________________Mata: ________________________________________________________Hidung: ________________________________________________________Mulut: ________________________________________________________Telinga: ________________________________________________________Leher: ________________________________________________________e. Thorak (Paru dan Jantung)Inspeksi1) Bentuk dada:_____________________________________________________2) Denyut jantung: __________________________________________________3) Ekspansi:________________________________________________________4) Kecepatan pernapasan:_____________________________________________5) Retraksi interkosta: _______________________________________________6) Suara batuk: _____________________________________________________Palpasi1) Nyeri dada: ______________________________________________________2) Kesimetrisan ekspansi: ____________________________________________3) Taktil fremitus: __________________________________________________4) Denyut apeks (letak dan kekuatan): ___________________________________
Perkusi__________________________________________________________________Auskultasi1) Suara paru: ______________________________________________________2) Suara jantung: ___________________________________________________f. AbdomenInspeksi______________________________________________________________________________________________________________________________________________________________________________________________________Auskultasi__________________________________________________________________Palpasi______________________________________________________________________________________________________________________________________________________________________________________________________Perkusi______________________________________________________________________________________________________________________________________________________________________________________________________g. Ekstremitas______________________________________________________________________________________________________________________________________________________________________________________________________h. Kulit____________________________________________________________________________________________________________________________________________________________________________________________________________i. Genetalia________________________________________________________________________________________________________________________________________5. Pemeriksaan Penunjanga. Pemeriksaan LaboratoriumNoParameterHasilSatuanNilai Normal
b.
6. TerapiNama ObatSediaanDosisJalur MasukFungsi
B. ANALISA DATADATAETIOLOGIMASALAH
C. PRIORITAS DIAGNOSA KEPERAWATAN___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________D. E. RENCANA KEPERAWATANNo.DxTujuanIntervensiRasional
No.DxTujuanIntervensiRasional
F. IMPLEMENTASITgl/JamNo. DxImplementasiResponParaf
Tgl/JamNo. DxImplementasiResponParaf
G. EVALUASITgl/JamNo. DxEvaluasi (SOAP)Paraf
Tgl/JamNo. DxEvaluasi (SOAP)Paraf
Related Documents
