Format Askep

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

NAMA MAHASISWA :..................................................... NIM

:.....................................................

RUANGAN

:.....................................................

RSUD :.........................................................

TGL PENGKAJIAN

:.....................................................

JAM :........................ WIB

I.

II.

IDENTITAS KLIEN Nama

:.................................................................................

No. RM :..................................

Umur

:.................................................................................

Jenis Kelamin

:.................................................................................

Agama

:.................................................................................

Alamat

:.................................................................................

Pendidikan

:.................................................................................

Suku Bangsa

:.................................................................................

Penanggung

:  ASKES  JAMSOSTEK  JAMKESMAS  SENDIRI ……………………..

RIWAYAT KEPERAWATAN A. RIWAYAT PENYAKIT SEKARANG (RPS) 1. Keluhan utama :............................................................................................................................................................ 2. Alasan masuk RS :............................................................................................................................................................ ............................................................................................................................................................. ............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 3. Riwayat Perawatan :............................................................................................................................. Di RS saat ini

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

Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

B. RIWAYAT PENYAKIT DAHULU 1............................................................................................................................................................R iwayat penyakit dahulu ............................................................................................................................................................... .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. 2............................................................................................................................................................R iwayat Alergi .............................................................................................................................................................. :............................................................................................................................................................. 3.

Kebiasaan

:  Merokok

 Minum Miras  Penggunaan Psikotropika  Fast food

 ...........................................................................................................

C. RIWAYAT PENYAKIT KELUARGA 1............................................................................................................................................................R iwayat penyakit :............................................................................................................................................................ yg sama dgn Klien ............................................................................................................................... 2............................................................................................................................................................R iwayat Penyakit keluarga :............................................................................................................................................................ ............................................................................................................................................................. ............................................................................................................................................................. 3............................................................................................................................................................P enyakit keturunan :............................................................................................................................... .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. .............................................................................................................................................................. D. GENOGRAM KETERANGAN Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

 : laki-laki O

: wanita

 : meninggal : menikah : keturunan : serumah  : klien III. OBSERVASI DAN PEMERIKSAAN FISIK A. Keadaan Umum Penampilan umum

:.............................................................................................................................. ...............................................................................................................................

Tingkat kesadaran

:..............................................................................................................................

Tanda Tanda Vital

: Blood Presure :...............mm/Hg Temperature :……..°C

Berat badan

:........................Kg

Orientasi

: Waktu

Respiratory Rate :....................X/mnt Pulse Rate

:....................X/mnt

Tinggi Badan

:........................cm

:...........................................................................................................

Tempat

:...........................................................................................................

Orang

:...........................................................................................................

B. Pemeriksaan Head to Toe 1. Kepala Rambut : Warna

Mudah dicabut

Tidak mudah dicabut

Kebersihan :…………………. Telinga : Bentuk :……………. Kebersihan:…………… Kemampuan mendengar:…………… Mata

: Cowong Sklera

 Tdk cowong :  Ikterik

 Putih

 Merah

 Kemerahan

Conjunctiva :  Anemis  Merah muda Pupil

:  Isokor

Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

 Anisokor

 Miosis

Midriasis

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

Kemampuan melihat/ lapang pandang :……………………………… Hidung :  Pernapasan cuping hidung Mulut

: a. Bibir

 Epistaksis

:  Sianosis  Kering

 Polip

 Lembab  Stomatitis

 Lesi bibir b. Mukosa :  Kering  Lembab c. Rongga mulut :  Lidah kotor  Gigi karies

 Gigi ompong

 Radang tenggorok Wajah

: ...........................................................................................................................................

Keluhan :............................................................................................................................................. 2. Leher

:  Pembesaran kelenjar limfe  Pembesaran kelenjar tiroid

 Kaku kuduk

 Peningkatan JVP Keluhan : ………………………………………………………………………………………. 3. Payudara dan ketiak :  Massa

 Lesi

 Nyeri tekan

Keluhan :……………………………………………………………………………………….. 4. Dada I

Pal

:  Ekspansi dada simetris

 Kifosis  Pigeon chest

 Funnel chest

 Skoliosis

:  Nyeri tekan

 Massa

 Barrel chest

 Lordosis

 Pulsasi apikal

Ekspansi simetris

 Pulsasi apikal

Taktil fremitus :…………………………………….. Per

:  Resonan

 Konsolidasi

 Hiperesonan

 Redup jantung pada IC……………………. A

:  Vesikuler

 Bronkovesikuler  Bronkhial  Trakheal

 Mengi

 Krekels

 Bunyi gesekan pleural

 S1 “LUP”

 S2 “DUP”  S3  S4

Keluhan : ……………………………………………………………………………………… 5. Abdomen I

:  Buncit

 Datar

A

:  Peristaltik normal

Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

 Hipoperistaltik

 Hiperperistaltik

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

Per

:  Timpani

 Pekak alih  Redup

Pal

:  Hepatomegali

 Hipertimpani

 Splenomegali

 Nyeri tekan  Supel

 Distensi Keluhan :………………………………………………………………………………………… 6. Genital :  JK laki2

 JK perempuan

 Bersih

 Kotor

 Sirkumsisi

 Menstruasi (siklus :…..hari) Keluhan : ………………………………………………………………………………… 7. Rectal :  Bersih  Haemoroid

 Kemerahan

 Melena

Keluhan : …………………………………………………………………………………… 8.

Muskuloskeletal :  Kekuatan otot :………………….  Parese  Hemiparese

9.

Integumen : Eritema

 Hemiplegi  Fraktur  Nodula

 Bula

 Krepitasi Vistula



Ulkus  Jahitan :…………cm 10. Neurologi

: GCS : E:……..V:……..M :……….  Refleks patologis tdk ada

 Refleks patologis ada :………………

Fungsi syaraf : NI

:  Normal

 Gangguan

NII

:  Normal  Gangguan

N III :  Normal  Gangguan N IV :  Normal  Gangguan N V :  Normal  Gangguan N VI :  Normal  Gangguan N VII :  Normal  Gangguan N IX :  Normal  Gangguan NX

:  Normal  Gangguan

N XI :  Normal  Gangguan Keluhan : ……………………………………………………………………………………… Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

IV. POLA GORDON A. Pola Persepsi Kesehatan dan Pengelolaan Kesehatan 1.

Persepsi pasien tentang kesehatan diri :

2.

Pengetahuan dan persepsi tentang penyakitnya :

3.

Upaya yang dilakukan dalam mempertahankan kesehatan :

 Gizi yang adekuat 

 pemeriksaan kesehatan berkala

Perawatan kebersihan diri  Imunisasi

4.

Kemampuan pasien untuk mengontrol kesehatan yang dilakukan bila sakit :

5.

Kebiasaan hidup :



Konsumsi obat-obatan/ jamu



Konsumsi alcohol



Konsumsi rokok



Konsumsi kopi



Olahraga

6.

Faktor social ekonomi yang berhubungan dengan kesehatan :

B. Pola Nutrisi Metabolik 1.

Pola makan: Sebelum sakit : Frekuensi : Porsi makan

:

Jenis

:

Selama sakit : Frekuensi

:

Porsi makan

:

Jenis

:

2.

Keadaan sakit mempengaruhi pola makan/ minum :  Ya

3.

Makanan yang disukai :

4.

Makanan yang tidak disukai :

5.

Keyakinan/ kebudayaan yang dianut yang mempengaruhi diit :

6.

Kebiasaan mengkonsumsi vitamin :  Ya

 Tidak

 Tidak

Jenis :……..Jumlah :

…… 7.

Ada penurunan BB :  Ya

8.

Minum : Frekuensi :……….x/hr Jenis :………….

Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

 Tidak Jumlah :………

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

9.

IVFD (Intra Venous Fluid Drip) :……………………

10.

Keluhan :……………………………………………………………………………

C. Pola Eliminasi 1.

Eliminasi Alfi Warna

: Frekuensi

:

:

Konsistensi : Keluhan

: …………………………………………………………………………..

2.

Eliminasi Uri Warna

:

Jumlah

:

Keluhan

: Frekuensi

:

: …………………………………………………………………………..

D. Pola Aktivitas Latihan 1. Kegiatan dalam pekerjaan

:

2. Olahraga yang dilakukan

:

3. Keluhan

:

E. Pola Istirahat Tidur 1. Kebiasaan tidur : Sebelum sakit :…………jam/hari. Selama sakit :…………jam/hari. 2. Gangguan tidur :  Ada :………..

 Tdk ada

F. Pola Kognitif Perseptual 1. Alat Bantu yang digunakan

:  Kaca mata

 Alat Bantu dengar

2. Kemampuan kognitif yang mengalami kemunduran :  Kemampuan mengingat/ memory

 Bicara dan memahami pesan yang diterima

 Mengambil keputusan sendiri 3. Persepei terhadap nyeri P

:

Q

:

Q

:

R

:

S

:

T

:

4. Keluhan

:

:………………………………………………………………………………….

G. Pola Konsep Diri Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

1. Harapan setelah mendapat perawatan :

2. Status emosi

:  Sedih

3. Konsep diri

:

a. Citra diri

:

b. Identitas

:

c. Peran

:

d. Ideal diri

:

e. Harga diri

:

 Marah

 Gembira

 Curiga

H. Pola Peran Dan Hubungan 1. Kemampuan berkomunikasi

:  Relevan

2. Orang terdekat

:

3. Sulit berhubungan dengan

:

4. Dukungan keluarga

:  Aktif

5. Dukungan kelompok/ masyarakat :  Aktif 6. Reaksi selama interaksi I.

 Kurang

 lainnya :………………..

 Tidak ada

 Kurang  Tidak ada

:  Kooperatif  Bermusuhan  Curiga

 Defensif

 Aktif

Pola Seksual dan Reproduksi Gangguan hubungan seksual

J.

 Jelas

:  Ada :………………..

 Tidak

Pola Koping dan Toleransi Stress 1. Mengambil keputusan

:  Sendiri

 Dibantu

2. Koping menghadapi stressor

:  Adaptif :……………  Maladaptif :………………

K. Pola Nilai dan Kepercayaan 1. Konsep tentang penguasa kehidupan :  Tuhan

 Allah

 Dewa

 Lainnya :……. 2. Ritual

:  Sholat

 Baca kitap suci

 Lainnya :…………….

3. Upaya kesehatan yang bertentangan dengan keyakinan :  Ada :……………  Tdk ada

V.

4. Motifasi untuk sembuh :  Ada

 Tdk ada

5. Persepsi teehadap penyebab penyakit

:  Hukuman

 Cobaan  Lainnya :………..

PEMERIKSAAN PENUNJANG A. Pemeriksaan laboratorium

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

Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

................................................................................................................................................................... ................................................................................................................................................................... ................................................................................................................................................................... ................................................................................................................................................................... B. Pemeriksaan Radiologi ................................................................................................................................................................... ................................................................................................................................................................... ................................................................................................................................................................... ................................................................................................................................................................... C. ECG ................................................................................................................................................................... D. …………………… ................................................................................................................................................................... ...................................................................................................................................................................

E.

THERAPY MEDIS IVFD

:..............................................................................................................................................

Injeksi

:.............................................................................................................................................. ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

Per Oral

:.............................................................................................................................................. ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................

………………..,…….………….2009 Mahasiswa, Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

NIM………………………………......

F.

No

ANALISA DATA Nama klien :................................................

Tanggal :.....................................................

No. RM

Jam

:................................................ Data Fokus

Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

Penyebab

:..................................................... Masalah

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

G.

DIAGNOSA KEPERAWATAN DAN PRIORITAS DIAGNOSA KEPERAWATAN 1. Diagnosa Keperawatan ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. 2. Prioritas Diagnosa Keperawatan ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. .................................................................................................................................................................

Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

H.

No

RENCANA INTERVENSI KEPERAWATAN Nama klien :................................................

Tanggal :.....................................................

No. RM

Jam

:................................................

Diagnosa Keperawatan

Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

Tujan

Rencana Intervensi

:..................................................... Rasional

Ttd Dan Nama

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

I.

IMPLEMENTASI KEPERAWATAN Nama klien :................................................

Tanggal :.....................................................

No. RM

Jam

Tanggal & Jam

:................................................ No. Dx

Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

IMPLEMENTASI

:.....................................................

RESPON HASIL

TTD dan Nama

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

J.

CATATAN PERKEMBANGAN Nama klien :................................................

Tanggal :.....................................................

No. RM

Jam

Tanggal & Jam

:................................................ No. Dx

Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009

EVALUASI

:..................................................... TTD dan Nama

Format Dokumentasi Asuhan Keperawatan Praktik Klinik Keperawatan Dasar dan Dasar Keperawatan

Dept. Dasar Keperawatan dan Keperawatan Dasar PSIK STIKES Kendal tahun 2009