SEKOLAH TINGGI ILMU KESEHATAN STIKES

  

SEKOLAH TINGGI ILMU KESEHATAN (STIKES)

NGUDIA HUSADA MADURA

Jl. RE. MARTADINATA Telp.  (031) 3091871

  

BANGKALAN 69116

FORMAT ASUHAN KEPERAWATAN

PADA PASIEN ...................................................................................................

  

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

  I. PENGKAJIAN

  A. IDENTITAS

  1. Identitas Klien Nama : ............................................................................

  Umur : ............................................................................ Pendidikan : ............................................................................ Alamat : ............................................................................ Tanggal Masuk : ............................................................................ No Register : ............................................................................ Tanggal Pengkajian : ............................................................................ Diagnosa Medis : ............................................................................

  2. Identitas Penanggung jawab Nama : ............................................................................

  Umur : ............................................................................ Pendidikan : ............................................................................ Alamat : ............................................................................ Hub. dengan klien : ............................................................................

  B. KELUHAN UTAMA ....................................................................................................................................................................

  C. RIWAYAT KESEHATAN SAAT INI ....................................................................................................................................................................

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

  D. RIWAYAT PERKAWINAN

  1. Perkawinan : ......................... kali

  2. Dengan suami sekarang : ......................... tahun

  3. Umur pertama kali kawin : ......................... tahun

  E. RIWAYAT KELUARGA BERENCANA 1. Cara kontrasepsi : ..................................................

  2. Kegagalan : ..................................................

  3. Lama pemakaian : ..................................................

  F. RIWAYAT MENSTRUASI

  1. Menarce : .................. tahun

  2. Lamanya haid : .................. hari

  3. Dismenorrhea : ada / tidak ada

  4. Siklus haid : .................. hari

  5. Banyaknya : banyak / sedang / sedikit 6. Haid terakhir : ..................

  7. Menopause usia : .................. tahun

  G. RIWAYAT KESEHATAN YANG LALU

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

  H. RIWAYAT KEHAMILAN SEKARANG 1. G….. P …………..

  2. Usia Kehamilan : ……………. minggu 3. Keluhan hamil muda : ……….…………….…………….…………….

  …………….…………….

  4. Keluhan hamil tua : ……….…………….…………….…………….

  …………….…………….

  5. Gerakan janin sejak : ……………. minggu 6. Tanda-tanda bahaya : ……….…………….…………….…………….

  …………….…………….

  7. ANC Jumlah : ............... kali Tempat : bidan / dokter TT : .............. kali, usia kehamilan ke ..........

  Terapi : ……….…………….…………….…………….…………….…………….

  I. RIWAYAT KEHAMILAN, PERSALINAN DAN NIFAS YANG LALU

  At/P/ Cara Kondisi BBL/ No Kehamilan Penolong L/P Umur H/M

  I/Ab/E Lahir nifas TB

  J. RIWAYAT KESEHATAN KELUARGA ....................................................................................................................................................................

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

  K. RIWAYAT PSIKOSOSIAL ....................................................................................................................................................................

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

  L. POLA AKTIVITAS SEHARI-HARI

  1. Nutrisi SMRS : ...............................................................................................................................................

  MRS : ...............................................................................................................................................

  2. Eliminasi SMRS : ...............................................................................................................................................

  MRS : ...............................................................................................................................................

  3. Aktivitas SMRS : ...............................................................................................................................................

  MRS : ...............................................................................................................................................

  4. Istirahat

  SMRS : ............................................................................................................................................... MRS : ...............................................................................................................................................

  5. Kebersihan Diri SMRS : ...............................................................................................................................................

  MRS : ...............................................................................................................................................

  M. PEMERIKSAAN FISIK Item Yang Diamati

  TB / BB ........ cm / ........ kg Tanda-Tanda Vital Suhu ........

  Nadi ......... kali/menit Respirasi ......... kali/menit Tekanan darah ........ / ........ mmHg

  Integument/ Kulit Inspeksi ..................................................................................................................

  Palpasi .................................................................................................................. Kepala Inspeksi ..................................................................................................................

  Palpasi .................................................................................................................. Wajah Inspeksi ..................................................................................................................

  Palpasi .................................................................................................................. Mata Inspeksi

  Reflek kornea .................................................................................................................. Reflek pupil terhadap cahaya .................................................................................................................. Hidung Inspeksi ..................................................................................................................

  Palpasi .................................................................................................................. Mulut Inspeksi .................................................................................................................. Telinga Inspeksi ..................................................................................................................

  Palpasi .................................................................................................................. Leher Inspeksi ..................................................................................................................

  Palpasi .................................................................................................................. Paru-paru Inspeksi ..................................................................................................................

  Palpasi .................................................................................................................. Perkusi .................................................................................................................. auskultasi .................................................................................................................. Jantung Inspeksi ..................................................................................................................

  Palpasi ..................................................................................................................

  .................................................................................................................. Auskultasi ..................................................................................................................

  Payudara Inspeksi ..................................................................................................................

  Palpasi .................................................................................................................. Abdomen Inspeksi ..................................................................................................................

  Palpasi .................................................................................................................. Perkusi .................................................................................................................. Auskultasi .................................................................................................................. Ekstrimitas Atas ..................................................................................................................

  .................................................................................................................. Bawah ..................................................................................................................

  .................................................................................................................. Genetalia dan Anus Keadaan vulva perineum ..................................................................................................................

  .................................................................................................................. Keadaan vagina ..................................................................................................................

  .................................................................................................................. Keadaan rectum ..................................................................................................................

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

  N. PEMERIKSAAN KHUSUS KEHAMILAN

  1. Palpasi Axilla : ...................................................................................................................................

  Abdomen : ................................................................................................................................... Leopold I : ................................................................................................................................... Leopold II : ................................................................................................................................... Leopold III : ................................................................................................................................... Leoplod IV : ...................................................................................................................................

  2. Auskultasi DJJ : ............ x/mnt 3. Perkusi : ...............................................................................................

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

  O. PEMERIKSAAN PENUNJANG ....................................................................................................................................................................

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

  P. TERAPI/PENGOBATAN ..........................................................................................................................................................................

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

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

  II. ANALISA DATA

  NO DATA MASALAH ETIOLOGI

  III. DIAGNOSA KEPERAWATAN ....................................................................................................................................................................

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

  IV. RENCANA TINDAKAN KEPERAWATAN

  Diagnosa Tujuan dan kriteria No

  Intervensi Rasional keperawatan hasil

V. IMPLEMENTASI

  Tanggal No

  Dan Implementasi Respon Dx

  Pukul

VI. EVALUASI

  Diagnosa S-O-A-P