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FORMAT DOKUMENTASI ASUHAN KEPERAWATAN MEDIKAL BEDAH PROGRAM STUDI ILMU KEPERAWATAN UNEJ A. PENGKAJIAN I. Identitas Klien: No. Rekam Medis (RM) Nama Klien Nama panggilan Tempat/tanggal lahir Umur Agama Jenis kelamin Alamat Pendidikan Pekerjaan Suku Bahasa yang dimengerti Diagnosa medis SMRS II.
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Tanggal MRS : Tanggal pengkajian: Sumber informasi :
Riwayat Penyakit 1. Keluhan Utama: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 2. Riwayat Penyakit Sekarang: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 3. Riwayat Penyakit Dahulu: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 4. Riwayat Penyakit Keluarga: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 1
.............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. Genogram:
III. Pengkajian Saat Ini (Pola Fungsional Kesehatan): 1. Persepsi dan pemeliharaan kesehatan. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. ...... 2. Pola nutrisi/metabolik a.Program diit RS :......................................................................................................... b. Intake makanan : Sebelum masuk RS:.......................................................................................................... ........................................................................................................... Saat di RS :.......................................................................................................... ........................................................................................................... ........................................................................................................... c. Intake cairan : Sebelum masuk RS:.......................................................................................................... ........................................................................................................... Saat di RS :.......................................................................................................... ........................................................................................................... ........................................................................................................... d. Riwayat alergi makanan:.................................................................................................. 3. Pola eliminasi a. Buang Air besar (BAB):................................................................................................. .................................................................................................. b. Buang Air kecil (BAK):................................................................................................. ................................................................................................... 4. Pola aktivitas dan latihan Kemampuan perawatan diri 0 1 2 3 4 Ket. Makan/minum Mandi Toileting Berpakaian Mobilitas di tempat tidur Berpindah/berjalan Ambulasi/ROM 0: mandiri; 1: dengan alat bantu; 2: dibantu orang lain; 3: dibantu orang lain dan alat; 4: tergantung total 2
Oksigenasi:.......................................................................................................................... . 5. Pola tidur dan istirahat .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 6. Pola persepsi-kognisi Penglihatan :....................................................................................................................... Pendengaran :....................................................................................................................... Pengecapan :....................................................................................................................... Penciuman :....................................................................................................................... Perasa :....................................................................................................................... Sensasi :....................................................................................................................... Orientasi (OTW):.................................................................................................................. 7. Pola persepsi diri-konsep diri .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 8. Pola seksualitas-reproduksi .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 9. Pola peran hubungan .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 10. Pola manajemen koping-stress .............................................................................................................................................. .............................................................................................................................................. ............................................................................................................................................. 11. Sistem nilai dan keyakinan .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. IV. Pemeriksaan Fisik: 1. Keluhan saat ini:..................................................................................................................... ......................................................................................................................... ......................................................................................................................... 2. Keadaan Umum:.....................................................................................................................
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: TD:......./..........mmHg N:............x/m S:...........0C BB/TB:..kg/.cm (sebelum masuk RS:..kg/.cm) 4. Pemeriksaan Cepalokaudal: a. Kepala dan leher :............................................................................................................... ................................................................................................................ ................................................................................................................ ................................................................................................................ ................................................................................................................ ................................................................................................................ b. Thoraks : I:................................................................................................ 3. TTV Pe:........................................................................................................... Pa:........................................................................................................... A:............................................................................................................ . c. Abdomen ............................................................................................................. : I:............................................................................................................ A:........................................................................................................... Pe:.......................................................................................................... Pa:..........................................................................................................
d. Inguinal Urinaria
Genitalia
e. Ekstremitas
:............................................................................................................... :............................................................................................................... ................................................................................................................ ................................................................................................................ :............................................................................................................... ................................................................................................................ ................................................................................................................ :............................................................................................................... ................................................................................................................ ................................................................................................................ ................................................................................................................ ................................................................................................................
V. PROGRAM TERAPI .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... ....................................................................................................................................................
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VI. Pemeriksaan Diagnostik Penunjang (tuliskan jenis pemeriksaan dan hasilnya) Laboratorium: Jenis Pemeriksaan Hematologi: Darah Perifer Lengkap LED Hb Ht Eritrosit MCV/Ver MCH/Her MCHC/Her Leukosit Trombosit Albumin Hitung jenis: Basofil Eosinofil Neutrofil Limfosit Monosit Urinalisis Urin Lengkap Warna Kejernihan Sedimen Sel epitel Leukosit Eritrosit Silinder Kristal Bakteri BJ pH Protein Glukosa Keton Darah/Hb Bilirubin Urobilinogen Nitrit Esterase Analisa Gas Darah (AGD) pH pCO2 pO2 5 Tanggal Normal Satuan
0-20 12-14 37-43 4.5-5.5 80-94 27-32 32-36 5-10 ribu 150-450 rb 3.5-5
g/dL % Juta/ L fL pg % / L / L g/dL
Kuning jernih
/LPB
Umol/L
7.35-7.45 35-45 85-100
mmHg mmHg
HCO3 Total CO2 BE SaO2 STD HCO3 STD BE Elektrolit: Na K Cl Ureum Creatinin
22-26 23-27 2 96-97
mmol/L mmol/L mmol/L %
mmol/L mmol/L mmol/L
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B. ANALISA DATA NO DATA 1. DS: ................................................................... ..... ............................................................. .................................................................... .................................................................... .................................................................... DO: .................................................................... .................................................................... ................................................................... .................................................................... ..................................................................... .................................................................... .................................................................... ................................................................... 2.
ETIOLOGI ............................... ............................... .............................. ............................... .............................. ..............................
MASALAH ................................... .................................. .................................... ................................... ....................................
3.
4.
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C. DIAGNOSA KEPERAWATAN Diagnosa Keperawatan dan kolaboratif berdasarkan prioritas: 1................................................................................................................................................... 2................................................................................................................................................... 3................................................................................................................................................... 4................................................................................................................................................... 5.................................................................................................................................................. 6.................................................................................................................................................. 7..................................................................................................................................................
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D. PERENCANAAN & INTERVENSI NO Diagnosa Perencanaan (NOC) Intervensi (NIC)
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E. IMPLEMENTASI & EVALUASI CATATAN PERKEMBANGAN Evaluasi
Hari/ tanggal
Jam
Diagnosa
Implementasi
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CATATAN PERKEMBANGAN Diagnosa: Hari/ Jam tanggal
Implementasi
Jam
Evaluasi
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P
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