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RESUME

ASUHAN KEPERAWATAN DI RUANG POLI ORTHOPEDI DAN

TRAUMATOLOGI RSD dr. SOEBANDI JEMBER

Oleh:

FIKRI ULIL ALBAB, S.Kep.

NIM. 092311101007

PROGRAM PENDIDIKAN PROFESI NERS

PROGRAM STUDI ILMU KEPERAWATAN

UNIVERSITAS JEMBER

2014

RESUME

ASUHAN KEPERAWATAN DI RUANG POLI MATA

RSD dr. SOEBANDI JEMBER

Oleh:

FIKRI ULIL ALBAB, S.Kep.

NIM. 092311101007



UNIVERSITAS JEMBER

2014

ASUHAN KEPERAWATAN PADA PASIEN DENGAN SPINAL CORD

INJURY FRAKTUR COMPRESI THORAKAL XI-XII DI RUANG BEDAH

ORTHOPEDI (SERUNI) RDS dr. SOEBANDI JEMBER

Disusun guna memenuhi tugas Program Pendidikan Profesi Ners (PPPN)

Stase Keperawatan Medikal Bedah

Oleh

Fikri Ulil Albab, S.Kep.

NIM.092311101007



UNIVERSITAS JEMBER

2014

PERSETUJUAN

Asuhan Keperawatan Pasien dengan ________________________________

telah dilaksanakan pada tanggal ______________ di Ruang _____________

RSD Dr. Soebandi Jember.

Jember, _________ 2014

Pembimbing Ruangan Pembimbing Akademik

( …………..........………… ) ( …............………………. )

Kepala Ruangan,

( …………………………………)

PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBERFORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :NIM :Tempat Pengkajian :Tanggal :

I. Identitas KlienNama : No. RM :Umur : Pekerjaan :Jenis Kelamin : Status Perkawinan :Agama : Tanggal MRS :Pendidikan : Tanggal

Pengkajian:

Alamat : Sumber Informasi :

II. Riwayat Kesehatan1. Diagnosa Medik:

………………………………………………………………………….................................………………..

2. Keluhan Utama:……………..………………………………………………………………………….………....……………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………

3. Riwayat penyakit sekarang: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...................................................................................................................………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………................

4. Riwayat kesehatan terdahulu:a. Penyakit yang pernah dialami:………………………………………………………………………….................................………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………….………………………………………………………………………………………………………………….………………………………………………………………………….................................………………..b. Alergi (obat, makanan, plester, dll):………………………………………………………………………….................................………………..

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................………………..c.Imunisasi:………………………………………………………………………….................................………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………

d.Kebiasaan/pola hidup/life style:………………………………………………………………………….................................………………..…………………………………………………………………………………………………………………………………………………………………………………………….................................………………..…………………………………………………………………………………………………………………………………………………………………………………………….................................………………..

e. Obat-obat yang digunakan:………………………………………………………………………….................................………………..…………………………………………………………………………………………………………………………………………………………………………………………….................................………………..………………………………………………………………………….................................………………..………………………………………………………………………….................................………………..

5. Riwayat penyakit keluarga:………………………………………………………………………….................................………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................………………..

Genogram:

III. Pengkajian Keperawatan1. Persepsi kesehatan & pemeliharaan kesehatan

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

2. Pola nutrisi/ metabolik (ABCD)- Antropometeri

………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………

- Biomedical sign : ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………

- Clinical Sign : ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………

- Diet Pattern :………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

3. Pola eliminasi: BAK

- Frekuensi :…………………………………………………………………………….. - Jumlah :……………………………………………………………………………..- Warna : ……………………………………………………………………………..- Bau : ……………………………………………………………………………..- Karakter : ……………………………………………………………………………..- BJ :…………………………………………………………………………….. - Alat Bantu : ……………………………………………………………………………..- Kemandirian : mandiri/dibantu- Lain : ……………………………………………………………………………..

BAB - Frekuensi :…………………………………………………………………………….. - Jumlah :……………………………………………………………………………..- Konsistensi : ……………………………………………………………………………..- Warna : ……………………………………………………………………………..- Bau : ……………………………………………………………………………..- Karakter : ……………………………………………………………………………..- BJ :…………………………………………………………………………….. - Alat Bantu : ……………………………………………………………………………..- Kemandirian : mandiri/dibantu - Lain : ……………………………………………………………………………..

Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

4. Pola aktivitas & latihan…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

c.1. Aktivitas harian (Activity Daily Living)Kemampuan perawatan diri 0 1 2 3 4Makan / minumToileting Berpakaian Mobilitas di tempat tidurBerpindah Ambulasi / ROM

Status Oksigenasi : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Fungsi kardiovaskuler : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Terapi oksigen : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

5. Pola tidur & istirahatDurasi : ……………………………………………………………………………………………………Gangguan tidur : ……………………………………………………………………………………….Keadaan bangun tidur : ………………………………………………………………..……………Lain-lain : …………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

6. Pola kognitif & perceptualFungsi Kognitif dan Memori : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Fungsi dan keadaan indera : ……………………………………………………………………………………………………………………………………………………….....................................................................................................................................................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

7. Pola persepsi diriGambaran diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Identitas diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Harga diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Ideal Diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Peran Diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

8. Pola seksualitas & reproduksiPola seksualitas ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Fungsi reproduksi …………………………………….................................................................................................................................................................................................................................................................................................................................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

9. Pola peran & hubungan……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

10. Pola manajemen koping-stress……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

11. System nilai & keyakinan…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

IV. Pemeriksaan FisikKeadaan umum:……………………………………………………………..……………………………..........................................……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Tanda vital:

- Tekanan Darah : mm/Hg- Nadi : X/mnt- RR : X/mnt- Suhu : C

Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………

Pengkajian Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi) 1. Kepala

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2. Mata …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

3. Telinga.…………………………………………………………………………………….........................................………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

4. Hidung…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

5. Mulut………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

6. Leher……………………………………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………

7. Dada.………………………………………………………………………………………...….…………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………………………………………

8. Abdomen……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

9. Urogenital………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

10. Ekstremitas……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

11. Kulit dan kuku……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

12. Keadaan lokal………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

V. Terapi.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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VI. Pemeriksaan Penunjang & Laboratorium..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Jember, April 2014

Pengambil Data,

(_________________________________)

ANALISA DATANO DATA PENUNJANG ETIOLOGI MASALAH

DAFTAR DIAGNOSA KEPERAWATAN

Tanggal No Dx Diagnosa Keperawatan Nama terang dan ttd

RENCANA TINDAKAN KEPERAWATAN

Diagnosa Keperawatan Tujuan dan Kriteria hasil Rencana Tindakan Keperawatan Rasional

TINDAKAN KEPERAWATANTanggal Jam Tindakan Keperawatan Nama dan TTD

EVALUASI KEPERAWATANTanggal No. Dx Evaluasi Keperawatan Nama dan TTD

CATATAN PERKEMBANGAN

DIAGNOSA:WAKTU IMPLEMENTASI PARAF EVALUASI

JAM:

FORMAT RESUME KASUS KELOLAAN HARIAN


IDENTITAS PASIENNama :Umur :Jenis Kelamin :Agama :Pendidikan :Pekerjaan :Alamat :No. RM :Ruangan :Diagnosa Medis :

S (Subjektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

O (Objektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan DO):.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

P(Perencanaan):..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................I (Implementasi):.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

E (Evaluasi):S (Subjektif): ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

O (Objektif): .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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

...............................................................................................................................................................................A (analisa): .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

P (Perencanaan: .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Jember, ____________ 2014

Petugas pelaksana,

(_________________________________)




S (Subjektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

O (Objektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................




O (Objektif): .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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

...............................................................................................................................................................................A (analisa): .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

P (Perencanaan: .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Jember, ____________ 2014

Petugas pelaksana,

(_________________________________)




S (Subjektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

O (Objektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................




O (Objektif): .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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

...............................................................................................................................................................................A (analisa): .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

P (Perencanaan: .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Jember, ____________ 2014

Petugas pelaksana,

(_________________________________)




S (Subjektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

O (Objektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................




O (Objektif): .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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

...............................................................................................................................................................................A (analisa): .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

P (Perencanaan: .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Jember, ____________ 2014

Petugas pelaksana,

(_________________________________)

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