ASUHAN KEPERAWATAN

ASUHAN KEPERAWATAN

PADA Tn. D DENGAN STATUS ABSES PERIANAL

DI Ruang 14 RS dr. Saiful Anwar Malang

I. IDENTITAS 1. Identitas klien

Nama :

Usia :

Jenis Kelamin :

Agama :

Pendidikan :

Pekerjaan :

Gol. Darah :

Alamat :

II. KELUHAN UTAMA

1. Keluhan Utama Saat MRS :.................................

2. Keluhan Utama Saat Pengkajian :..........................

III. Diagnosa Medis :

1. ...........................

2. ...........................

3. ...........................

IV. RIWAYAT KESEHATAN

1. Riwayat Penyakit Sekarang :

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1

Tgl Pengkajian : - - 2015

Jam pengkajian :

Ruang/Kelas : Ruang 14

No. RM :

Tgl.MRS :

2. Identitas Penanggung JawabNama :

Usia :

Jenis Kelamin :

Agama :

Pekerjaan :

Alamat :

Hubungan dengan Klien :

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2. Riwayat Kesehatan Terdahulu

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3. Riwayat Kesehatan Keluarga

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GENOGRAM

Keterangan :

: laki - laki

: perempuan

: pasien

: tinggal serumah

: meninggal

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V. RIWAYAT KEPERAWATAN KLIEN

1. Pola Nutrisi-Metabolik

ItemDeskripsi

di Rumah di Rumah SakitJenis diet/makanan/

Komposisi menu

Porsi/jumlah

Pantangan

Nafsu makan

Peningkatan/Penurunan

BB 6 bulan terakhir

2. Pola Eliminasi

ITEMDeskripsi

di Rumah di Rumah SakitBAB

Frekuensi/pola x sehari x sehari

Konsistensi

Warna/bau

Kesulitan

Upaya mengatasi

BAK Frekuensi/pola

x sehari x sehari

Konsistensi

Warna/bau

Kesulitan

Upaya mengatasi

3. Pola TidurITEM Di Rumah Di Rumah Sakit

Jumlah/waktu

Gangguan Tidur

Upaya mengatasi

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4. Pola Kebersihan DiriITEM Di Rumah Di Rumah Sakit

Frekuensi mandi x sehari x sehari

Frekuensi cuci rambut x seminggu x seminggu

Frekuensi gosok gigi x sehari x sehari

5. Aktivitas Lain

Aktivitas yang dilakukan untuk

mengisi waktu luang

Di Rumah Di Rumah Sakit

6. Riwayat Psikologi

a. Status emosi.........................................................

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b. Gaya Komunikasi.........................................................

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c. Riwayat Sosial.........................................................

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d. Riwayat Spiritual

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VI. PEMERIKSAAN FISIK 1. Keadaaan Umum2. Kepala dan Leher

Kepala: bentuk normochepal, lesi (-), benjolan (-), rambut tipis tidak mudah rontok, penyebaran rambut merata

Kepala: bulat,simetris, dan luka ( ) Mata :Simetris,anemis -|-, tampak sedikit cowong-- dan

rangsangan terhadap cahaya ( ), Hidung : simetris, sinusitis ( ), perdarahan ( ),

oksigen via Nasal Canul 3 lpm. Mulut dan Tenggorokan : mukosa bibir kering, warna

kemerahan, perdarahan tidak ada, berdahak ( ) Telinga : simetris dextra sinistra, nyeri tekan ( ) Leher : nadi carotis teraba, posisi trachea simetris,

tidak distensi vena jugularis

2. DadaInspeksi

Bentuk thorak Normal chest

Palpasi Nyeri tekan ( )

Perkusi +/+

Auskultasi Paru

Suara Nafas Deskripsi

Ο Bronkial -

Ο Bronkovesikuler -

Ο Vesikuler Seluruh lapang paru

Suara Ucapan - -

Bronkoponi/Pectoryloquy/Egophoni - -

SuaraTambahan - -

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Kesadaran :

GCS :

TD = / mmHg RR = x/mnt

N = x/mnt BB = kg

S = ºC TB = cm

- -

--

--

- -

--

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Rales/Rhonchi/Wheezing/Pleural Friction

Rhonchi Wheezing

Pemeriksaan jantung

Inspeksi dan Palpasi Prekordium

Area Aorta-Pulmonum Pulsasi:

Area tricuspid-Ventrikel

kanan

Pulsasi:

Letak Ictus Cordis

Perkusi

Batas jantung ICS .... parasternum dextra

ICS .... parasternum

ICS .... parasternum sinistra

Suara

Auskultasi

Bunyi Jantung I

Bunyi Jantung II

Bunyi Jantung

III

Murmur ( ), Gallop ( )

Bunyi Jantung IV

Keluhan

3. Punggung :Lesi ( ), Massa ( ), kelainan bentuk tulang( ), Nyeri ( )

4. Mamae dan Axila: Benjolan/massa ( ) Nyeri:.............

5. Abdomen Inspeksi Lesi ( ), Scar ( ), Massa ( ), Distensi( ), Asites

( )Auskultasi Bising Usus ( )Palpasi Scibala ( ), Pembesaran Hati dan Limpa ( )PerkusiLain-lain Massa ( ), residu: jernih / tidak jernih

6. Genetalia Pengkajian Data/Gejala Deskripsi

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Inspeksi Luka ( ),Massa ( ) Distensi( ) Pus ( )

Palpasi Nyeri tekan ( )Keluhan

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...........................7. Ekstremitas

Atas

Lesi ( ), Scar( ), Kontraktur ( ),Deformitas( ), Edema ( ), Nyeri ( ), Clubbing finger ( )Akral hangat, CRT < ... detik

BawahLesi ( ), Scar ( ), Kontraktur ( ), Deformitas ( ), Edema ( ), Nyeri ( ), Pteki ( )Akral hangat, CRT < ... detik

Kekuatan Otot

8. Pemeriksaan fungsi Pendengaran/Penghidung/Tenggerokan Pendengaran :............................................ Penghidung :............................................ Tenggerokan :............................................

9. Pemeriksaan fungsi penglihatan

Ketajaman penglihatan :.....................................

10. Pemeriksaan fungsi Neurologis

Menilai respon membuka mata :..............................

Menilai respon verbal :..............................

Menilai respon motorik :..............................

11. Metabolisme/Integumen KULIT :.................................................

Warna:...................................................

Suhu:....................................................

Turgor:..................................................

Edema:...................................................

Memar:...................................................

Kemerahan :..............................................

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Pruritus:................................................

Pteki:...................................................

RAMBUT

Penyebaran :.............................................

Warna:...................................................

Alopesia :...............................................

Hirsutisme :.............................................

Rontok :.................................................

KUKU

Warna :..................................................

Bentuk :.................................................

Kebersihan kuku :........................................

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12. Data Penunjang

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VII. Program Terapi

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PETUGAS

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(ANDI WAHID KAHAR)

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ANALISIS DATANO DATA ETIOLOGI PROBLEM

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ANALISIS DATANO DATA ETIOLOGI PROBLEM

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PRIORITAS DIAGNOSA KEPERAWATAN

Tanggal Diagnosa Prioritas

I

II

III

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INTERVENSI KEPERAWATAN

No.DX TANGGAL DAN JAM

NOC NIC

I

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IMPLEMENTASI KEPERAWATAN

IMPLEMENTASI TANGGAL JUlI 2015Hari / Tgl/ Jam

No. DX TindakanKeperawatan TTD

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EVALUASITGL Jam Dx kep Evaluasi Paraf

Dx S :

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ASUHAN KEPERAWATAN

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