FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWADeskripsi lengkap
Deskripsi lengkap
KRITISDeskripsi lengkap
neoFull description
Full description
Full description
Deskripsi lengkap
Full description
Format Pengkajian KebidananFull description
oke
Deskripsi lengkap
Full description
gFull description
LAPORAN KASUS
ASUHAN KEPERAWATAN PADA KLIEN DENGAN ................................... DI .................. RUMKITAL Dr. RAMELAN SURABAYA Tanggal .............. s/d ..................
LEMBAR PENGESAHAN
ASUHAN KEPERAWATAN PADA KLIEN DENGAN ................................... DI .................. RUMKITAL Dr. RAMELAN SURABAYA Tanggal .............. s/d ..................
8. Riwayat kesehatan keluarga : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 9. Susunan keluarga (genogram) :
10. Riwayat alergi : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... III. POLA NUTRISI DAN METABOLIK 1. Pola makan Di rumah
Di rumah sakit
2. Buang air kecil Di rumah Di rumah sakit Frekuensi : .................................. Frekuensi : .................................. Jumlah : .................................. Jumlah : .................................. Warna : .................................. Warna : .................................. Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria ( ) retensi ( ) inkontinen Kateter : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari
V. POLA AKTIVITAS DAN LATIHAN 1. Kemampuan perawatan diri
Aktivitas Mandi Berpakaian/berdandan Eliminasi/toileting Mobilitas di tempat tidur Berpindah Berjalan Naik tangga Berbelanja Memasak
0
SMRS 1 2 3
4
0
1
MRS 2
3
4
VII. POLA KOGNITIF DAN PERSEPTUAL Berbicara : ( ) normal ( ) gagap ( ) bicara tak jelas Bahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya, .................................... Kemampuan membaca : ( ) bisa ( ) tidak Tingkat ansietas : ( ) ringan ( ) sedang ( ) berat ( ) panik Sebab, ................................................................................................... Kemampuan interaksi : ( ) sesuai ( ) tidak, .................................................................... Vertigo : ( ) tidak ( ) ya Nyeri : ( ) tidak ( ) ya
VIII. POLA PERSEPSI DIRI / KONSEP DIRI 1. Body image/gambaran diri ( ) cacat fisik ( ) perubahan ukuran fisik ( ) fungsi alat tubuh terganggu ( ) keluhan karena kondisi tubuh
( ( ( (
) pernah operasi ) proses patologi penyakit ) kegagalan fungsi tubuh ) gangguan struktur tubuh
( ) merasa tidak berdaya
( ) enggan membicarakan masa depan
Jelaskan : ........................................................................................................................................... ........................................................................................................................................... Masalah keperawatan : ...................................................................................................................... IX. POLA PERAN DAN HUBUNGAN Pekerjaan : .......................................................................................................... Kualitas bekerja : .......................................................................................................... Hubungan dengan orang lain : Sistem pendukung : ( ) pasangan ( ) tetangga/teman ( ) tidak ada ( ) lainnya, ...................................................................................... Masalah keluarga mengenai perawatan di RS : ................................................................................... X. POLA SEKSUALITAS / REPRODUKSI Menstruasi terakhir : ..................................................................................................................... Masalah menstruasi : ..................................................................................................................... Pap smear terakhir : ..................................................................................................................... Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidak Masalah seksual yang berhubungan dengan penyakit : ............................................................... XI. POLA KOPING / TOLERANSI STRESS 1. Masalah utama selama MRS (penyakit, biaya, perawatan diri) ......................................................................................................................................................... .........................................................................................................................................................
2. Sistem Pernafasan ( Breath ) ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 3. Sistem Kardiovaskuler ( Blood ) ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 4. Sistem Persarafan ( Brain ) ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 5. Sistem Perkemihan ( Bladder ) ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 6. Sistem Pencernaan ( Bowel ) ......................................................................................................................................................... .........................................................................................................................................................