RENCANA ASUHAN KEPERAWATAN pada STROKE

RENCANA ASUHAN KEPERAWATAN

Nama klien : Tn. A
Tgl Pengkajian :
No. Reg :
Diagnosa Medis : Stroke

"No "Tgl "Diagnosa Keperawatan "Tujuan & Kriteria hasil "Intervensi "Rasional "
"1. " "Ketidakefektifan "Setelah dilakukan tindakan "NIC : " "
" " "Perfusi jaringan "keperawatan selama 3 x 24 jam, "Intrakranial Pressure (ICP)" "
" " "serebral berhubungan "aliran darah yang terhambat "Monitoring (Monitor tekanan" "
" " "dengan aliran darah ke"menjadi lancar "intrakranial) " "
" " "otak terhambat "NOC : " Berikan informasi kepada " "
" " " "Circulation status "keluarga " "
" " " "No " Monitor tekanan perfusi " "
" " " "Indikator "serebral " "
" " " "1 "Catat respon pasien " "
" " " "2 "terhadap stimuli " "
" " " "3 "Monitor tekanan " "
" " " "4 "intrakranial pasien dan " "
" " " "5 "respon neurology terhadap " "
" " " " "aktivitas " "
" " " "1 " Monitor jumlah drainage " "
" " " "Systolic blood pressure "cairan serebrospinal " "
" " " " " Monitor intake dan output " "
" " " " "cairan " "
" " " " " Monitor suhu dan angka WBC" "
" " " "v "Kolaborasi pemberian " "
" " " " "antibiotik " "
" " " " " Posisikan pasien pada " "
" " " "2 "posisi semifowler " "
" " " "Diastolic blood pressure "Minimalkan stimuli dari " "
" " " " "Lingkungan " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "3 " " "
" " " "Pulse pressure " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "4 " " "
" " " "Urine output " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "Tissue Prefusion : Cerebral " " "
" " " "No " " "
" " " "Indikator " " "
" " " "1 " " "
" " " "2 " " "
" " " "3 " " "
" " " "4 " " "
" " " "5 " " "
" " " " " " "
" " " "1 " " "
" " " "Intracranial pressure " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "2 " " "
" " " "Diastolic blood pressure " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "3 " " "
" " " "Sistolic blood pressure " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "Kriteria Hasil : " " "
" " " "Sesuai dengan indicator " " "
" " "Ketidakseimbangan "Setelah dilakukan tindakan "NIC : " "
" " "Nutrisi : kurang dari "keperawatan selama 2x 24 jam, "Self care assistance: " "
" " "kebutuhan tubuh "diharapkan kebutuhan nutrisi "Feeding " "
" " "berhubungan dengan "klien dapat terpenuhi "Monitor kemampuan pasien " "
" " "penurunan kemampuan "NOC : "untuk menelan " "
" " "untuk mengunyah "Nutritional Status "Menyediakan pendampingan " "
" " " "No "fisik " "
" " " "Indikator "Memastikan dengan tepat " "
" " " "1 "posisi pasien untuk dapat " "
" " " "2 "menelan serta mengunyah " "
" " " "3 "Monitor BB pasien " "
" " " "4 "Sediakan sedotan " "
" " " "5 "Tempatkan pasien dalam " "
" " " " "posisi ynag nyaman untuk " "
" " " "1 "makan " "
" " " "Nutrient intake "Interaksi social " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "2 " " "
" " " "Food intake " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "3 " " "
" " " "Fluid intake " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "Self Care: Eating " " "
" " " "No " " "
" " " "Indikator " " "
" " " "1 " " "
" " " "2 " " "
" " " "3 " " "
" " " "4 " " "
" " " "5 " " "
" " " " " " "
" " " "1 " " "
" " " "Chews food " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " "2 " " "
" " " "Completes a meal " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "3 " " "
" " " "Swallows food " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "4 " " "
" " " "Swallows fluid " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "5 " " "
" " " "Manipulates food in mouth " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "Kriteria Hasil : " " "
" " " "Sesuai dengan indikator " " "
" " "Defisit perawatan "Setelah dilakukan tindakan "NIC : " "
" " "diri: makan, mandi, "keperawatan selama 3x 24 jam, "Self Care assistance : ADLs" "
" " "berpakaian, toileting "diharapkan kebutuhan mandiri " Monitor kemempuan klien " "
" " "berhubungan dengan "klien terpenuhi, dengan kriteria "untuk perawatan diri yang " "
" " "ketidakmampuan "hasil: "mandiri. " "
" " "bergerak "NOC : "Monitor kebutuhan klien " "
" " " "Self care : Activity of Daily "untuk alat-alat bantu untuk" "
" " " "Living (ADLs) "kebersihan diri, " "
" " " "No "berpakaian, berhias, " "
" " " "Indikator "toileting dan makan. " "
" " " "1 " Sediakan bantuan sampai " "
" " " "2 "klien mampu secara utuh " "
" " " "3 "untuk melakukan self-care. " "
" " " "4 " Dorong klien untuk " "
" " " "5 "melakukan aktivitas " "
" " " " "sehari-hari yang normal " "
" " " "1 "sesuai kemampuan yang " "
" " " "Eating "dimiliki. " "
" " " " " Dorong untuk melakukan " "
" " " " "secara mandiri, tapi beri " "
" " " " "bantuan ketika klien tidak " "
" " " "v "mampu melakukannya. " "
" " " " " Ajarkan klien/ keluarga " "
" " " " "untuk mendorong " "
" " " "2 "kemandirian, untuk " "
" " " "Dressing "memberikan bantuan hanya " "
" " " " "jika pasien tidak mampu " "
" " " " "untuk melakukannya. " "
" " " " " Berikan aktivitas rutin " "
" " " "v "sehari- hari sesuai " "
" " " " "kemampuan. " "
" " " " " Pertimbangkan usia klien " "
" " " "3 "jika mendorong pelaksanaan " "
" " " "Toileting "aktivitas sehari-hari. " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "4 " " "
" " " "Bathing " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "5 " " "
" " " "Transfer perfomence " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "6 " " "
" " " "Walking " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "7 " " "
" " " "Position self " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "Kriteria Hasil : " " "
" " " "Sesuai dengan indikator " " "
" " "Kerusakan mobilitas "Setelah dilakukan tindakan "NIC : " "
" " "fisik berhubungan "keperawatan selama 3x24 jam, "Exercise therapy : " "
" " "dengan kerusakan "diharapkan klien dapat melakukan "ambulation " "
" " "neurovaskuler "gerakan fisik " Monitoring vital sign " "
" " " "NOC "sebelm/sesudah latihan dan " "
" " " "Mobility "lihat respon pasien saat " "
" " " "No "latihan " "
" " " "Indikator " Konsultasikan dengan " "
" " " "1 "terapi fisik tentang " "
" " " "2 "rencana ambulasi sesuai " "
" " " "3 "dengan kebutuhan " "
" " " "4 " Bantu klien untuk " "
" " " "5 "menggunakan tongkat saat " "
" " " " "berjalan dan cegah terhadap" "
" " " "1 "cedera " "
" " " "Muscle movement " Ajarkan pasien atau tenaga" "
" " " " "kesehatan lain tentang " "
" " " " "teknik ambulasi " "
" " " " " Kaji kemampuan pasien " "
" " " "v "dalam mobilisasi " "
" " " " " Latih pasien dalam " "
" " " " "pemenuhan kebutuhan ADLs " "
" " " "2 "secara mandiri sesuai " "
" " " "Transfer performance "kemampuan " "
" " " " "Dampingi dan Bantu pasien " "
" " " " "saat mobilisasi dan bantu " "
" " " " "penuhi kebutuhan ADLs ps. " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "3 " " "
" " " "Walking " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " "4 " " "
" " " "Moving with ease " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "v " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " " " " "
" " " "Kriteria Hasil : " " "
" " " "Sesuai dengan indikator " " "
IMPLEMENTASI KEPERAWATAN
Nama klien : Tn. A

No. Reg :


"No "Tgl "Diagnosa "Jam "Implementasi "Evaluasi Hasil "
" " "Keperawatan " " " "
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CATATAN PERKEMBANGAN KLIEN
Nama klien : Tn. A

No Reg :


No. dx "Tgl "S "O "A "P "I "E "R " " " "













" " " " " " " "
R E S U M E
Nama klien : Tn. A
Tanggal :
No. Reg :
Diagnosa medis :: Stroke
Dx. Kep "S "O "A "P "I "E "R " " "














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