Академический Документы
Профессиональный Документы
Культура Документы
A. PENGKAJIAN
1. IDENTITAS
a. Klien
Nama klien :
Tempat/tanggal lahir :
Umur :
Jenis kelamin :
Pendidikan terakhir :
Pekerjaan :
Alamat :
Diagnosa medis :
b. Penanggung Jawab
Nama klien :
Jenis kelamin :
Umur :
Pendidikan terakhir :
Pekerjaan :
Alamat :
2. KELUHAN UTAMA
3. GENOGRAM
Keterangan Genogram:
: Laki-laki
: Perempuan
: Sudah Meninggal
: Tinggal Serumah
: Klien
4. RIWAYAT KESEHATAN
7. RIWAYAT REKREASI
f. Hidung dan Sinus
g. Mulut dan Tenggorokan
h. Leher
i. Payudara
j. Pernapasan
k. Kardiovaskuler
l. Gastrointestinal
m. Perkemihan
n. Genitourinaria
o. Muskuloskletal
p. System Saraf Pusat
q. System Endokrin
r. Reproduksi
8. Berdahak/sputum
Fungsi Jantung
9. Jantung berdebar-debar
D
10. Cepat lelah pada kaki/tangan
11. Nyeri dada
Fungsi Pencernaan
12. Mual/muntah
13. Nyeri ulu hati
E 14. Makan dan minum banyak
15. Perubahan kebiasaan BAB
(diare/konstipasi)
Fungsi Pergerakan
16. Nyeri kaki saat berjalan
F
17. Nyeri pinggang atau tulang belakang
18. Nyeri persendian/bengkak
Fungsi Persyarafan
19. Lumpuh/kelemahan
G 20. Kehilangan rasa
21. Gemetar/tremor
22. Nyeri/pegal pada daerah tengkuk
Fungsi Saluran Perkemihan
23. BAK banyak
H 24. Sering BAK pada malam hari
25. Tidak mampu mengontrol pengeluaran air
kemih (ngompol)
Jumlah
TOTAL
Skor:
25 = Masalah kesehatan kronis ringan
26-50 = Masalah kesehatan kronis sedang
51 = Masalah kesehatan kronis berat
INTERPRETASI HASIL PEMERIKSAAN: ......................................................................
b. Identifikasi Masalah Emosional
Pertanyaan tahap 1
(Tuliskanlah jawaban YA/TIDAK sesuai kondisi yang dialami klien)
Apakah klien mengalami kesulitan tidur (...)
Apakah klien sering merasa gelisah (...)
Apakah klien sering murung dan menangis sendiri (...)
Apakah klien sering was-was atau kuatir (...)
Lanjutkan ke pertanyaan tahap 2 jika lebih dari atau sama dengan 1 jawaban ya
Pertanyaan tahap 2
(Tuliskanlah jawaban YA/TIDAK sesuai kondisi yang dialami klien)
Keluhan lebih dari 3 bulan atau lebih dari 1 kali dalam 1 bulan? (...)
Ada atau banyak pikiran? (...)
Ada gangguan/masalah dengan keluarga lain? (...)
Menggunakan obat tidur/penenang atas anjuran dokter? (...)
Cenderung mengurung diri? (...)
Bila lebih dari atau sama dengan1 jawaban ya,
maka MASALAH EMOSIONAL POSITIF (+)
INTERPRETASI HASIL PEMERIKSAAN: ......................................................
c. Spiritual
(Kaji agama, kegiatan keagamaan, konsep/keyakinan klien tentang kematian,
harapan-harapan klien, dll)
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Berpindah dari kursi roda ...................................................
3 5-10 15 ...................................................
ketempat tidur/sebaliknya
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Frekuensi:
Personal toilet (cuci muka, ...................................................
...................................................
4 menyisir rambut, 0 5
...................................................
menggosok gigi) ...................................................
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Keluar masuk toilet ...................................................
5 (mencuci pakaian, menyeka 5 10 ...................................................
...................................................
tubuh, menyiram) ...................................................
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6 Mandi 5 15 ...................................................
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Frekuensi:
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7 Jalan di permukaan datar 0 5 ...................................................
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8 Naik turun tangga 5 10 ...................................................
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9 Menggunakan pakaian 5 10 ...................................................
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Frekuensi:
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10 Kontrol bowel (BAB) 5 10
Konsistensi:
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Frekuensi :
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11 Kontrol Bladder (BAK) 5 10
Warna :
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TOTAL SKOR
Keterangan:
110 : Mandiri
65-105 : Ketergantungan sebagian
60 : Ketergantungan total
INTERPRETASI: .....................................................................................................
3 REGISTRASI 3 disebutkan).
Obyek: ............................
Obyek: ............................
Obyek: ............................
4 PERHATIAN 5 Minta klien untuk memulai dari angka 100
DAN kemudian dikurangi 7 sampai 5 kali.
93
86
KALKULASI 79
72
65
Minta klien untuk mengulangi ketiga obyek pada
5 MENGINGAT 3 nomer 2 (registrasi) tadi, bila benar 1 point untuk
masing masing obyek.
1) Tunjukkan pada klien suatu benda dan
tanyakan namanya pada klien (misal jam
tangan atau pensil)
Penilaian:
> 23 : Aspek kognitif dari fungsi mental baik
18-22 : Kerusakan aspek fungsi mental ringan
17 : Terdapat kerusakan aspek fungsi mental berat
INTERPRETASI: .....................................................................................................
16. PENGOBATAN
No Tanggal Terapy (Nama, Waktu, Dosis, Rute)
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Dx TTD
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Dibuat dalam bentuk SOAPIE untuk pasien pulang atau pindah ruangan. Untuk S dan O dibuat dari hasil awal kajian, A sebagai diagnosa
yang ditemukan, P sebagai perancanaan yang akan dilakukan, I sebagai tindakan keperawatan yang telah dilakukan, dan E sebagai evaluasi
keadaan terakhir klien.
Discharge Planning
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Klien ...... L/P MRS pada tanggal .............. jam ... dengan diagnose medis ......................................... telah diberikan tindakan
keperawatan diatas. Untuk itu perlu perawatan lanjutan di .........................../kunjungan rutin ke ....................... mulai tanggal .........................
Anjuran:
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Denpasar, ...........................................
Perawat
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