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    6 просмотров18 страниц

    ADAPTASI ROYsip

    Загружено:

    njunaidi
    hashdahudauhh

    Авторское право:

    © All Rights Reserved
    Скачайте в формате DOCX, PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    из 18

    Pengkajian Keperawatan Model Adaptasi Roy 2018

    PENGKAJIAN TEORI MODEL ADAPTASI ROY


    PADA KLIEN DENGAN GANGGUAN SISTEM NEFROLOGI

    I. INFORMASI UMUM Tanggal :.................... Waktu:............ WIB


    A. Identitas Pasien

    Nama : RM :
    Umur : Jenis kelamin :
    Agama : Pendidikan :
    terakhir
    Pekerjaan :

    Alamat :

    Diagnosa :
    Medis

    B. Identitas Penanggungjawab

    Nama : Umur :
    Hubungan :
    No Tlp :
    Alamat :

    C. Riwayat Kesehatan

    Keluhan utama

    Riwayat Kesehatan Sekarang:

    Riwayat Kesehatan Masa Lalu

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    Konsumsi obat/ suplemen saat ini : tanggal ...................................

    Riwayat Penggunaan Obat-obatan:


    NSAID:

    Herbal:

    Allergi
    Obat :Tidak/ Ada : sebutkan............
    Makanan : Tidak/ Ada : sebutkan............
    Lainnya : Tidak/ Ada : sebutkan............
    Riwayat operasi/Kemotherapi/Radioterapi
     __________________________________ tahun _________________
     __________________________________ tahun _________________

    Riwayat penyakit keturunan:


    Tidak ada / Ada: sebutkan............
     Diabetes / Hipertensi / Asma / Jantung / Kanker / Lainnya : Tidak / ada
    Hasil Pemeriksaan Penunjang:
    Foto polos abdomen:

    Renal angiogram (renal arteriogram):

    Ct scan renal:

    Biopsy renal:

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    Rotgent thoraks:

    Dopler cimino:

    Hasil Pemeriksaan Lab.

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    II. ADAPTASI
    A. FISIOLOGIS
    1. OKSIGENASI
    Data Subjektif:

    Data Objetif:
    a. Fisik

    b. Pengkajian Stimulus
    Stimulus Fokal:
    Stimulus Kontekstual:
    Stimulus Residual:
    2. SIRKULASI
    Data Subjektif:

    Data Objetif:
    a. Fisik

    b. Pengkajian Stimulus
    Stimulus Fokal:
    Stimulus Kontekstual:
    Stimulus Residual:

    3. NUTRISI
    Data Subjetif:

    Data Objektif:
    a. Antropometri
    TB: cm, BB: Kg, IMT:
    Kesimpulan:

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    b. Biomedic

    c. Clinical

    d. Diet

    e. Pemeriksaan fisik abdomen

    f. Pengkajian Stimulus
    Stimulus Fokal:
    Stimulus Kontekstual:
    Stimulus Residual:

    4. ELIMINASI
    Data Subjektif:

    Data Objektif:
    a. Fisik
    BAK:
    a. Pola eliminasi urin:
    - Frekuensi berkemih: anuri, oliguri, poliuria:
    - Inkontinensia urin:
    - Nokturia:
    - Disuria:
    b. Karakteristik urin (warna, bau, jumlah, hematuria, atau nanah)
    c. Kesulitan berkemih:

    BAB:

    b. Pengkajian Stimulus
    Stimulus Fokal:
    Stimulus Kontekstual:

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    Stimulus Residual:

    5. AKTIVITAS DAN ISTIRAHAT


    a. Fisik
    Aktivitas:

    Kemampuan:
    Istirahat dan tidur:
    Bhartel Indexs:
    b. Pengkajian Stimulus
    Stimulus Fokal:
    Stimulus Kontekstual:
    Stimulus Residual:

    6. PROTEKSI DAN PERLINDUNGAN


    a. Fisik
    Skor Penilaian Skala Jatuh Pada Pasien (Morse):
    Resiko Jatuh:

    b. Pengkajian Stimulus
    Stimulus Fokal:
    Stimulus Kontekstual:
    Stimulus Residual:

    7. SENSORI
    a. Fisik
    Nyeri P:
    Q:
    R:
    S:
    T:

    Penglihatan Ketajaman : Visus: Konjungtiva:


    Sklera: ikterik/Tidak. Reflek cahaya : /

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    Penciuman  Sumbatan Kanan/Kiri  Perdarahan Kanan/ Kiri


     Kanan /  Kiri /
    Pengecapan  Manis  Asin  Asam
    Pendengaran Kanan / Kiri /

    b. Lainnya

    c. Pengkajian Stimulus
    Stimulus Fokal:
    Stimulus Kontekstual:
    Stimulus Residual:

    8. CAIRAN DAN ELEKTROLIT


    a. Fisik
    Intake cairan sebelumnya :.............cc.
    Intake Output
    Minum+makan : …….ml/24jam Urine : …….. ml/24 jam
    Intravena : …….ml/24jam Drain : .......... ml/24 jam
    IWL : …….. ml/24 jam
    Diare : .......... ml/24 jam
    Muntah : .......... ml/24 jam
    Perdarahan : .......... ml/24 jam

    Total : ……. ml/8 jam Total : …….. ml/8 jam


    Balance : ……. cc
    Tanda Dehidrasi : Rasa haus Kulit kering Mukosa bibir kering
    Turgor kulit < 3 dtk
    Distensi vena jugularis Tidak  Ya
    Edema Tidak  Ya  Sacral Anasarca
    Pitting Edema:
    GFR:

    Osmolaritas:

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    b. Pengkajian Stimulus
    Stimulus Fokal:
    Stimulus Kontekstual:
    Stimulus Residual:
    9. FUNGSI NEUROLOGI
    a. Fisik
    Lainnya
    Status Mental
    Tk. Kesadaran Compos mentis /apatis / delirium / letargi / sopor /
    soporacomatous
    Memory :  Panjang  Pendek
    Perhatian :  Dapat mengulang Tidak dapat mengulang
    Bahasa :  Baik  Tidak
    Kognisi :  Baik  Tidak
    Orientasi :  Orang  Tempat  Waktu
    Saraf sensori Nyeri tusuk  Suhu  Sentuhan
    Lainnya: ______________
    Saraf koordinasi  Ya  Tidak
    (cerebral)
    GCS : E M V =

    PengkajPengkajian Stimulus
    Stimulus Fokal:
    Stimulus Kontekstual:
    Stimulus Residual:

    10. ENDOKRIN
    a. Fisik
    Kalenjar tiroid Pembesaran:  Ya Tidak
    Tremor : Ya Tidak
    b. P
    Pankreas Trias DM : Ya Tidak
    e
    Adrenal Tanda Syndrom cushing  Ya Tidak
    n
    Pengkajian lain

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    c. Pengkajian stimulus
    Stimulus Fokal:
    Stimulus Kontekstual:
    Stimulus Residual:

    3. KONSEP DIRI
    a. Physical Self

    b. Personal Self
    Stimulus Fokal :
    Stimulus Kontekstual :
    Stimulus Residual :

    4. Fungsi Peran
    Stimulus Fokal :
    Stimulus Kontekstual :
    Stimulus Residual :

    5. Interdependen
    Stimulus Fokal :
    Stimulus Kontekstual :
    Stimulus Residual :

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    1. Adaptasi Konsep Diri


    Pengkajian Stimulus
    Pola Pengkajian Perilaku
    Stimulus Fokal Stimulus Kontekstual Stimulus Residual
    Perkembangan
    diri

    Focus diri

    Identitas diri

    2. Adaptasi Fungsi Peran


    Pengkajian Stimulus
    Pola Pengkajian Perilaku
    Stimulus Fokal Stimulus Kontekstual Stimulus Residual
    Pengembangan
    peran

    Pengambilan
    peran

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    Pengkajian Stimulus
    Pola Pengkajian Perilaku
    Stimulus Fokal Stimulus Kontekstual Stimulus Residual
    Integrasi peran

    3. Adaptasi Interdependensi
    Pengkajian Stimulus
    Pola Pengkajian Perilaku
    Stimulus Fokal Stimulus Kontekstual Stimulus Residual
    Affectional
    adequacy

    Sumber daya
    yang adekuat

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    4. Diagnosis Keperawatan

    1. ..............................................................................................................................................
    ..............................................................................................................................................
    2. ..............................................................................................................................................
    ..............................................................................................................................................
    3. ..............................................................................................................................................
    ..............................................................................................................................................
    4. ..............................................................................................................................................
    ..............................................................................................................................................
    5. ..............................................................................................................................................
    ..............................................................................................................................................

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    5. Intervensi Keperawatan (Kroteria NOC & NIC)

    No Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi

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


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    2 ................................................... ................................................................................. ................................................................................
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    3 ................................................... ................................................................................ ................................................................................
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    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

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


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    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

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    6 ................................................... ................................................................................. ................................................................................
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    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    6. IMPLEMENTASI

    Waktu Implementasi TTD Waktu Implementasi TTD

    Dx : .......................................................................................... Dx : S:
    .......................................................................................... ..........................................................................................
    .......................................................................................... ..........................................................................................
    Hari: .......................................................................................... Hari: ..........................................................................................
    ............ .......................................................................................... ............ ..........................................................................................
    Tgl .......................................................................................... Tgl ..........................................................................................
    ............ .......................................................................................... ............ ..........................................................................................
    Jam: .......................................................................................... Jam: ..........................................................................................
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    Dx : .......................................................................................... Dx : S:
    .......................................................................................... ..........................................................................................
    .......................................................................................... ..........................................................................................
    Hari: .......................................................................................... Hari: ..........................................................................................
    ............ .......................................................................................... ............ ..........................................................................................
    Tgl .......................................................................................... Tgl ..........................................................................................
    ............ .......................................................................................... ............ ..........................................................................................
    Jam: .......................................................................................... Jam: ..........................................................................................
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    ..........................................................................................

    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    7. EVALUASI

    Waktu Evaluasi TTD Waktu Evaluasi TTD

    Hari: S: Hari: S:
    ............ .......................................................................................... ............ ..........................................................................................
    Tgl .......................................................................................... Tgl ..........................................................................................
    ............ .......................................................................................... ............ ..........................................................................................
    Jam: .......................................................................................... Jam: ..........................................................................................
    ............ .......................................................................................... ............ ..........................................................................................
    .......................................................................................... ..........................................................................................
    .......................................................................................... ..........................................................................................
    O: O:
    .......................................................................................... ..........................................................................................
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    A A
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    P: P:
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    @Napsan Junaidi/1506707341
    Pengkajian Keperawatan Model Adaptasi Roy 2018

    @Napsan Junaidi/1506707341

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