format pengkajian dm ns.margaretha bangkut sem iv

8/17/2019 Format Pengkajian DM Ns.margaretha Bangkut Sem IV

1/23

FORMAT PENGKAJIAN KEPERAWATAN

KEPERAWATAN MEDIAKAL BEDAH

FAKULTAS KEPERAWATAN UNIVERSITAS SARI PUTRA INDONESIA

TOMOHON

UNIT : TGL PENGKAJIAN :

RUANG/KAMAR : WAKTU PENGKAJIAN :

TGL MASUK RS : Auto Anamnese :

AlloAnamnese :

I. IDENTITAS

A. KLIEN :

NAMA INITIAL :

TEMPAT/TGL LAHIR(UMUR :

JENIS KELAMIN : LAKI!LAKI PEREMPUAN

STATUS PERKAWINAN :

JUMLAH ANAK :

AGAMA/SUKU :

WARGA NEGARA : IND"NESIA ASING#AHASA $ANG DIGUNAKAN : IND"NESIA

DAERAH%%%%%%%%%%%%%%%.

ASING%%%%%%%%%%%%%%%%..

PENDIDIKAN :

PEKERJAAN :

ALAMAT RUMAH :#. PENANGGUNG JAWA#

NAMA :

ALAMAT :

HU#UNGAN DENGAN KLIEN :

II. DATA MEDIK :

A. DIKIRIM "LEH : UGD D"KTER PRAKTEK #. DIAGN"SA MEDIK :

SAAT MASUK :

SAAT PENGKAJIAN :

III. KEADAAN UMUM

A. KEADAAN SAKIT :

1

NAMA MAHASISWA YANG MENGKAJI: NIM:


2/23

#. ALASAN :

&. KELUHAN UTAMA :

D. RIWA$AT KELUHAN UTAMA :

E. KELUHAN $ANG MEN$ERTAI :

'. TANDA!TANDA ITAL :). KEASADARAN

Kual*tat*+ : &om,os ment*s Somnolens &oma

A,at*s So,o-oomateus

Kuant*tat*+ :

Sala &oma Glas0o1:

• Res,on moto-* :

• Res,on 2*a-a :

• Res,on mem2ua mata :

Kes*m,ulan :

'la,*n0 T-emo-/aste-*s*s : Pos*t*+ Ne0at*3e

4. TEKANAN DARAH :

MAP :%%%%%%%%%%%%%%%mmH0

Kes*m,ulan :

5. SUHU : o-al A6*lla- Retal

7. NADI :

8. PERNAPASAN :

I-ama : Te-atu- Kusmaul &9enes!stoes

Jen*s : Da;a Pe-ut

G. PENGUKURAN). L*n0a- len0an atas :%%%%%%%%%m

4. L*,at ul*t t-*e,s :%%%%%%%%%m

5. T*n00* 2a;an :%%%%%%%%%m #e-at 2a;an :%%%%%.0

I.M.T (*n;e6 massa tu2u9 :%%%%%%%%%0/ m2

Kes*m,ulan :%%%%%%%%%%%%%%%%%%%%%%%%%...

&atatan :%%%%%%%%%%%%%%%%%%%%%%%%%...

H. GEN"GRAM

2


3/23

I. PENGKAJIAN P"LA KESEHATAN ()) G"RD"N

A. KAJIAN PERSEPSI KESEHATAN PEMELIHARAAN KESEHATAN

R*1aat ,ena*t an0 ,e-na9 ;*alam*:Sa*t 2e-at< ;*-a1at


4/23

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

2. Kea;aanse=asa*t:

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

2. Data #bjet!"

a. "2se-3as*

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

b. Peme-*saan+*s*

• Kea;aan-am2ut%%%%%%%%%%%%%%%%%%%%%%%%%%%

• H*;-as*ul*t%%%%%%%%%%%%%%%%%%%%%%%%%%%%...

• Pal,e2-ae%%%%%%%%%%%%%

on=un0t*3a%%%%%%%%%%%%%%%%...

• Sle-a%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.

• H*;un0%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%...

• Ron00amulut%%%%%%%%%%%Gus*%%%%%%%%%%%%%%%.

• G*0* 0el*0*%%%%%%%%%%%%...G*0* ,alsu%%%%%%%%%%%%..

• Kemam,uanmen0una9e-as%%%%%%%%%%%%%%%%%%%%%.

• L*;a9%%%%%%%%%%%%%%%Tons*l%%%%%%%%%%%%%%

• P9a-*n0%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%...

• Kelen=a-0eta92en*n0le9e-%%%%%%%%%%%%%%%%%%%%%%...

• Kelen=a-,a-ot*s%%%%%%%%%%%.Kelen=a-t*-o*;%%%%%%%%%%.

• A2;omen

Ins,es* : #entu%%%%%%%%%%%%%%%%%%%%%%

#aan0an 3ena%%%%%%%%%%%%%%%%%%...

#en=olan 3ena%%%%%%%%%%%%%%%%%%%

Ausultas* : Pe-*stalt*%%%%6/men*t

Pal,as* : Tan;ane-*umum%%%%%%%%%%%%%%%%%.

Massa%%%%%%%%%%%%%%%%%%%%%%

H*;-as*ul*t%%%%%%%%%%%%%%%%%%%...

Ne-*tean: R. E,*0ast-*a T*t* M. #u-ne

R. Su,-a,u2*a R. Ill*aaHe,a-%%%%%%%%%%%%%%%%%%%%%%.

L*en%%%%%%%%%%%%%%%%%%%%%%%

Pe-us* : %%%%%%%%%%%%%%%%%%%%%%%%...

As*tes : Ne0at*3e

Pos*t*3e< l*n0a-,e-ut%%%%/%%%../%%%%.m

• Kelen=a-l*m+e *n0u*nal%%%%%%%%%%%%%%%%%%%%%%%%%

4


5/23

• Kul*t :

o S,*;e- nae3* : Ne0at*+ Pos*t*+

o U-em* +-ost : Ne0at*+ Pos*t*+

o E;ema : Ne0at*+ Pos*t*+

o Ite-* : Ne0at*+ Pos*t*+

o

Tan;a-a;an0%%%%%%%%%%%%%%%%%%%%%%%%%..• Les*%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

$. Pe%e&!'aa(D!a)(#'t!

• La2o-ato-*um:

• La*n!la*n

5


6/23

*. Te&a+!,

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

-. KAJIAN POLA ELIMINASI1. Data Subjet!"

a. Kea*aa( 'ebeu% 'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

b. Kea*aa( 'eja 'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%2. Data Objet!"

a. Ob'e&/a'!

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

b. Pe%e&!'a( "!'!

• Pe-*stalt* usus:%%%%%.6/men*t

• Pal,as*su,-a,u2*a :an;un0em*9 ,enu9 Koson0

• Ne-*etu0*n=al :*-*

• Mulutu-et-a : anan

• Anus :

Pe-a;an0an :

'*ssu-a :

Hemo--9o*; :

P-ola,ses -et* :

'*stula an* :

Massa tumo- :

$. Pe%e&!'aa(*!a)(#'t!

• La2o-ato-*um

• La*n!la*n

*. Te&a+!,

6


7/23

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

D. KAJIAN POLA AKTIFITAS DAN LATIHAN

1. Data Subjet!"

a. Kea*aa('ebeu%'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

b. Kea*aa('eja'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

2. Data Objet!" a. Ob'e&/a'!

• At*+*tas9a-*an

Maan :

Man;* :

#e-,aa*an :

Ke-a,*9an :

#uan0 a*- 2esa- :

#uan0 a*- e*l :

Mo2*l*tas ;* tem,att*;u- :

Am2ulas* : man;*-*/ton0at/u-s*-o;a/tem,att*;u-

• Postu-tu2u9 : %%%%%%%%%%%%%%%%..• Gaa =alan : %%%%%%%%%%%%%%%%..

• An00ota0e-a an0 aat: %%%%%%%%%%%%%%%%..

• '*sas* : %%%%%%%%%%%%%%%%..

• T-a9eostom : %%%%%%%%%%%%%%%%..

b. Pe%e&!'a("!'!

• JP%%%%%%%.mH4"%%%%%%%%%%%%%%%%%%%

• Pe-us*,em2ulu,e-*+e- uu%%%%%%%%%%%%%%%%%%%

• T9o-as;an,e-na,asan

#entuto-a6 :

St-*;o- : Ne0at*+ Pos*t*+

Ds,noe;>E++o-t : Ne0at*+ Pos*t*+ Sanos*s : Ne0at*+ Pos*t*+

Pal,as* : 3oal +e-m*tus

Pe-us* : Sono- Re;u, Pea

#atas ,a-u9e,a- : %%%%%%%%%%%%...

Kes*m,ulan : %%%%%%%%%%%%...

Ausultas* :Sua-ana,as : %%%%%%%%%%%%...

Sua-aua,an : %%%%%%%%%%%%...

7

0 :mandiri

1 :bantuandn!ana"at

2 :bantuan #ran!

3 :bantuan #ran!

dana"at


8/23

Sua-atam2a9an : %%%%%%%%%%%%...

• Jantun0

Ins,es* : Itus o-;*s

Kl*enmenn0unaanalat,au=an0tun0 Ne0at*+ Pos*t*+

Pal,as* : Itus o-;*s

Pe-us* : #atas atas=antun0 : %%%%%%%%%%%......

#atas anan=antun0 :

%%%%%%%%%%%%%..

#atas *-*=antun0 :

%%%%%%%%%%%%%

Ausultas* : #un*=antun0 II A :

#un*=antun0 II P :

#un*=antun0 I T :

#un*=antun0 I M :

#un*=antun0 III I-amaGallo, : Ne0at*+

Pos*t*+ Mu-mu- : Ne0at*+ Pos*t*+< Tem,at :

%%%%.

G-a;e :

%%%%.

HR :%%%%%%%..6/men*t

#un* ao-ta : Ne0at*+ Pos*t*+

A-te-*-enal*s : Ne0at*+ Pos*t*+

Mat*A-te-*+emo-al*s : Ne0at*+ Pos*t*+

• Len0an;antun0a*

At-o+*otot : Ne0at*+ Pos*t*+

Rentan00e-a :

%%%%%%%%%%%%%%%%%%%%%%.

Mat*sen;* :

%%%%%%%%%%%%%%%%%%%%%%.

Kausen;* :

%%%%%%%%%%%%%%%%%%%%%%.

U=*euatanotot : K*-* :

Kanan :

Re+le6 +*s*olo0* :

%%%%%%%%%%%%%%%%%%%%%%.

Re+le6 ,atolo0* : #a2*ns* *-* : Ne0at*+ Pos*t*+

#a2*ns* anan : Ne0at*+ Pos*t*+

&lu22*n0 =a-*!=a-* : Ne0at*+ Pos*t*+

a-*sestun0a* : Ne0at*+ Pos*t*+

• &olumna3e-te2-al*s

Ins,es* :

%%%%%%%%%%%%%%%%%%%%%%.

&

) 4 5 7 8

) 4 5 7 8


9/23

Pal,as* :Ne-*tean Ne0at*+ Pos*t*+

N III!I!I :

%%%%%%%%%%%%%%%%%%%%%%.

N III test -om2e-0 : Ne0at*+ Pos*t*+

N ?I :

%%%%%%%%%%%%%%%%%%%%%%.

Kauu;u :

%%%%%%%%%%%%%%%%%%%%%%.

$. Pe%e&!'aa(*!a)(#'t!

Lab#&at#&!u%

La!(0a!(

*. Te&a+!,

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%

E. KAJIAN POLA TIDUR DAN ISTIRAHAT

1. Data Subjet!"


%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%

b. Kea*aa('eja'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%

2. Data Objet!"

a. Ob'e&/a'!

• Es,-es*1a=a9men0antu : Ne0at*+ Pos*t*+

• #anamen0ua, : Ne0at*+ Pos*t*+

• Pal,e2-ae *n+e-*o- 2e-1a-na0ela, : Ne0at*+ Pos*t*+

'


10/23

b. Te&a+!,

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%

F. KAJIAN POLA PERSEPSI KOGNITIF

1. Data Subjet!"


%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%

b. Kea*aa('eja'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%

2. Data Objet!"

a. Ob'e&/a'!

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%

b. Pe%e&!'a("!'!

• Pen0l*9atan

&o-nea :

%%%%%%%%%%%%%%%%%%%%%%%

10


11/23

*sus :

%%%%%%%%%%%%%%%%%%%%%%%

Pu,*l :

%%%%%%%%%%%%%%%%%%%%%%%

Lensamata :

%%%%%%%%%%%%%%%%%%%%%%% Teanan Int-a "ule- :

%%%%%%%%%%%%%%%%%%%%%%%

• Pen;en0a-an

P*na :

%%%%%%%%%%%%%%%%%%%%%%%

&anal*s :

%%%%%%%%%%%%%%%%%%%%%%%

Mem2-ane Tm,an* :

%%%%%%%%%%%%%%%%%%%%%%%

Tes,en;en0a-an :

%%%%%%%%%%%%%%%%%%%%%%%• Pen0enalan -asa ,os*s*,a;a0e-aanlen0an;antun0a*

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%...

• N I :

%%%%%%%%%%%%%%%%%%%%%%%

• N II :

%%%%%%%%%%%%%%%%%%%%%%%

• N Senso-* :

%%%%%%%%%%%%%%%%%%%%%%%

• N III Pen;en0a-an :

%%%%%%%%%%%%%%%%%%%%%%%

• TesRom2e0 :

%%%%%%%%%%%%%%%%%%%%%%%

$. Pe%e&!'aa(*!a)(#'t!

Lab#&at#&!u%

La!(0a!(

*. Te&a+!,

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

11


12/23

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%

G. KAJIAN POLA PERSEPSI DAN KONSEP DIRI

1. Data Subjet!"


%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%

b. Kea*aa('eja'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%

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%%%%%%%%

2. Data Objet!"

a. Ob'e&/a'!

• Kontamata :

%%%%%%%%%%%%%%%%%%%%%%...

• Rentan0,e-9at*an :

%%%%%%%%%%%%%%%%%%%%%%...

• Sua-a;ana-a2*a-a :

%%%%%%%%%%%%%%%%%%%%%%...

• Postu-tu2u9 :

%%%%%%%%%%%%%%%%%%%%%%...

b. Pe%e&!'a("!'!

• Kela*nan2a1aan an0 nata :

%%%%%%%%%%%%%%%%%%%%%%...

•

A2;omen: #entu :%%%%%%%%%%%%%%%%%%%%%%...

#aan0an 3ena :

%%%%%%%%%%%%%%%%%%%%%%...

#aan0anmassa :

%%%%%%%%%%%%%%%%%%%%%%...

• Kul*t : Les*ul*t :

• Pen00unaan,-otesa : H*;un0 Pau;a-a

12


13/23

Len0an Tun0a*

H. KAJIAN POLA PERAN DAN HUBUNGAN DENGAN SESAMA

1. Data Subjet!"


%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%

b. Kea*aa('eja'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%

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%%%%%%

I. KAJIAN POLA REPRODUKSI0SEKSUALITAS

1. Data Subjet!" a. Kea*aa('ebeu%'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%

b. Kea*aa('eja'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%

2. Data Objet!"

a. Ob'e&/a'!

13


14/23

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%

b. Pe%e&!'a("!'!

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%

$. Pe%e&!'aa(*!a)(#'t!

Lab#&at#&!u%

La!(0a!(

*. Te&a+!,

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%

J. KAJIAN MEKANISME KOPING DAN TOLERANSI TERHADAP STRES

1. Data Subjet!"


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%%%%%%%%%%%%

14


15/23

b. Kea*aa('eja'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%

2. Data Objet!"

a. Ob'e&/a'!

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%

b. Pe%e&!'a("!'!

• Teanan;a-a9 : #e-2a-*n0 : %%%%%%.mmH0

Du;u : %%%%%%.mmH0

#e-;*-* : %%%%%%.mmH0

Kes*m,ulanH*,otens*"-tostat* : Ne0at*+ Pos*t*+

• HR : %%%%%%%%%%%%%.6/men*t

• Kul*t : Ke-*n0at;*n0*n :

%%%%%%%%%%%%%%%%%%%%.

#asa9 :

%%%%%%%%%%%%%%%%%%%%.

$. Te&a+!,

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%

K. KAJIAN POLA NILAI KEPER-AAAN

1. Data Subjet!"


%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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15


16/23

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%%%%%

b. Kea*aa('eja'a!t

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%

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%%%%%%%%

2. Data Objet!" a. Ob'e&/a'!

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

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%%%%%%%%%%

16

Namadan(anda(an!an )an!Mn!*a+i


17/23

FAKULTAS KEPERAWATAN

UNIVERSITAS SARIPUTRA NDONESIA TOMOHON

KLASIFIKASI DATA

NO DATA SUBJEKTIF DATA OBJEKTIF

17


18/23



PATOFLOWPENIMPANGAN KDM

1&


19/23



ANALISA DATA

NO DATA ETHIOLOGI DATA OBJEKTIF

1'


20/23



DIAGNOSA KEPERAWATAN

NAMA ,RUMAH SAKIT ,

RUANGKAMAR ,

NO DATA ETHIOLOGI DATA OBJEKTIF

20


21/23



INTERVENSI (NursingCare Plan)

DI UNIT RAWAT INAP RS,3333333333

NAMA PASIEN , 333333333 RUANGAN,3333.. NO RM ,

33333

NO DIAGNOSA

KEPERAWATAN

TUJUAN INTERVENSI RASIONAL

21


22/23



ASUHAN KEPEAWATAN

DI UNIT RAWAT INAP RS,3333333333

NAMA PASIEN , 333333333 RUANGAN,3333.. NO RM ,

33333

NO DIAGNOSA

KEPERAWATAN

IMPLEMENTASI EVALUASI NAMA

JELAS

22


23/23

23

format pengkajian dm ns.margaretha bangkut sem iv

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