Académique Documents
Professionnel Documents
Culture Documents
I. KELUHAN UTAMA
a. Keluhan Masuk Rumah Sakit
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Keterangan:
: Laki-laki : Klien
V. RIWAYAT SOSIAL
1. Sistem pendukung/ keluarga terdekat yang dapat dihubungi
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2. Lingkungan rumah
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3. Problem sosial yang penting
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3. Status Cairan:
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4. Aktivitas Anak
Sebelum Masuk Rumah Sakit:
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Saat Dirawat Di Rumah Sakit:
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4. Kepala dan Leher
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5. Mata
Posisi bola mata : ...........................................................................................
Gerakan mata : ...............................................................................................
Konjungtiva : .............................................................................................................
Kornea : .....................................................................................................................
Sklera : ......................................................................................................................
Pupil :.........................................................................................................................
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6. THT
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7. Ekstremitas
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8. Toraks
Inspeksi : ................................................................................................................
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Palpasi : ................................................................................................................
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Perkusi : ................................................................................................................
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Auskultasi : ................................................................................................................
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9. Jantung
Inspeksi : ................................................................................................................
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Palpasi : ................................................................................................................
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Perkusi : ................................................................................................................
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Auskultasi : ................................................................................................................
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10. Abdomen
Inspeksi : ................................................................................................................
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Auskultasi : ................................................................................................................
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Perkusi : ................................................................................................................
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Palpasi : ................................................................................................................
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11. Genitalia
Frekuensi BAK: ......................../hari , Jumlah Urine: ........................ cc
Warna Urine: .............................................................................................................
Penggunaan Alat bantu berkemih: ............................................................................
Kondisi Blast: ............................................................................................................
Tanggal defekasi terakhir: .........................................................................................
Frekuensi BAB: .........../hari, Konsistensi: ..............., Warna: ......................
Penggunaan Alat bantu (Laksatif): ............................................................................
12. Tumbuh Kembang
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NCHS
a. BB/U
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b. TB/U
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c. BB/TB
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d. CDC 2000
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Lampiran 1. Daftar Obat-Obatan
No Obat Dosis Indikasi
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Lampiran 2. Hasil Pemeriksaan Laboraturium
Pemeriksaan Hasil Nilai Normal Satuan
HEMATOLOGI
Hemoglobin ................. 10.00-17.00 g/dl
Lekosit ................. 4.0-10.5 ribu/ul
Eritrosit ................. 3.40-5.50 juta/ul
Hematokrit ................. 35.00-50.00 vol%
Trombosit ................. 150-450 ribu/ul
RDW-CV ................. 11.5-14.7 %
MCV,MCH, MCHC
MCV ................. 80.0 – 97.00 fl
MCH ................. 27.0 – 32.0 pg
MCHC ................. 32.0 – 38.0 %
HITUNG JENIS
Gran% ................. 50.0 – 70.0 %
Limfosit% ................. 25.0 – 40.0 %
MID% ................. 4.0-11.0 %
Gran# ................. 2.50 – 7.00 ribu/ul
Limfosit# ................. 1.25-4.0 ribu/ul
MID# ................. ribu/ul
KIMIA DARAH
Glukosa Darah Sewaktu ................. <200 mg/dl
HATI
SGOT ................. 0-46 u/l
SGPT ................. 0-45 u/l
GINJAL
Ureum ................. 10-50 mg/dl
Kreatinin ................. 0.7-1.4 mg/dl
ELEKTROLIT
Natrium ................. 135-146 mmol/l
Kalium ................. 3.4-5.4 mmol/l
Chlorida ................. 95-100 mmol/l
ANALISIS DATA
Nama Klien : ..............................................
Umur : ..............................................
Ruangan/Kamar : ..............................................
No. Data Penyebab Masalah
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PRIORITAS MASALAH
Nama klien : ..............................................
Umur : ..............................................
Ruangan/kamar : ..............................................
No. RM : ..............................................
Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama Perawat)
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RENCANA KEPERAWATAN
Tujuan Dan
No. Diagnosa Keperawatan Intervensi Rasional
Kriteria Hasil
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IMPLEMENTASI KEPERAWATAN DAN CATATAN PERKEMBANGAN
No.
Waktu Waktu
Dx Implementasi TT Evaluasi TT
Tgl/jam Tgl/jam
Kep
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