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ASUHAN KEPERAWATAN An.

S
DENGAN GANGGUAN RASA NYAMAN (NYERI) DI RUANG CENDANA 4
RSUP DR. SARDJITO YOGYAKARTA

A. Identitas Pasien
Nama Pasien : .............................................................................................
No RM : .............................................................................................
Tempat tanggal lahir : .............................................................................................
Umur : ............................................................................................
Agama : .............................................................................................
Status Perkawinan : .............................................................................................
Pendidikan : .............................................................................................
Alamat : .............................................................................................
Pekerjaan : .............................................................................................
Jenis Kelamin : .............................................................................................
Suku / Bangsa : .............................................................................................
Dx Medis : .............................................................................................
Tanggal Masuk RS : .............................................................................................
Tanggal Pengkajian : .............................................................................................
Sumber Informasi : .............................................................................................

Penanggung Jawab
Nama : .............................................................................................
Tempat Tanggal Lahir : .............................................................................................
Umur : .............................................................................................
Agama : .............................................................................................
Alamat : .............................................................................................
Pekerjaan : .............................................................................................
Jenis Kelamin : .............................................................................................
Hubungan dengan pasien : .............................................................................................

B. Riwayat Kesehatan
1. Riwayat Kesehatan
a) Keluhan Utama :
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b) Riwayat Penyakit Sekarang :
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c) Riwayat Penyakit Dahulu :
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d) Riwayat Penyakit Keluarga:
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e) Genogeram
C. Pengkajian Pemenuhan Kebutuhan Dasar Manusia Menurut Gordon (11 Pola):
1. Pola Persepsi dan Pemeliharaan Kesehatan
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2. Pola Nutrisi
Sebelum Sakit
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Selama Sakit
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3. Pola Eliminasi
Sebelum Sakit
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Selama Sakit
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4. Aktivitas dan Latihan
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5. Tidur dan Istirahat
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6. Sensori, Persepsi, dan Kognitif
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7. Konsep diri
a. Identitas
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b. Gambaran Diri
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c. Ideal Diri
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d. Harga Diri
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e. Peran Diri
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8. Seksual dan Reproduksi
Sebelum Sakit
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Selama Sakit
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9. Pola Peran Hubungan
Sebelum Sakit
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Selama Sakit
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10. Manajemen Koping Stress
Sebelum Sakit
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Selama Sakit
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11. Sistem Nilai dan Keyakinan
Sebelum Sakit
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Selama Sakit
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D. Pemeriksaan Fisik
1. Tingkat Kesadaran :
2. TTV :S 0C,N x/mnt, RR x/mnt, TD: mmhg

3. Kepala :
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4. Mata, Telinga, Hidung
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5. Mulut
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6. Leher
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7. Data / Thoraks
Inspeksi:
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Palpasi:
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Perkusi:
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Auskultasi:
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8. Abdomen:
Inspeksi:
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Palpasi:
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Perkusi:
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Auskultasi:
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9. Genitalia:
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10. Ekstremitas:
Atas:
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Bawah:
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11. Kulit:
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E. PEMERIKSAAN PENUNJANG
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F. Terapi
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G. ANALISA DATA

Data Problem Etiologi


H. DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS MASALAH

1. .............................................................................................................................................
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RENCANA ASUHAN KEPERAWATAN

No Diagnosa Keperawatan Tujuan (NOC) Intervensi (NIC)


CATATAN PERKEMBANGAN

Nama Pasien : Umur :

No. Rm Diagnosa Medis :

Hari/ TTD/
Tanggal / Diagnosa Keperawatan Implementasi Evaluasi Nama
Jam Terang