kmb1_form askep angsoka 1

8/19/2019 Kmb1_form Askep Angsoka 1

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,. Ke"arga ter)ekat -ang )apat )ih"%"ngi 'rangt"a/ wai/ s"ami/ istri/ )an ain0ain1

Peker!aan : .............................................. Pen)i)ikan : .......................................................

Aamat : .......................................................................................................................

2. Aergi :

Tipe : ..........................................................................................................................

Reaksi : .........................................................................................................................

Tin)akan : ........................................................................................................................

3. Ke%iasaan : mer'k'k# k'pi # '%at # ak'h' # ain0ain

(ika -a !easkan .................................................................................................

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4. P'a Pernapasan

Kes"itan %erna&as : a)a#ti)ak

Kes"itan )irasakan : menarik#menge"arkan na&as

Ke"han -ang )irasakan :

5. P'a n"trisi

6rek"ensi#p'rsi makan : .................................................................................................

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

*erat *a)an : ............................... Tinggi *a)an: ........................

(enis makanan : .................................................................................................

Makanan -ang )is"kai : .................................................................................................Makanan ti)ak )is"kai : .................................................................................................

Makanan pantangan : ................................................................................................

Na&s" makan : 7 8 %aik

7 8 se)ang/ aasan : m"a#m"ntah#sariawan#)

7 8 k"rang/ aasan : m"a#m"ntah#sariawan#)

Per"%ahan ** 3 %"an terakhir :

7 8 %ertam%ah ........................... kg

7 8 tetap


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7 8 %erk"rang ........................... kg

9. P'a eiminasi

a. *"ang air %esar :

6rek"ensi : .................................... Wakt" :pagi#siang#s're#maam

Warna : .................................... K'nsistensi :...................................

Pengg"naan Penahar : ........................................

%. *"ang air kei :

6rek"ensi : ............................ Warna :.....................................

*a" : ............................

;. P'a ti)"r )an istirahat :

Wakt" ti)"r !am1 : ......................................................................................

$ama ti)"r#hari : ......................................................................................

Ke%iasaan pengantar ti)"r : ......................................................................................

Ke%iasaan saat ti)"r : ......................................................................................

Kes"itan )aam ha ti)"r : 7 8 men!eang ti)"r

7 8 sering#m")ah ter%ang"n

7 8 merasa ti)ak p"as seteah %ang"n ti)"r


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II. Riwayat Kekuarga

Gen'gram :


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III. Riwayat Lingkungan

,. Ke%ersihan $ingk"ngan : ....................................................................................................

2. *aha-a : ....................................................................................................

3. P'"si : ....................................................................................................

IV. Aspek Psikososial

,. P'a pikir )an persepsi

a. Aat %ant" -ang )ig"nakan :

7 8 kaa mata 7 8 aat %ant" pen)engaran

%. Kes"itan -ang )iaami :

7 8 sering p"sing

7 8 men"r"nn-a sensiti&itas terha)ap panas )ingin

7 8 mem%aa#men"is2. Persepsi )iri

Ha -ang )ipikirkan saat ini : ................................................................

Harapan seteah men!aani perawatan : ..............................................................

Per"%ahan -ang )irasakan seteah sakit : .............................................................

3. S"asana hati

: ......................................................................................

4. H"%"ngan#k'm"nikasi : ..........................................................................

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

a. *iara

7 8 !eas %ahasa "tama : ................................

7 8 ree=an %ahasa )aerah : ................................

7 8 mamp" mengekspresikan

7 8 mamp" mengerti 'rang ain

%. Tempat tingga

7 8 sen)iri

7 8 %ersama 'rang ain/ -ait" ...................................................................

. Kehi)"pan ke"arga

- A)at istia)at -ang )ian"t : ....................................................

- Pem%"atan kep"t"san )aam ke"arga : ...................................................


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- P'a k'm"nikasi : ...................................................

- Ke"angan : 7 8 mema)ai 7 8 k"rang

). Kes"itan )aam ke"arga

7 8 h"%"ngan )engan 'rang t"a

7 8 h"%"ngan )engan sanak ke"arga

7 8 h"%"ngan )engan s"ami#istri

5. Ke%iasaan seks"a

a. Gangg"an h"%"ngan seks"a )ise%a%kan k'n)isi se%agai %erik"t :

7 8 &ertiitas 7 8 menstr"asi

7 8 i%i)' 7 8 kehamian

7 8 ereksi 7 8 aat k'ntrasepsi %. Pemahaman terha)ap &"ngsi

seks"a : .........................................................................................................................

.........

9. Pertahanan k'ping

a. Pengam%ian kep"t"san

7 8 sen)iri

7 8 )i%ant" 'rang ain@ se%"tkan .......................................................................

%. +ang )is"kai tentang )iri sen)iri

: ........................................................................

. +ang ingin )ir"%ah )ari

kehi)"pan : ....................................................................

). +ang )iak"kan !ika se)ang stress :

7 8 pemeahan masaah 7 8 ari pert''ngan

7 8 makan 7 8 makan '%at

7 8 ti)"r

7 8 ain0ain misan-a marah/ )iam )1

se%"tkan .................................................................................................................

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;. Sistem niai kepera-aan


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a. Siapa ata" apa -ang men!a)i s"m%er kek"atan :

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%. Apakah T"han/ Agama/ Kepera-aan penting "nt"k an)a :

7 8 -a 7 8 ti)ak

. Kegiatan Agama ata" Kepera-aan -ang )iak"kan maam )an &rek"ensi1

Se%"tkan : .............................................................................................................

). Kegiatan Agama ata" Kepera-aan -ang ingin )iak"kan seama )i

r"mah sakit/

Se%"tkan: ...............................................................................................................

V. Pengkajian Fisik

A. Bita Sign

Tekanan )arah :

S"h" :

Na)i :

Perna&asan :

*. Kesa)aran : CCCCCCCCC GS :CCC..

E-e :CC..

Ber%a :CC..

M't'rik :CC..

. Kea)aan "m"m :

Sakit# n-eri : ,. ringan 2. se)ang 3. %erat

Skaa n-eri : CCCCCCC...........................................................

N-eri )i )aerah : CCCCCCCC........................................................

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Stat"s gii : ,. gem"k 2. n'rma 3. k"r"s

** : CCCC..T* : CCCCC.

Sikap : ,. tenang 2. geisah 3. menahan n-eri

Pers'na h-giene : ,. %ersih 2. k't'r 3. ain0ainCC.

>rientasi wakt"# tempat# 'rang : ,. %aik 2. tergangg"CC


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D. Pemeriksaan 6isik Hea) T' T'e

,. Kepaa

*ent"k : ,. mes'hepae 2. mikr'hepae

3. hi)r'hepae 4. ain0 ainCCCCC

$esi# "ka : ,. hemat'm 2. per)arahan 3. "ka s'%ek

4. ain0ainCCCC.

2. Ram%"t

Warna : CCCCCC.

Keainan : r'nt'k# )CCCC.

3. Mata Pengihatan : ,. n'rma 2. kaa mata# ensa 3. ain0ainCC.

Skera : ,. ikterik 2. ti)ak ikterik

K'n!"ngti=a : ,. anemis 2. ti)ak anemis

P"pi : ,. is'k'r 2.anis'k'r 3. mi)riasis 4. katarak

Keainan : ke%"taan kanak#kiriCCC.

Data tam%ahanCCCCC.

4. Hi)"ng

Penghi)" : ,. n'rma 2. a)a gangg"anCCCC

Sekret# )arah# p'ip : CCCCCC.

Tarikan aping hi)"ng: ,. -a 2. ti)ak

5. Teinga

Pen)engaran : ,. n'rma 2. ker"sakan 3. t"i kanan#kiri

4. tinnit"s 5. aat %ant" )engar 9. ainn-a

Skret# airan# )arah : ,. a)a#ti)ak 2. %a"CC.. 3. warnaCCC

9. M""t Dan Gigi

*i%ir : ,. em%a% 2. kering 3. ian'sis 4. peah0paah

M""t )an tengg'r'kan: ,. n'rma 2. esi 3. st'matitis

Gigi : ,. pen"h#n'rma 2. 'mp'ng 3. ain0ainCCC..

;. $eher


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Pem%esaran t-r'i) : ,. -a 2. ti)ak

$esi : ,. ti)ak 2. -a/ )i se%eahCC.

Na)i kar'tis : ,. tera%a 2. ti)ak

Pem%esaran im&'i) : ,. -a 2. ti)ak


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,2. Ekstrimitas

Kek"atan 't't :

R > M : ,. pen"h 2. ter%atas

Hemipegi#parese : ,. ti)ak 2. -a/ kanan#kiri

Akra : ,. hangat 2. )ingin

apiar- re&i time : ,. 3 )etik 2. 3 )etik

E)ema : ,. ti)ak a)a 2. a)a )i )aerahCCCC.

$ain0ain : CCCCCC..

,3. Data pemeriksaan &isik ne"r''gis


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A. ANALISA DATA

DATA F!"S ANALISIS #ASALA$ #ASALA$

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%. DIA&NSA K'P'RA(ATAN DAN PRIRITAS #ASALA$

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20/27

!. P'R'N!ANAAN K'P'RA(ATAN

N

DIA&NSA

R'N!ANA K'P'RA(ATAN

T")"AN INT'RV'NSI RASINAL

N DIA&NSA R'N!ANA K'P'RA(ATAN


21/27


N

DIA&NSA

R'N!ANA K'P'RA(ATAN



22/27

D. I#PL'#'NTASI K'P'RA(ATAN

N T&L* N. I#PL'#'NTASI R'SPN PARAF


23/27

)A# D+

N

T&L*

)A#

N.

D+I#PL'#'NTASI R'SPN PARAF


24/27

N

T&L*

)A#

N.



25/27

N

T&L*

)A#

N.



26/27

'. 'VAL"ASI K'P'RA(ATAN

NT&L,)A

#!ATATAN P'RK'#%AN&AN PARAF

S :


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> :

A :

P :

kmb1_form askep angsoka 1

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