LAPORAN ASUHAN KEPERAWATAN

ASUHAN KEPERAWATAN PADA NY. E

DENGAN GANGGUAN SISTEM PENCERNAAN : APPENDISITIS
DI RUANG CVE RSUD KOTA BOGOR

OLEH:
MUH. IQBAL YUNUS
18170100073

PROGAM PENDIDIKAN PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN INDONESIA MAJU (STIKIM)
2018/2019
 LEMBAR PENGESAHAN
ASUHAN KEPERAWATAN PADA NY. E
DENGAN GANGGUAN SISTEM PENCERNAAN : APPENDISITIS
DI RUANG CVE RSUD KOTA BOGOR

Telah Disyahkan
Pada tanggal: Mei 2018

Mengetahui :

Pembimbing Akademik Pembimbing Klinik

(………………………..)
(………………………………)

PROGAM PENDIDIKAN PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN INDONESIA MAJU
 ASUHAN KEPERAWATAN PADA …….
DENGAN GANGUAN SISTEM ………….………… : ……………………….
DI RUANG DAHLIA RSUD KOTA BOGOR

A. IDENTITAS KLIEN
Nama :
Umur :
Jenis kelamin :
Alamat :
Status :
Agama :
Suku :
Pendidikan :
Pekerjaan :
Tanggal masuk RS :
Tanggal pengkajian :
DX Medis :
B. IDENTITAS PENANGGUNG JAWAB
Nama :
Umur :
Jenis kelamin :
Alamat :
Pendidikan :
Pekerjaan :

C. PENGKAJIAN
1. Keluhan utama :
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2. Riwayat penyakit sekarang :
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3. Riwayat Penyakit dahulu :
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4. Riwayat penyakit keluarga :
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5. Genogram

6. Pemeriksaan Fisik Sistem Tubuh

a. Sistem Pernapasan
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b. Sistem Kardiovaskuler
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c. Sistem Persyarafan
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d. Sistem Perkemihan
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e. Sistem Pencernaan
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f. Sistem Muskuloskeletal
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g. Sistim Endokrin
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h. Sistim sensori persepsi/Pengideraan

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i. Sistim integument
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j. Sistim imun dan hematologi
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 k. Sistem Reproduksi
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7. Pengkajian Fungsional

1. Oksigenasi
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2. Cairan dan Elektrolit
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3. Nutrisi
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4. Aman dan Nyaman
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5. Eliminasi
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6. Aktivitas dan Istirahat
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7. Psikososial
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8. Komunikasi
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 9. Seksual
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10. Nilai dan Keyakinan
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11. Belajar
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8. Pemeriksaan Penunjang
a. Hasil Laboratorium
Tanggal Pemeriksaan Hasil Nilai Normal Interpretasi

b. Pemeriksaan Diagnostik
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9. Progam Terapi
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D. ANALISA DATA

Hari/Tgl/Jam Data Fokus Etiologi Problem

PRIORITAS DIAGNOSA KEPERAWATAN

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Nama : ........................................................... Umur : ..................................................... No. Dokumen RM :
Ruang : .......................................................... Kelas : ..................................................... Tanggal :

INTERVENSI

Hari/Tgl/Ja No Diagnosa Tujuan Dan Kriteria Hasil Intervensi Rasionalisasi TTD

m (DP) (NOC) (NIC)
Nama : .............................................. Umur : ..................................................... No. Dokumen RM :
Ruang : .............................................. Kelas : ..................................................... Tanggal :

IMPLEMENTASI KEPERAWATAN

Hari/Tgl/Jam No DP Implementasi Respon Pasien TTD

Nama : ........................................................... Umur : ..................................................... No. Dokumen RM :
Ruang : .......................................................... Kelas : ..................................................... Tanggal :

LEMBAR EVALUASI

Hari/Tgl/Jam No DP SOAP TTD