LAPORAN PENDAHULUAN
PRAKTIK BLOK IV (SISTEM
KARDIOVASKULER)
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS RIAU
Nama mahasiswa
:
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NIM :.......................................................
Tanggal :.......................................................
Ruang Praktik :.......................................................
I.
Diagnosa Medik :.....................................................................................................
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II.
Definisi :.....................................................................................................
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III.
Etiologi :.....................................................................................................
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IV.Klasifikasi :
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V.
Patofisiologi (buat web of caution):.............................................................................
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VI. Pemeriksaan fisik
:..................................................................................................
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VII. Pemeriksaan Laboratorium &
Diagnostik Penunjang:..................................................
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VIII. Diagnosa Keperawatan,
intervensi keperawatan dan Rasional yang sering muncul (min4):.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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IX. Daftar Pustaka (minimal 5)
:...................................................................................
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FORMAT
PENGKAJIAN
PRAKTIK BLOK IV (SISTEM KARDIOVASKULER)
PROGRAM STUDI ILMU KEPERAWATAN UNRI
A. INFORMASI
UMUM
Nama
…………………….................... Umur ………………….............................
Tanggal
lahir …….................………. Jenis kelamin………………........…………..
Suku Bangsa ………...............……… Tanggal
Masuk………………………..........
Tanggal Pengkajian …...............… Dari/Rujukan………………………..........
Diagnosa Medik………...............…. Nomor
Medical Record……………….....
B. ALASAN
MASUK RUMAH SAKIT
........................................……………………………………………………………………………………......
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C. KELUHAN
UTAMA SAAT PENGKAJIAN
……………………………………………........................................……………………………………………
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D. RIWAYAT
KESEHATAN SEBELUMNYA
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E. RIWAYAT
KESEHATAN KELUARGA (Buat Genogram)
…………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………….………….........................................................................................................................……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….….……………………………………………………………………………………………..............................
F. PEMERIKSAAN
FISIK
·
Tanda-tanda vital :
TD :…............………………..... Suhu :…...……............................
Nadi :……………….................. Pernafasan
:…..............................
Tinggi Badan :...................... Berat
Badan :...............................
- Kepala
Rambut :
panjang/pendek/tanpa rambut/kotor/mudah rontok/gatal-gatal
Lain-lain
:...........................................................................................................
Masalah keperawatan
:........................................................................................
Mata : Ikterik/midriasis/pakai kacamata/contact
lens/gangguan penglihatan
Lain-lain
:...........................................................................................................
Masalah keperawatan :........................................................................................
Hidung :
perdarahan/sinusitis/gangguan penciuman/malformasi/terpasang NGT
Lain-lain
:...........................................................................................................
Masalah keperawatan : .......................................................................................
Mulut :
Kotor/bau/terpasang/ ETT/Gudel/perdarahan/lidah kotor/gangguan pengecapan
Lain-lain :............................................................................................................
Masalah keperawatan
:........................................................................................
Gigi : Gigi palsu/kotor/kawat gigi/karies/tidak
ada gigi
Lain-lain
:...........................................................................................................
Masalah keperawatan
:........................................................................................
Telinga :
Perdarahan/terpasang alat bantu dengar/infeksi/gangguan pendengaran
Lain-lain
:...........................................................................................................
Masalah keperawatan
:........................................................................................
II. Leher
Pembesaran
KGB/kaku kuduk/terpasang trakeostomi/ JVP :.............................................
Lain-lain
:.....................................................................................................................
MasalahKeperawatan
:...................................................................................................
III. Dada :
Jantung:
Inspeksi :.....................................................................................................................
Palpasi
:...............................................................................
......................................
Perkusi :......................................................................................................................
Auskultasi
:...................................................................................................................
Masalah
Keperawatan :..................................................................................................
Lain-lain:......................................................................................................................
Paru:
Inspeksi
:.....................................................................................................................
Palpasi
:.......................................................................................................................
Perkusi
:......................................................................................................................
Auskultasi
:...................................................................................................................
Masalah
Keperawatan :..................................................................................................
IV. Tangan
: Utuh/luka/lecet/sianosis/capllary refill time/clubbing
finger/dingin/fraktur/edema
Lain-lain
:.....................................................................................................................
Masalah
Keperawatan :.................................................................................................
V. Abdomen :
Inspeksi
:......................................................................................................................
Palpasi
:.....................................................................................................................
Perkusi :.....................................................................................................................
Auskultasi
:...................................................................................................................
Masalah
Keperawatan : .................................................................................................
VI. Genitalia
: Perdarahan/terpasang kateter/trauma/malformasi/menstruasi/infeksi
Lain-lain
:......................................................................................................................
Masalah
keperawatan : .................................................................................................
VII. Kaki:Fraktur/edema/malformasi/luka/infeks
/keganasan /sianosis/dingin
Lain-lain
:......................................................................................................................
Masalah
keperawatan :..................................................................................................
VIII. Punggung :
Lordosis/kiposis/skoliosis/luka/dekubitus/infeksi
Lain-lain
:......................................................................................................................
Masalah
keperawatan :..................................................................................................
G. PEMERIKSAAN
PSIKOSOSIAL
............................................................................................................................................................................................................................................................................................................................................................................................................
Hasil Pemeriksaan Laboratorium dan Diagnostik
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Medikasi/ obat-obatan yang diberikan saat ini
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Diagnosa keperawatan
1......................................................................................................................................................................................................................................................................
2......................................................................................................................................................................................................................................................................
3..................................................................................................................................
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4..................................................................................................................................
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5......................................................................................................................................................................................................................................................................
Pekanbaru, ....................
Mahasiswa
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FORMAT ANALISA DATA
PRAKTIK BLOK IV (SISTEM
KARDIOVASKULER)
|
Data
|
Etiologi
|
Masalah Keperawatan
|
|
Data Subjektif
:.....................................
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Data Objektif
:......................................
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Data Subjektif
:.....................................
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Data Objektif
:......................................
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Data Subjektif
:.....................................
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Data Objektif
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FORMAT
RENCANA ASUHAN KEPERAWATAN
BLOK IV (SISTEM KARDIOVASKULER)
Nama Pasien : Nama
Mahasiswa :
Ruang : NIM :
No.
M.R :
|
No
|
Diagnosa
keperawatan
|
Tujuan/
sasaran
|
Intervensi
|
Rasional
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