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LAPORAN KASUS ASUHAN KEPERAWATAN
______________________________________________________
______________________________________________________
RUMAH SAKIT UMUM PUSAT DR. HASAN SADIKIN BANDUNG
A. PENGKAJIAN
1. Identitas Pasien
Nama (inisial)
: ______________________________________
No RM
: ______________________________________
Usia
: ___________________ (lahir: ____, _________, _____)
Jenis Kelamin
:
laki-laki
perempuan
Status Marital
:
duda/janda
:
belum menikah
menikah
Pekerjaan
______________________________________
Suku Bangsa
: ______________________________________
Alamat Rumah
: ______________________________________
Sumber biaya
: ______________________________________
Diagnosa Medis
: ______________________________________
Tanggal MRS
: ______________________________________
Tanggal Pengkajian
: ______________________________________
2. Identitas Penanggung Jawab
Nama (inisial): ______________________________________
Usia: ______________________________________
Hubungan dgn pasien : ______________________________________
Pendidikan: ______________________________________
Alamat: ______________________________________
Riwayat Kesehatan
Keluhan Utama
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Riwayat Penyakit Saat Ini
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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Riwayat Kesehatan Masa Lalu
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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Riwayat Kesehatan Keluarga
__________________________________________________________________
__________________________________________________________________
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Genogram:
Pengukuran
a. Tanda-tanda Vital
Blood Pump
: _____________
mmHg
Heart Rate
: _____________
x/menit
Respiration
: _____________
x/menit
Temperature
: _____________
oC
b. Fisiologis
Berat Badan
: _____________
Kg
Tinggi Badan
: _____________
Cm
IMT
:
(
)
(
)
= ______
Klasifikasi IMT:
< 18,5
: BB Kurang
18,5 22,9
: BB Normal
> 23,0
: BB Lebih
23,0 24,9
: BB Pra Obes
25,0 29,9
: BB Obesitas I
> 30,0
: BB Obesitas II
Klasifikasi IMT : ____________
BB Ideal: (TB 100) ((TB-100)x10%)
( _____ - 100) (( _____ -100) x 10%) ( _____ ) ( _____ )
= ________
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5. Pola Pemenuhan Kebutuhan Dasar Manusia
NILAI RUJUKAN NORMAL
KH
: 60 75 % energi total
Prot
: 10 15 % energi total
Lemak : 10 25 % energi total
Rujukan:
1 gr KH
= 4 Kkal
1 gr Prot
= 4 Kkal
1 gr Lemak
= 9 Kkal
Keb. Total Kalori Normal (TK):
TK = KB + AF KU
Keb. Basal Kalori (KB)
Pria
= BBI x 30
Wanita
= BBI x 25
Aktivitas Fisik (AF)
-
Ringan
= 10 % x KB
-
Sedang
= 20 % x KB
NUTRISI
-
Berat
= 40 % x KB
Koreksi Usia (KU)
-
< 40 tahun
= 0 % x KB
-
40 59 tahun = 5 % x KB
-
60 69 tahun = 10 % x KB
-
> 70 tahun
= 20 % x KB
Keb. Cairan Normal (KC):
KC = 30-50 cc/KgBB/24 jam
CAIRAN
POLA
KEADAAN PASIEN SAAT INI
KEBUTUHAN
Asupan Nutrisi BBI Pasien
= ________
Kg
KB Pasien
= BBI x ____
= ____ x ____
= _________
Kkal
AF Pasien
= ___% x KB
= ___% x ___
= _________
Kkal
KU Pasien
= ___% x KB
= ___% x ___
= _________
Kkal
TK = KB + AF KU
= _____ + _____ - _____
= _________ Kkal
Kebutuhan Yang Diberikan Saat Ini:
Frekuensi
Cara
Alergi
Keterangan lainnya
Asupan Cairan Tranfusi
Makanan
Parenteral
Keterangan
Lainnya
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Output Berdasarkan GFR:
BAK
Rata-rata Output Dlm 24 jam
Warna
: _____________
Keluhan
: _____________
Keterangan Lain
ELIMINASI
Rumus dari Cockcroft-gault
Produksi Urine Normal:
BAB
Warna
: ______________
Rata-rata Output Dlm 24 jam
PU = 1 2 cc/KgBB/Jam
Konsistens : ______________
IWL normal:
Keluhan
: ______________
IWL =
(
)
Keterangan Lain
IWL dgn kenaikan suhu tubuh:
(10% CM) kenaikan suhu tubuh
24 jam
+ 37,5 cc
IWL
Pelaksanaan
personal
Frekuensi
: ____________ / hari
HYGIENE
hygiene secara umum jika
Mandi
Cara
: ______________
tidak ada
kolom,
uraikan
Keterbatasan : ______________
di bawah ini:
Frekuensi
: ____________ / hari
Oral Hygiene
Cara
: ______________
PERSONAL
Keterbatasan : ______________
Keramas / Cuci
Frekuensi
: ______________
Cara
: ______________
Rambut
Keterbatasan : ______________
Keterangan
Lainnya
Siang
: _____________ jam
ISTIRAHAT
Durasi Tirus
Malam
: _____________ jam
Total
: ___________ jam/hr
Kebiasaan
Gangguan
INFO LAIN
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6.
Pemeriksaan Fisik
NILAI RUJUKAN
HASIL PEMERIKSAAN PASIEN SAAT INI
Kuantitatif (GCS):
Eye (4)
Verbal (5)
Motor (6)
spontan
orientasi baik
ikut perintah
dengan suara
kacau/bingung
lokalisir nyeri
dengan nyeri
tidak teratur
fleksi normal
tidak respon
mengerang
fleksi abnormal
KESADARAN
tidak ada
ekstensi abnormal
tidak ada
Kualitatif:
Compos mentis
: kesadaran penuh
Apatis
: tampak segan atau acuh tak acuh terhadap lingkungan
Somnolent
: mengantuk
yang masih dapat
pulih bila dirangsang, tetapi bila
Sopor/Stupor
rangsangan berhenti pasien kembali tidur
: mengantuk yang dalam, pasien dapat
dibangunkan
dengan rangsang
Soporo Coma
yang kuat
: penurunan
kesadaran dimana
tidak
memberikan
respon terhadap
rangsang verbal, tidak dapat dibangunkan, tetapi reflek (korne, pupil)
Coma
masih baik, respon terhadap rangsang nyeri tidak adekuat.
: penurunan kesadaran sangat dalam, tidak ada gerakan spontan, tidak
ada respon terhadap rangsang nyeri.
Masukkan info lainnya:
Simetris
Ikterus
Nistagmus
Lesi
MATA
Ptosis
Xantelasma
Konjungtiva
: __________________
Reflek Pupil
: __________________
Kesimetrisan
: __________________
Ukuran Pupil
: Ka
_________ mm
Ki
_________ mm
KEPALA-LEHER
Masukkan info lainnya:
Simetris
: _______________
HIDUNGTELINGA
Serumen
: _______________
Peradangan
: _______________
Gg. Pndengaran
: _______________
Alat Bantu
: _______________
Cairan Telinga
: _______________
Masukkan info lainnya:
Terpasang NGT
: _______________
Kebersihan
: _______________
Sumbatan
: _______________
Program O2
: _______________
Masukkan info lainnya:
Gigi tanggal
: _______________
MULUT
Gigi Berlubang
: _______________
Stomatitis
: _______________
Keadaan Lidah
: _______________
Mukosa Bibir
: _______________
Gg. Menelan
: _______________
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6
LEHER
Masukkan info lainnya:
Deviasi trakea
: _______________
Kelenjar thiroid
: _______________
Reflek menelan
: _______________
JVP
: _______________
Sirkulasi Perifer
Frekuensi Nadi
: _____________ x/menit
Irama Nadi
: _____________
Temperatur Kulit : _____________
Warna Kulit
: _____________
CRT
: _____________
JANTUNG
Flebitis
: _____________
Varises
: _____________
Sirkulasi Central
Ictus cordis
: _____________
Keluhan
: _____________
Bunyi Jantung
: S1 _____________
S2 _____________
DADA
Kelainan BJ
: _____________
CVP
: _____________
Gerakan Dada
Irama
: ________________________
Frekuensi
: ________________________
Kedalaman
: Ka
: __________________
Ki
: __________________
Retraksi Intercostae
: __________________
PARU
Suara sumbatan
: __________________
Suara Nafas
Suara auskultasi
: __________________
Suara Perkusi Dada
: __________________
Pengg. Alat Bantu Nafas
Keterangan Lain
GERAK)
Nilai Kekuatan Otot
5
: melawan gravitasi dengan
Kekuatan otot
full resistensi
4
: melawan gravitasi dengan
(ALAT
resistensi sedikit
3
: melawan gravitasi tanpa
IV Line (Flebitis)
resistensi
2
: tidak bisa melawan gravitas
EKSTREMITAS
1
: ada kontraksi, gerakan
hanya pada jari
Edema
0
: tidak ada kontrasi otot
Kontraktur Sendi
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7
Nyeri Sendi
Tanda Fraktur
Pencernaan
Masa pada abdomen
Kekakuatan otot abdomen (distensi)
Ascites
ABDOMEN
Bising Usus
: ________________ x/mnt
Mual/Muntah
: __________ / __________
Fisiologis
Nyeri tekan abdomen
Nyeri lepas abdomen
Perkusi Hepar
_______________________________________
Perkusi Gaster
_______________________________________
Fisiologis
Testis
: Ka
: _________________
Ki
: _________________
Kelamin
: ______________________
URIGENITAL
Keadaan
: ______________________
Kelainan
Distensi Bladder
: _________________
Urinaria
Terpasang Folley Catheter
Kelainan Urine
Anuria
Disuria
Hematuria
Poliuria
Olfaktorius
Kanan
Kiri
KRANIAL
Optikus
Kanan
Kiri
Okulomotorius
SYARAF
Kanan
Kiri
Troklearis
Trigeminus
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ENDOKRIN
TEMUAN FISIK LAINNYA
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Abdussen
Fasialis
Akustikus
Glosopharingeus
Vagus
Aksesorius
Hipoglosus
Bau Nafas
Kondisi Luka (jika ada gambarkan)
Tanda Peningkatan GD
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7. Pemeriksaan Penunjang
Jenis
Tanggal
Hasil
8.
Pemeriksaan Laboratorium
TGL
Pemeriksaan
Hasil
Nilai
Normal
Nilai
PemeriksaanHasil
Normal
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9. Tindakan Medis
Jenis
Tanggal
Keterangan
10. Teraphy Farmakologi
Nama Obat
Dosis
Rute
Nama Obat
Dosis
Rute
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B. ANALISA DATA
No
Data Senjang
Etiologi
Problem
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C. DIAGNOSA DAN INTERVENSI KEPERAWATAN
N
Diagnosa Keperawatan Tujuan dan Kriteria HasilRencana TindakanRasional
o
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D. IMPLEMEN DAN EVALUASI KEPERAWATAN
TGL
DiagnosaImplementasi KeperawatanEvaluasi
& Jam
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