LAPORAN ASUHAN KEPERAWATAN PADA ........................ DENGAN................................................... DI RUANG.........................................RSUP SANGLAH DENPASAR TANGGAL .......................................S/D....................................2010

OLEH: ................................................................................. NIM:................................................

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA 2010

ASUHAN KEPERAWATAN PADA ............................. DENGAN.................................................................................. .... DI RUANG............................................ RSUP SANGLAH DENPASAR A. PENGKAJIAN 1. Identitas Pasien Nama : .................................................................. Umur : .................................................................. Jenis kelamin : .................................................................. Pendidikan : .................................................................. Pekerjaan .......... Status Agama ... Suku : .................................................................. Alamat : ................................................................. Tanggal : .................................................................. Tanggal Sumber : .................................................................. pengkajian Informasi : .................................................................. masuk perkawinan : ............................................................... : .................................................................. : ........................................................

Diagnosa : .................................................................. Penanggung Nama : .................................................................. Hubungan 2. Riwayat keluarga Genogram (kalau perlu) dengan

masuk

pasien

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

Keterangan genogram

3. Status kesehatan a. Status Kesehatan Saat Ini Keluhan utama (saat MRS dan saat ini) .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................. Alasan masuk Rumah Sakit dan perjalanan Penyakit saat ini .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................. Upaya yang dilakukan untuk mengatasinya .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. ..............................................................................................

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

b. Status Kesehatan Masa Lalu Penyakit yang pernah dialami .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................. Pernah dirawat .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................. Riwayat alergi : Ya Tidak Jelaskan:................................................................................ .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. ........ Riwayat tranfusi : Kebiasaan :

Ya

Tidak

Merokok

Ya

Tidak

Sejak:.................................................................................. ................

Jumlah:................................................................................ ..............

Minum kopi .......................

Ya

Tidak

Sejak:........................................................................... Jumlah:......................................................................... .....................

Penggunaan Alkohol

Ya

Tidak

Sejak:.................................................................................. ................ Jumlah:................................................................................ .............. Lain-lain: Jelaskan:....................................................................... ..................................................................................... ..................................................................................... ..................................................................................... ..................................................................................... ..... 4. Riwayat Penyakit Keluarga ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ................................................................. 5. Diagnosa Medis dan therapy

....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ....................................................................................................... ............................................................................................. 6. Riwayat Penyakit Saat Ini (11 Pola Fungsional Gordon) a. Pemeliharaan dan persepsi terhadap kesehatan ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ........................................ b. Nutrisi/ metabolic ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. .................................................................................................

................................................................................................. ................................................................................................. ................................................................................................. .................................................................. c. Pola eliminasi ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. .................................................................. d. Pola aktivitas dan latihan Kemampuan perawatan 0 1 2 3 4 diri Makan/minum Mandi Toileting Berpakaian Mobilisasi di tempat tidur Berpindah Ambulasi ROM Keterangan: 0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total. Lainlain: ......................................................................................... ................................................................................................. .................................................................................................

................................................................................................. ................................................................................................. ............... e. Pola tidur dan istirahat .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ............ f. Pola kognitif-perseptual .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ...................................... g. Pola persepsi diri/konsep diri .................................................................................................. .................................................................................................. ..................................................................................................

.................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ............ h. Pola seksual dan reproduksi .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ............ i. Pola peran-hubungan .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ............ j. Pola manajemen koping stress

.................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ............ k. Pola keyakinan dan nilai .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ............ 7. Riwayat Kesehatan dan Pemeriksaan Fisik Keadaan umum : Lemah Kesadaran: TTV: TD: Nadi : Suhu: RR: Baik Sedang

a. Kulit, Rambut dan Kuku Distribusi rambut : Lesi Ya Tidak

Warna kulit Pucat Akral Dingin Turgor:

Ikterik Hangat

Sianosis Kemerahan Panas Dingin kering

... ............. ... Oedem Lokasi: . ...W arna kuku: Lain-lain: .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ...... b. Kepala dan Leher Kepala Lesi: Deviasi trakea Pembesaran kelenjar tiroid Lain-lain: .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ................................ Simetris Asimetris, Ya Ya Ya Tidak Tidak Tidak Pink Sianosis lain-lain Ya Tidak

c. Mata dan Telinga Gangguan pengelihatan Menggunakan kacamata Pupil Sklera/ konjungtiva Gangguan pendengaran Ya Ya Isokor Anemis Ya Ya Tidak Tidak Anisokor Ikterus Tidak Tidak Weber: Rinne: Swabach:

Visus: Ukuran:

Menggunakan alat bantu dengar Tes

. Tes . Tes Lain-lain: .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ...... d. Sistem Pernafasan: Batuk: Sesak:

Ya Ya

Tidak Tidak

Inspeksi: ...............................................................................

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

Palpasi: .................................................................................

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

Perkusi: ................................................................................

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

Auskultasi: ............................................................................

.................................................................................................. .................................................................................................. .................................................................................................. .................... . ... ............................................................................ .................... Lain-lain: ... .......

e. Sistem Kardiovaskular : Nyeri dada Palpitasi CRT

Ya Ya < 3 dtk

Tidak Tidak > 3 dtk

Inspeksi: ............................................................................... .............................................................................................. .............................................................................................. .............................................................................................

Palpasi: ................................................................................. .............................................................................................. .............................................................................................. ...........................................................................................

Perkusi: ................................................................................. .............................................................................................. .............................................................................................. ...........................................................................................

Auskultasi: ............................................................................ .............................................................................................. .............................................................................................. .............................................................................................. .. Lain-lain: .............................................................................................. .......................... .............................................................................................. ..........................

f. Payudara Wanita dan Pria: .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ..................................................................................................

.................................................................................................. .......................................................... g. Sistem Gastrointestinal: Mulut Mukosa Bersih Kotor Berbau Stomatitis Tidak Asites x/mnt Nyeri tekan

Lembab Kering Ya

Pembesaran hepar Abdomen Lain-lain :

Meteorismus

Peristaltik:..

.................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ...... h. Sistem Urinarius : Penggunaan alat bantu/ kateter Ya Kandung kencing, nyeri tekan Gangguan Anuria Inkontinensia Lain-lain: .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ................................ Ya Tidak Tidak

Oliguria Retensi Nokturia

i. Sistem Reproduksi Wanita/Pria : .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. .................................................................................................. ...... j. Sistem Saraf: GCS: Eye: Verbal: Brudzinski I Bisep Oppenheim Motorik: Brudzinski II Achiles Rangsangan meningeal: Kaku kuduk Kernig Refleks fisiologis: Patela Refleks patologis Babinski Rossolimo Gordon Gerakan Lain-lain: k. Sistem Muskuloskeletal: Kemampuan pergerakan sendi Deformitas Lokasi: Fraktur Lokasi: Ya Tidak Ya Bebas Tidak Terbatas Schaefer Stransky involunter Gonda : Chaddock Trisep

Kekakuan Nyeri sendi/otot Kekuatan

Ya Ya

Tidak Tidak otot :

Lain-lain . ... l. Sistem Imun: Perdarahan Gusi Perdarahan lama Pembengkakan KGB Lokasi: Keletihan/kelemahan Lain-lain: ... m. Sistem Endokrin: Hiperglikemia Hipoglikemia Luka gangrene Lain-lain: Ya Ya Ya Tidak Tidak Tidak Ya Tidak Ya Ya Ya Tidak Tidak Tidak

8. Pemeriksaan Penunjang a. Data laboratorium yang berhubungan ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ................................................................................................... ...................................................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... b. Pemeriksaan Radiologi

................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ................................................................................................... ...................................................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... c. Hasil Konsultasi ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ...........................

................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... d. Pemeriksaan penunjang diagnostik lain ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... .......................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ........................... ................................................................................................... ...........................