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1

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

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

[email protected]

2

Riwayat Kesehatan Masa Lalu

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

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Riwayat Kesehatan Keluarga

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

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%) ( _____ ) ( _____ )

= ________

[email protected]

3

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

[email protected]

4

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

[email protected]

5

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

: _______________

[email protected]

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

[email protected]

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

[email protected]

ENDOKRIN

TEMUAN FISIK LAINNYA

8

Abdussen

Fasialis

Akustikus

Glosopharingeus

Vagus

Aksesorius

Hipoglosus

Bau Nafas

Kondisi Luka (jika ada gambarkan)

Tanda Peningkatan GD

[email protected]

9

7. Pemeriksaan Penunjang

Jenis

Tanggal

Hasil

8.

Pemeriksaan Laboratorium

TGL

Pemeriksaan

Hasil

Nilai

Normal

Nilai

PemeriksaanHasil

Normal

[email protected]

10

9. Tindakan Medis

Jenis

Tanggal

Keterangan

10. Teraphy Farmakologi

Nama Obat

Dosis

Rute

Nama Obat

Dosis

Rute

[email protected]

11

B. ANALISA DATA

No

Data Senjang

Etiologi

Problem

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[email protected]

12

C. DIAGNOSA DAN INTERVENSI KEPERAWATAN

N

Diagnosa Keperawatan Tujuan dan Kriteria HasilRencana TindakanRasional

o

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[email protected]

13

D. IMPLEMEN DAN EVALUASI KEPERAWATAN

TGL

DiagnosaImplementasi KeperawatanEvaluasi

& Jam

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[email protected]