LAPORAN KASUS

ASUHAN KEPERAWATAN PADA KLIEN DENGAN

Tanggal .............. s/d ..................

Oleh :_________________________NIM ...............................

PROGRAM STUDI ILMU KEPERAWATANSEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA

LEMBAR PENGESAHAN

ASUHAN KEPERAWATAN PADA KLIEN DENGAN

Tanggal .............. s/d ..................

Oleh :_________________________NIM ...............................

Mengetahui,Penguji Pendidikan

______________________

Surabaya, ................ 20.....Penguji Lahan

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FORMAT PROSES KEPERAWATAN KMBMAHASISWA PRODI D III KEPERAWATANSTIKES HANG TUAH SURABAYA

Nama mahasiswa:........................................Tgl/jam pengkajian:........................................Diagnosa medis:................................................................................Tgl/jam MRS:........................................No. RM:........................................Ruangan/kelas:........................................No.kamar:........................................

I. PENGKAJIANa. Identitas

Nama:Jenis kelamin:Umur:Agama:Pekerjaan:Pendidikan:Alamat:Status:Suku/bangsa:Bahasa:Penanggung jawab:

b. RIWAYAT PENYAKITKeluhan utama........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ .....................................................................................................................................................................Riwayat penyakit sekarang :......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .....................................................................................................................................................................Riwayat penyakit yang pernah diderita :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Riwayat kesehatan keluarga :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Riwayat pembedahan.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Riwayat Alergi.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

c. POLA FUNGSI KESEHATAN1. Persepsi Terhadap Kesehatan (Keyakinan Terhadap Kesehatan & Sakitnya)...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2. Pola Aktivitas Dan Latihana. Kemampuan perawatan diriAktivitasSMRSMRS

0123401234

Mandi

Berpakaian/berdandan

Eliminasi/toileting

Mobilitas di tempat tidur

Berpindah

Berjalan

Naik tangga

Berbelanja

Memasak

Pemeliharaan rumah

Skor

0 = mandiri1 = alat bantu2 = dibantu orang lain3 = dibantu orang lain & alat4 = tergantung/tidak mampu

Alat bantu : ( ) tidak ( ) kruk ( ) tongkat( ) pispot disamping tempat tidur ( ) kursi roda

b. Kebersihan diri

Di rumah

Mandi :......................../hr

Gosok gigi:......................../hr

Keramas:..................../mgg

Potong kuku:..................../mggDi rumah sakit

Mandi :......................../hr

Gosok gigi:......................../hr

Keramas:..................../mgg

Potong kuku:..................../mggc.

d. Aktivitas sehari-hari...................................................................................................................................................e. Rekreasi...................................................................................................................................................f. Olahraga : ( ) tidak ( ) ya...................................................................................................................................................

3. Pola Istirahat Dan Tidur

Di rumahWaktu tidur : Siang ..............-...............Malam ............-...............Jumlah jam tidur : ..................................Di rumah sakitWaktu tidur : Siang ..............-...............Malam ............-...............Jumlah jam tidur : ..................................

Masalah di RS : ( ) tidak ada ( ) terbangun dini ( ) mimpi buruk( ) insomnia ( ) Lainnya, ...............................

4. Pola Nutrisi Metabolika. b. Pola makan

Di rumahFrekuensi:.........................Jenis:.........................Porsi:.........................Pantangan:.........................Makanan disukai:.........................Di rumah sakitFrekuensi:..................................Jenis:..................................Porsi:..................................Diit khusus:..................................Nafsu makan di RS:( ) normal ( ) bertambah ( ) berkurang( ) mual ( ) muntah, .............. cc ( ) stomatitisKesulitan menelan:( ) tidak ( ) yaGigi palsu:( ) tidak ( ) yaNG tube:( ) tidak ( ) ya

c. Pola minum

Di rumahFrekuensi:.........................Jenis:.........................Jumlah:.........................Pantangan:.........................Minuman disukai:.........................Di rumah sakitFrekuensi:..................................Jenis:..................................Jumlah:..................................

5.

6. Pola Eliminasia. Buang air besar

Di rumahFrekuensi:..................................Konsistensi:..................................Warna:..................................

Di rumah sakitFrekuensi:..................................Konsistensi:..................................Warna:( ) kuning ( ) bercampur darah ( ) lainnya, ..............Masalah di RS:( ) konstipasi ( ) diare ( ) inkontinenKolostomi :( ) tidak ( ) ya

b. Buang air kecil

Di rumahFrekuensi:..................................Konsistensi:..................................Warna:..................................Di rumah sakitFrekuensi:..................................Konsistensi:..................................Warna:..................................

Masalah di RS:( ) disuria( ) nokturia( ) hematuria( ) retensi( ) inkontinenKolostomi :( ) tidak( ) ya, kateter ........................... produksi : .................. cc/hari

7. Pola Kognitif PerseptualBerbicara:( ) normal( ) gagap( ) bicara tak jelasBahasa sehari-hari:( ) Indonesia( ) Jawa( ) lainnya, ....................................Kemampuan membaca:( ) bisa( ) tidakTingkat ansietas:( ) ringan( ) sedang( ) berat( ) panikSebab, ...................................................................................................Kemampuan interaksi:( ) sesuai( ) tidak, ...................................................................Vertigo:( ) tidak( ) yaNyeri:( ) tidak( ) yaBila ya, P:.................................................................................................................................Q:.................................................................................................................................R:.................................................................................................................................S:.................................................................................................................................T:................................................................................................................................. Prsepsi terhadap penyakit....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 8. Pola Konsep Diri....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9. Pola KopingMasalah utama selama MRS (penyakit, biaya, perawatan diri)........................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Kehilangan perubahan yang terjadi sebelumnya...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Kemampuan adaptasi...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

10. Pola Seksual ReproduksiMenstruasi terakhir:.....................................................................................................................Masalah menstruasi:.....................................................................................................................Pap smear terakhir:.....................................................................................................................Pemeriksaan payudara/testis sendiri tiap bulan: ( ) ya ( ) tidakMasalah seksual yang berhubungan dengan penyakit:...............................................................

11. Pola Peran HubunganPekerjaan:......................................................................................................Kualitas bekerja:......................................................................................................Hubungan dengan orang lain:......................................................................................................Sistem pendukung:( ) pasangan ( ) tetangga/teman ( ) tidak ada( ) lainnya, .................................................................................Masalah keluarga mengenai perawatan di RS : .............................................................................

12. Pola Nilai Kepercayaan Agama:................................................................................................Pelaksanaan ibadah:................................................................................................Pantangan agama:( ) tidak ( ) ya, ................................................................Meminta kunjungan rohaniawan:( ) tidak ( ) ya

d. PENGKAJIAN POLA FUNGSI KESEHATAN1. Tanda-Tanda VitalTD:Suhu:Nadi:RR:TB:BB:

2. Sistem Pernafasan (Breath)Bentuk Dada:Pergerakan: Otot bantu nafas:jika ada, jelaskan :Irama nafas:Kelaianan: Suara nafas:Sesak nafas:Batuk:Sputum:Warna:Ekskresi : Kemampuan aktivitas :

3. Sistem Kardiovaskuler (Blood)Ictus cordis:Irama jantung : Nyeri dada: Jika ya, jelaskan (PQRST) :

Bunyi jantung:CRT: Sianosis:Jika ya, lokasi: Akral: Oedema:Jika ya, jelaskan: 4. Sistem Persarafan (Brain)GCSEye: Verbal: Motorik: Total: Refleks fisiologis: Refleks Patologis: Kepala: Nyeri kepala: Jika ya, jelaskan:

Paralisis: PenciumanBentuk Hidung: Septum:Polip: Gangguan:

Wajah dan penglihatan Mata:Kelainan: Pupil:Reflek Cahaya: Konjungtiva/sklera :Lapang pandang: PendengaranTelingga: Kelainan:Kebersihan: Gangguan:Alat bantu:LidahKebersihan: Uvula:Kesulitan telan:Berbicara:

5. Sistem Perkemihan (Bladder)Kebersihan:Ekskresi: Kandung kemih:Nyeri tekan: Eliminasi uri SMRSFrek:Alat bantu: Jumlah:Gangguan:Warna:

Eliminasi uri MRSFrek:Alat bantu: Jumlah:Gangguan:Warna:

6. Sistem Pencernaan (Bowel)Mulut: Membran mukosa: Gigi/ gigi pasu:Faring: Diit (Makan dan Minum) SMRS:

Diit di RSDiit: Frekuensi: Nafsu makan: Muntah: Mual: Jenis: Porsi:

Minum Frekuensi minum:Jumlah : Jenis :

AbdomenBentuk perut:Peristaltik: Kelainan abdomen : Hepar:Lien:Nyeri abdomen :

Rectum dan Anus: Eliminasi alvi SMRS:

Eliminasi alvi MRSKonsistensi: Colostomi:

7. Sistem Muskuloskeletal (Bone)Rambut, kulit kepala: Warna kulit: Turgor kulit: ROM: jika terbtas, pada sendi:

Kekuatan otot

Tulang: Kelainan jaringan:

e. PEMERIKSAAN PENUNJANG1. Laboratorium..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Photo......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................3. Lain-lain...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

f. TERAPI/ obat yang dikonsumsi.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Surabaya, .....................Mahasiswa

(...............................)ANALISA DATA

Nama klien:..............................................Umur:..............................................Ruangan/kamar:..............................................No. RM:..............................................

No.Data (Symptom)Penyebab (Etiologi)Masalah (Problem)

PRIORITAS MASALAH

Nama klien:..............................................Umur:..............................................Ruangan/kamar:..............................................No. RM:..............................................

No.Masalah KeperawatanTanggalParaf(Nama Perawat

DitemukanTeratasi

RENCANA KEPERAWATAN

No.Diagnosa KeperawatanTujuan Dan Kriteria HasilIntervensiRasional

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No.WaktuTgl/jamTindakanTTWaktuTgl/jamCatatan Perkembangan(SOAP)TT