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LAPORAN KASUS
ASUHAN KEPERAWATAN PADA KLIEN DENGAN ...................................
DI .................. RUMKITAL Dr. RAMELAN SURABAYA
Tanggal .............. s/d ..................
Oleh :
_________________________
NIM ...............................
PROGRAM STUDI PENDIDIKAN PROFESI NERS
SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA
TA. 2011/2012
LEMBAR PENGESAHAN
ASUHAN KEPERAWATAN PADA KLIEN DENGAN ...................................
DI .................. RUMKITAL Dr. RAMELAN SURABAYA
Tanggal .............. s/d ..................
Oleh :
_________________________
NIM ...............................
Mengetahui,
Penguji Pendidikan
______________________
Surabaya, ................ 20.....
Penguji Lahan
______________________
PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN PSIKOSOSIAL
STIKES HANG TUAH SURABAYA
Nama mahasiswa : ........................................Tgl/jam pengkajian : ........................................Diagnosa medis : ........................................
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Tgl/jam MRS : ........................................No. RM : ........................................Ruangan/kelas : ........................................No.kamar : ........................................
I. IDENTITAS1. Nama : .....................................................................................................................2. Umur : .....................................................................................................................3. Jenis kelamin : .....................................................................................................................4. Status : .....................................................................................................................5. Agama : .....................................................................................................................6. Suku/bangsa : .....................................................................................................................7. Bahasa : .....................................................................................................................8. Pendidikan : .....................................................................................................................9. Pekerjaan : .....................................................................................................................10. Alamat dan no. telp : .....................................................................................................................11. Penanggung jawab : .....................................................................................................................
II. POLA PERSEPSI KESEHATAN ATAU PENANGANAN KESEHATAN1. Keluhan utama :
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.........................................................................................................................................................2. Riwayat penyakit sekarang :
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.........................................................................................................................................................3. Lamanya keluhan
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.........................................................................................................................................................4. Faktor yang Memperberat
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.........................................................................................................................................................5. Upaya yang Dilakukan Untuk Mengatasi Keluhan
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.........................................................................................................................................................6. Riwayat penyakit dahulu :
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.........................................................................................................................................................7. Persepsi klien tentang status kesehatan dan kesejahteraan
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8. Riwayat kesehatan keluarga :....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9. Susunan keluarga (genogram) :
10. Riwayat alergi :....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
III. POLA NUTRISI DAN METABOLIK1. 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 ( ) stomatitis
Kesulitan menelan : ( ) tidak ( ) yaGigi palsu : ( ) tidak ( ) yaNG tube : ( ) tidak ( ) ya
2. Pola minumDi rumahFrekuensi : .........................Jenis : .........................Jumlah : .........................Pantangan : .........................Minuman disukai : .........................
Di rumah sakitFrekuensi : ..................................Jenis : ..................................Jumlah : ..................................
IV. POLA ELIMINASI1. Buang air besar
Di rumahFrekuensi : ..................................Konsistensi : ..................................Warna : ..................................
Di rumah sakitFrekuensi : ..................................Konsistensi : ..................................Warna : ( ) kuning
( ) bercampur darah ( ) lainnya, ..............
Masalah di RS : ( ) konstipasi ( ) diare ( ) inkontinenKolostomi : ( ) tidak ( ) ya
2. Buang air kecilDi rumahFrekuensi : ..................................Jumlah : ..................................Warna : ..................................
Di rumah sakitFrekuensi : ..................................Jumlah : ..................................Warna : ..................................
Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria( ) retensi ( ) inkontinen
Kateter : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari
V. POLA AKTIVITAS DAN LATIHAN1. Kemampuan perawatan diri
AktivitasSMRS MRS
0 1 2 3 4 0 1 2 3 4MandiBerpakaian/berdandanEliminasi/toiletingMobilitas di tempat tidurBerpindahBerjalanNaik tanggaBerbelanjaMemasakPemeliharaan rumah
Skor 0 = mandiri1 = alat bantu2 = dibantu orang lain
3 = dibantu orang lain & alat4 = tergantung/tidak mampu
Alat bantu : ( ) tidak ( ) kruk ( ) tongkat( ) pispot disamping tempat tidur ( ) kursi roda
2. Kebersihan diriDi rumahMandi : ........................¿/hrGosok gigi : ........................¿/hrKeramas : ....................¿ /mggPotong kuku : ....................¿ /mgg
Di rumah sakitMandi : ........................¿/hrGosok gigi : ........................¿/hrKeramas : ....................¿ /mggPotong kuku : ....................¿ /mgg
3. Aktivitas sehari-hari.........................................................................................................................................................
4. Rekreasi..................................................................................................................................................................................................................................................................................................................
5. Olahraga : ( ) tidak ( ) ya.........................................................................................................................................................
VI. POLA ISTIRAHAT DAN TIDURDi 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, ..............................................................................
VII. POLA KOGNITIF DAN PERSEPTUALBerbicara : ( ) normal ( ) gagap ( ) bicara tak jelasBahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya, ....................................Kemampuan membaca : ( ) bisa ( ) tidakTingkat ansietas : ( ) ringan ( ) sedang ( ) berat ( ) panik
Sebab, ...................................................................................................Kemampuan interaksi : ( ) sesuai ( ) tidak,....................................................................
Vertigo : ( ) tidak ( ) yaNyeri : ( ) tidak ( ) ya
Bila ya, P : .........................................................................................................................................Q : .........................................................................................................................................R : .........................................................................................................................................S : .........................................................................................................................................T : .........................................................................................................................................
VIII. POLA PERSEPSI DIRI / KONSEP DIRI1. Body image/gambaran diri( ) cacat fisik
( ) perubahan ukuran fisik( ) fungsi alat tubuh terganggu( ) keluhan karena kondisi tubuh( ) transplantasi alat tubuh
( ) pernah operasi( ) proses patologi penyakit( ) kegagalan fungsi tubuh( ) gangguan struktur tubuh( ) menolak berkaca
( ) prosedur pengobatan yang mengubah fungsi alat tubuh( ) perubahan fisiologis tumbuh kembangJelaskan : ........................................................................................................................................
.........................................................................................................................................Masalah keperawatan : ...................................................................................................................
2. Role/peran( ) overload peran( ) konflik peran
( ) perubahan peran( ) keraguan peran
( ) transisi peran karena sakit
Jelaskan : ........................................................................................................................................
........................................................................................................................................Masalah keperawatan : ...................................................................................................................
3. Identity/identitas diri( ) kurang percaya diri( ) merasa terkekang( ) tidak mampu menerima perubahan
( ) merasa kurang memiliki potensi( ) kurang mampu menentukan pilihan( ) menolak menjadi tua
Jelaskan : ........................................................................................................................................
........................................................................................................................................Masalah keperawatan : ...................................................................................................................
4. Self esteem/harga diri( ) mengkritik diri sendiri dan orang lain( ) merasa jadi orang penting( ) menunda tugas( ) merusak diri( ) menyangkal kemampuan pribadi( ) rasa bersalah
( ) menyangkal kepuasan diri( ) polarisasi pandangan hidup( ) mencemooh diri( ) mengecilkan diri( ) keluhan fisik( ) menyalahgunakan zat
Jelaskan : .......................................................................................................................................
........................................................................................................................................Masalah keperawatan : ...................................................................................................................
5. Self ideal/ideal diri( ) masa depan suram( ) terserah pada nasib( ) merasa tidak memiliki kemampuan( ) tidak memiliki harapan
( ) tidak ingin berusaha( ) tidak memiliki cita-cita( ) merasa tidak berdaya( ) enggan membicarakan masa depan
Jelaskan : ......................................................................................................................................................................................................................................................................................
Masalah keperawatan : ......................................................................................................................
IX. POLA PERAN DAN HUBUNGANPekerjaan : ..........................................................................................................Kualitas bekerja : ..........................................................................................................Hubungan dengan orang lain :Sistem pendukung : ( ) pasangan ( ) tetangga/teman ( ) tidak ada
( ) lainnya,......................................................................................Masalah keluarga mengenai perawatan di RS : ...................................................................................
X. POLA SEKSUALITAS / REPRODUKSIMenstruasi terakhir : .....................................................................................................................Masalah menstruasi : .....................................................................................................................Pap smear terakhir : .....................................................................................................................Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidakMasalah seksual yang berhubungan dengan penyakit : ...............................................................
XI. POLA KOPING / TOLERANSI STRESS1. Masalah utama selama MRS (penyakit, biaya, perawatan diri)
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.........................................................................................................................................................2. Kehilangan perubahan yang terjadi sebelumnya
a. Tahap Denial/Penolakan( ) penolakan terhadap situasi( ) tidak percaya pada orang lain
( ) merasa tertekan( ) wawasan sempit
Jelaskan : ..................................................................................................................................
..................................................................................................................................Masalah keperawatan : .............................................................................................................
b. Tahap Anger/Marah( ) marah pada diri sendiri( ) marah pada orang lain
( ) meningkatnya kesadaran klien pada realita
Jelaskan : .................................................................................................................................
..................................................................................................................................Masalah keperawatan : .............................................................................................................
3. Kemampuan adaptasi....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
XII. POLA NILAI / KEPERCAYAANAgama : ................................................................................................Pelaksanaan ibadah : ................................................................................................Pantangan agama : ( ) tidak ( ) ya, ................................................................Meminta kunjungan rohaniawan : ( ) tidak ( ) ya
XIII. PENGKAJIAN PERSISTEM (Review of System)1. Tanda-Tanda Vital
a. Suhu : ................... °C lokasi : ......................b. Nadi : ................... ¿ /menit irama : ...................... pulsasi : ......................c. Tekanan darah : ................... mmHg lokasi : ......................
d. Frekuensi nafas : ................... ¿ /menit irama : ......................e. Tinggi badan : ................... cmf. Berat badan : SMRS ................... kg MRS .................... kg
2. Sistem Pernafasan (Breath)....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Sistem Kardiovaskuler (Blood)....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4. Sistem Persarafan (Brain)....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
5. Sistem Perkemihan (Bladder)....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
6. Sistem Pencernaan (Bowel)....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
7. Sistem Muskuloskeletal (Bone)....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
8. Sistem Integumen ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9. Sistem PenginderaanMata...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Hidung...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Telinga...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
10. Sistem Reproduksi Dan Genetalia....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
XIV. PEMERIKSAAN PENUNJANG1. Laboratorium
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.........................................................................................................................................................3. Lain-lain
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XV. TERAPI..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
XVI. POHON MASALAH
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 KeperawatanTanggal Paraf
(Nama perawat)Ditemukan Teratasi
RENCANA KEPERAWATAN
No. Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi Rasional
TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN
No.WaktuTgl/jam
Tindakan TTWaktuTgl/jam
Catatan Perkembangan(SOAP)
TT
