LAPORAN KASUS

ASUHAN KEPERAWATAN PADA KLIEN DENGAN ...................................

DI ..................

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

Oleh :

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NIM ...............................

PROGRAM STUDI DIII KEPERAWATAN

UNIVERSITAS BONDOWOSO

TA. 2011/2012

LEMBAR PENGESAHAN

ASUHAN KEPERAWATAN PADA KLIEN DENGAN ...................................

DI ..................

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

Oleh :

_________________________

NIM ...............................

Mengetahui,

Pembimbing Akademik

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Surabaya, ................ 20.....

CI

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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. RIWAYAT SAKIT DAN KESEHATAN1. Keluhan utama :

.........................................................................................................................................................2. Riwayat penyakit sekarang :

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.........................................................................................................................................................3. Riwayat penyakit dahulu :

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.........................................................................................................................................................4. Riwayat kesehatan keluarga :

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.........................................................................................................................................................5. Susunan keluarga (genogram) :

6. Riwayat alergi :

PENGKAJIAN KEPERAWATANASUHAN KEPERAWATAN MEDIKAL BEDAH

PRODI DIII KEPERAWTAAN UNIBO

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

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2. Pola Aktivitas Dan Latihana. 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

b. Kebersihan diriDi rumahMandi : ........................ /hrGosok gigi : ........................ /hrKeramas : .................... /mggPotong kuku : .................... /mgg

Di rumah sakitMandi : ........................ /hrGosok gigi : ........................ /hrKeramas : .................... /mggPotong kuku : .................... /mgg

c. Aktivitas sehari-hari...................................................................................................................................................

d. Rekreasi...................................................................................................................................................

e. Olahraga : ( ) tidak ( ) ya...................................................................................................................................................

3. 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, ...............................

4. Pola Nutrisi – Metabolik

a. Pola makanDi 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

b. Pola minumDi rumahFrekuensi : .........................Jenis : .........................Jumlah : .........................Pantangan : .........................Minuman disukai : .........................

Di rumah sakitFrekuensi : ..................................Jenis : ..................................Jumlah : ..................................

5. 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 kecilDi rumahFrekuensi : ..................................Konsistensi : ..................................Warna : ..................................

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

Masalah di RS: ( ) disuria ( ) nokturia ( ) hematuria( ) retensi ( ) inkontinen

Kolostomi : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari

6. Pola Kognitif 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 : .................................................................................................................................

7. Pola Konsep Diri

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

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

10. Pola Peran – HubunganPekerjaan : ......................................................................................................Kualitas bekerja : ......................................................................................................Hubungan dengan orang lain : ......................................................................................................Sistem pendukung : ( ) pasangan ( ) tetangga/teman ( ) tidak ada

( ) lainnya, .................................................................................Masalah keluarga mengenai perawatan di RS : .............................................................................

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

IV. 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)

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

V. PEMERIKSAAN PENUNJANG

1. Laboratorium..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2. Photo........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Lain-lain...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................

VI. TERAPI.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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 PerawatDitemukan 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