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LAPORAN KASUS ASUHAN KEPERAWATAN PADA KLIEN DENGAN ................................... DI ..................Tanggal .............. s/d ..................

Oleh : _________________________ 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

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

______________________

______________________

PENGKAJIAN KEPERAWATAN ASUHAN KEPERAWATAN MEDIKAL BEDAH PRODI DIII KEPERAWTAAN UNIBONama mahasiswa : ........................................ Tgl/jam pengkajian : ........................................ Diagnosa medis : ........................................ ........................................ Tgl/jam MRS No. RM Ruangan/kelas No.kamar : : : : ........................................ ........................................ ........................................ ........................................

I. IDENTITAS 1. 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 KESEHATAN 1. Keluhan utama : ......................................................................................................................................................... 2. Riwayat penyakit sekarang : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 3. Riwayat penyakit dahulu : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 4. Riwayat kesehatan keluarga : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 5. Susunan keluarga (genogram) :

6. Riwayat alergi : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... III. POLA FUNGSI KESEHATAN 1. Persepsi Terhadap Kesehatan (Keyakinan Terhadap Kesehatan & Sakitnya) ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 2. Pola Aktivitas Dan Latihan a. Kemampuan perawatan diri Aktivitas Mandi Berpakaian/berdandan Eliminasi/toileting Mobilitas di tempat tidur Berpindah Berjalan Naik tangga Berbelanja Memasak Pemeliharaan rumah Skor 0 = mandiri 1 = alat bantu 2 = dibantu orang lain 3 = dibantu orang lain & alat 4 = tergantung/tidak mampu 0 SMRS 1 2 3 4 0 MRS 1 2 3 4

Alat bantu : ( ) tidak ( ) kruk ( ) tongkat ( ) pispot disamping tempat tidur ( ) kursi roda b. Kebersihan diri Di rumah Di rumah sakit /hr Mandi : ........................ Mandi : ........................ /hr Gosok gigi : ........................ /hr Gosok gigi : ........................ /hr /mgg Keramas : .................... Keramas : .................... /mgg Potong kuku : .................... /mgg Potong kuku : .................... /mgg c. Aktivitas sehari-hari ................................................................................................................................................... d. Rekreasi ................................................................................................................................................... e. Olahraga : ( ) tidak ( ) ya ................................................................................................................................................... 3. Pola Istirahat Dan Tidur Di rumah Di rumah sakit Waktu tidur : Siang ..............-............... Waktu tidur : Siang ..............-............... Malam ............-............... Malam ............-............... Jumlah jam tidur : .................................. Jumlah jam tidur : .................................. Masalah di RS : ( ) tidak ada ( ) terbangun dini ( ) mimpi buruk ( ) insomnia ( ) Lainnya, ...............................

4. Pola Nutrisi Metabolik a. Pola makan Di rumah Frekuensi : ......................... Jenis : ......................... Porsi : ......................... Pantangan : ......................... Makanan disukai : ......................... Nafsu makan di RS : ( ) normal ( ) mual Kesulitan menelan : ( ) tidak ( Gigi palsu : ( ) tidak ( NG tube : ( ) tidak ( b. Pola minum Di rumah Frekuensi : Jenis : Jumlah : Pantangan : Minuman disukai :

Di rumah sakit Frekuensi : .................................. Jenis : .................................. Porsi : .................................. Diit khusus : .................................. ( ) bertambah ( ) muntah, .............. cc ) ya ) ya ) ya ( ) berkurang ( ) stomatitis

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

Di rumah sakit Frekuensi : .................................. Jenis : .................................. Jumlah : ..................................

5. Pola Eliminasi a. Buang air besar Di rumah Frekuensi : .................................. Konsistensi : .................................. Warna : .................................. Masalah di RS : ( ) konstipasi ( ) diare Kolostomi : ( ) tidak ( ) ya

Di rumah sakit Frekuensi : .................................. Konsistensi : .................................. Warna : ( ) kuning ( ) bercampur darah ( ) lainnya, .............. ( ) inkontinen

b. Buang air kecil Di rumah Di rumah sakit Frekuensi : .................................. Frekuensi : .................................. Konsist