LAPORAN KASUS ASUHAN KEPERAWATAN PADA KLIEN DENGAN ................................... DI .................. RUMKITAL Dr. RAMELAN SURABAYATanggal .............. 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 SURABAYATanggal .............. 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 : ........................................ ........................................

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 : 11. Penanggung :

: : : : : : : : : dan no. telp jawab

II. POLA PERSEPSI KESEHATAN ATAU PENANGANAN KESEHATAN 1. Keluhan utama : ......................................................................................................................................................... ......................................................................................................................................................... 2. Riwayat penyakit sekarang : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 3. Lamanya keluhan ......................................................................................................................................................... ......................................................................................................................................................... 4. Faktor yang Memperberat ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 5. Upaya yang Dilakukan Untuk Mengatasi Keluhan

......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 6. Riwayat penyakit dahulu : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 7. Persepsi klien tentang status kesehatan dan kesejahteraan ......................................................................................................................................................... ......................................................................................................................................................... .........................................................................................................................................................

8. Riwayat kesehatan keluarga : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 9. Susunan keluarga (genogram) :

10. Riwayat alergi : ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... III. POLA NUTRISI DAN METABOLIK 1. 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 ( 2. 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 : ..................................

IV. POLA ELIMINASI 1. Buang air besar Di rumah Frekuensi : .................................. Konsistensi : .................................. Warna : .................................. Masalah di RS Kolostomi : ( ) konstipasi ( ) diare : ( ) tidak ( ) ya

Di rumah sakit Frekuensi Konsistensi Warna ( ( ( ) inkontinen

: .................................. : .................................. : ( ) kuning ) bercampur darah ) lainnya, ..............

2. Buang air kecil Di rumah Di rumah sakit Frekuensi : .................................. Frekuensi : .................................. Jumlah : .................................. Jumlah : .................................. Warna : .................................. Warna : .................................. Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria ( ) retensi ( ) inkontinen Kateter : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari V. POLA AKTIVITAS DAN LATIHAN 1. 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 2. Kebersihan diri Di rumah Di rumah sakit Mandi : ........................ Mandi : ........................ /hr /hr Gosok gigi : ........................ Gosok gigi : ........................ /hr /hr Keramas : .................... Keramas : .................... /mgg /mgg Potong kuku : .................... Potong kuku : .................... /mgg /mgg 3. Aktivitas sehari-hari ......................................................................................................................................................... 4. Rekreasi ......................................................................................................................................................... ......................................................................................................................................................... 5. Olahraga : ( ) tidak ( ) ya ......................................................................................................................................................... VI. 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,

.

VII. POLA KOGNITIF DAN PERSEPTUAL Berbicara : ( ) normal ( ) gagap Bahasa sehari-hari : ( ) Indonesia ( ) Jawa Kemampuan membaca Tingkat ansietas Kemampuan interaksi Vertigo Nyeri Bila ya, P : Q : R : S : T : : ( ) bisa : ( ) ringan Sebab, : ( ) sesuai : ( ) tidak : ( ) tidak ( ) tidak ( ) sedang ( ( ) ya ( ) ya

( ) bicara tak jelas ( ) ( ) berat

lainnya,

( ) panik ) tidak,

VIII. POLA PERSEPSI DIRI / KONSEP DIRI 1. Body image/gambaran diri ( ) cacat fisik ( ) pernah operasi ( ) perubahan ukuran fisik ( ) proses patologi penyakit ( ) fungsi alat tubuh terganggu ( ) kegagalan fungsi tubuh ( ) keluhan karena kondisi tubuh ( ) gangguan struktur tubuh ( ) transplantasi alat tubuh ( ) menolak berkaca ( ) prosedur pengobatan yang mengubah fungsi alat tubuh ( ) perubahan fisiologis tumbuh kembang Jelaskan : ......................................................................................................................................... Masalah keperawatan : ............................................................................................................................................................ 2. Role/peran ( ) overload peran ( ) perubahan peran ( ) transisi peran karena sakit ( ) konflik peran ( ) keraguan peran Jelaskan : ........................................................................................................................................ Masalah keperawatan : .................................................................................................................................................................. 3. Identity/identitas diri ( ) kurang percaya diri ( ) merasa terkekang

( ) tidak mampu menerima perubahan ( ) merasa kurang memiliki potensi Jelaskan

( ) kurang mampu menentukan pilihan ( ) menolak menjadi tua :

........................................................................................................................................ Masalah keperawatan : .................................................................................................................................................................. 4. Self esteem/harga diri ( ) mengkritik diri sendiri dan orang lain ( ) menyangkal kepuasan diri ( ) merasa jadi orang penting ( ) polarisasi pandangan hidup ( ) menunda tugas ( ) mencemooh diri ( ) merusak diri ( ) mengecilkan diri ( ) menyangkal kemampuan pribadi ( ) keluhan fisik ( ) rasa bersalah ( ) menyalahgunakan zat Jelaskan : ........................................................................................................................................ Masalah keperawatan : .................................................................................................................................................................. 5. Self ideal/ideal diri ( ) masa depan suram ( ) tidak ingin berusaha ( ) terserah pada nasib ( ) tidak memiliki cita-cita ( ) merasa tidak memiliki kemampuan ( ) merasa tidak berdaya ( ) tidak memiliki harapan ( ) enggan membicarakan masa depan

Jelaskan : ........................................................................................................................................... Masalah keperawatan : ..................................................................................................................................................................... IX. POLA PERAN DAN HUBUNGAN Pekerjaan : Kualitas bekerja Hubungan dengan orang lain Sistem pendukung Masalah keluarga : : : ( ) pasangan ( mengenai ( ) tetangga/teman perawatan di ( ) tidak ada ) RS :

lainnya,

X. POLA SEKSUALITAS / REPRODUKSI Menstruasi terakhir : Masalah menstruasi Pap smear terakhir : : : ( ) ya : ( ) tidak

Pemeriksaan payudara/testis sendiri tiap bulan Masalah seksual yang berhubungan dengan penyakit

XI. POLA KOPING / TOLERANSI STRESS 1. Masalah utama selama MRS (penyakit, biaya, perawatan diri) ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 2. Kehilangan perubahan yang terjadi sebelumnya a. Tahap Denial/Penolakan ( ) penolakan terhadap situasi ( ) merasa tertekan ( ) tidak percaya pada orang lain ( ) wawasan sempit Jelaskan : .................................................................................................................................. Masalah keperawatan : ............................................................................................................................................................ b. Tahap Anger/Marah ( ) marah pada diri sendiri ( ) meningkatnya kesadaran klien pada ( ) marah pada orang lain realita Jelaskan : .................................................................................................................................. Masalah keperawatan : ............................................................................................................................................................ 3. Kemampuan adaptasi ......................................................................................................................................................... .........................................................................................................................................................

......................................................................................................................................................... ......................................................................................................................................................... XII. POLA NILAI / KEPERCAYAAN Agama : Pelaksanaan ibadah : Pantangan agama : Meminta kunjungan rohaniawan : ................................................................................................ ................................................................................................ ( ) tidak ( ) ya, ................................................................ ( ) 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 : ................... cm f. Berat badan : SMRS ................... kgMRS .................... 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 Penginderaan

Mata ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Hidung ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... Telinga ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 10. Sistem Reproduksi Dan Genetalia ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... .........................................................................................................................................................

XIV. PEMERIKSAAN PENUNJANG 1. Laboratorium ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 2. Photo ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 3. Lain-lain ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... XV. TERAPI ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... XVI. POHON MASALAH

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

(...............................)

ANALISA DATA Nama klien Umur No. : .............................................. : .............................................. Data (Symptom) Ruangan/kamar : .............................................. No. RM : .............................................. Masalah (Problem)

Penyebab (Etiologi)

PRIORITAS MASALAH Nama klien Umur No. : .............................................. : .............................................. Ruangan/kamar : .............................................. No. RM : .............................................. Tanggal Ditemukan Teratasi Paraf (Nama perawat)

Masalah Keperawatan

RENCANA KEPERAWATAN No. Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi Rasional

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN No. Waktu Tgl/jam Tindakan TT Waktu Tgl/jam Catatan Perkembangan (SOAP) TT