LAPORAN ASUHAN KEPERAWATAN PADA .............................................

DENGAN .............................................................................................

DI RUANG ................................. RSUP SANGLAH

TANGGAL ...................................... s.d ..........................................

OLEH:

A A ARI NOVIA SULISTIAWATI

1102105008

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN

UNIVERSITAS UDAYANA

2015

A. PENGKAJIAN

1. IDENTITAS

Pasien

Nama : ..................................................................................

Umur : ..................................................................................

Jenis kelamin : ..................................................................................

Pendidikan : ..................................................................................

Pekerjaan : ..................................................................................

Status perkawinan : ..................................................................................

Agama : ..................................................................................

Suku : ..................................................................................

Alamat : ..................................................................................

Tanggal masuk : ..................................................................................

Tanggal pengkajian: ..................................................................................

Sumber Informasi : ..................................................................................

Diagnosa masuk : ..................................................................................

Penanggung

Nama : ......................................................................

Hubungan dengan pasien : ......................................................................

2. RIWAYAT KELUARGA

Genogram (kalau perlu)

Keterangan genogram:

: Laki-laki

: Perempuan

: Sudah Meninggal

: Tinggal Serumah

: Klien

3. STATUS KESEHATAN

a. Status Kesehatan Saat Ini

Keluhan utama (saat MRS dan saat ini)

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Alasan masuk Rumah Sakit dan perjalanan Penyakit saat ini

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Upaya yang dilakukan untuk mengatasinya

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b. Status Kesehatan Masa Lalu

Penyakit yang pernah dialami

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Pernah dirawat

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Riwayat alergi : Ya Tidak

Jelaskan: ......................................................................................................................

Riwayat tranfusi : Ya Tidak

Kebiasaan:

Merokok Ya Tidak Sejak: Jumlah:

Minum kopi Ya Tidak Sejak: Jumlah:

Penggunaan Alkohol Ya Tidak Sejak: Jumlah:

Lain-lain:

Jelaskan: ..........................................................................................................

4. RIWAYAT PENYAKIT KELUARGA:

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5. DIAGNOSA MEDIS DAN THERAPY

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6. POLA FUNGSI KESEHATAN

a. Pemeliharaan dan persepsi terhadap kesehatan

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b. Nutrisi/ metabolic

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c. Pola eliminasi

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d. Pola aktivitas dan latihan

Kemampuan perawatan diri

0 1 2 3 4

Makan/minum

MandiToiletingBerpakaia

nMobilisas

i di tempat tidur

Berpindah

Ambulasi ROM

0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4:

tergantung total.

Keterangan:

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e. Pola tidur dan istirahat

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f. Pola kognitif-perseptual

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g. Pola persepsi diri/konsep diri

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h. Pola seksual dan reproduksi

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i. Pola peran-hubungan

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j. Pola manajemen koping stress

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k. Pola keyakinan-nilai

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7. RIWAYAT KESEHATAN DAN PEMERIKSAAN FISIK

Keadaan umum : Baik Sedang Lemah Kesadaran:

TTV : TD: mmHg Nadi : x/menit

Suhu: ? C RR : x/menit

a. Kulit, Rambut dan Kuku

Distribusi rambut:

Lesi Ya Tidak

Warna kulit Ikterik Sianosis Kemerahan Pucat

Akral Hangat Panas Dingin kering Dingin

Turgor:

Oedem Ya Tidak Lokasi:

Warna kuku: Pink Sianosis lain-lain

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b. Kepala dan Leher

Kepala Simetris Asimetris

Lesi: ya Tidak

Deviasi trakea Ya Tidak

Pembesaran kelenjar tiroid Ya Tidak

Lain-lain:

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c. Mata dan Telinga

Gangguan pengelihatan Ya Tidak

Menggunakan kacamata Ya Tidak

Visus:

Pupil Isokor Anisokor

Ukuran:

Sklera/ konjungtiva Anemis Ikterus

Gangguan pendengaran Ya Tidak

Menggunakan alat bantu dengar Ya Tidak

Tes webber :

Tes Rinne :

Tes Swabach :

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d. Sistem Pernafasan

Batuk: Ya Tidak

Sesak: Ya Tidak

Inspeksi:

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Palpasi:

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Perkusi:

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Auskultasi:

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e. Sistem Kardiovaskular

Nyeri dada Ya Tidak

Palpitasi Ya Tidak

CRT < 3 dtk > 3 dtk

Inspeksi:

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Palpasi

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Perkusi:

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Auskultasi:

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f. Payudara Wanita dan Pria

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g. Sistem Gastrointestinal

Mulut Bersih Kotor Berbau

Mukosa Lembab Kering Stomatitis

Pembesaran hepar Ya Tidak

Abdomen Meteorismus Asites Nyeri tekan

Peristaltik: x/mnt

Lain-lain

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h. Sistem Urinarius

Penggunaan alat bantu/ kateter Ya Tidak

Kandung kencing, nyeri tekan Ya Tidak

Gangguan Anuria Oliguria Retensi Inkontinensia

Nokturia

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i. Sistem Reproduksi Wanita/Pria

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j. Sistem Saraf

GCS: Eye: Verbal: Motorik:

Rangsangan meningeal Kaku kuduk Kernig Brudzinski I

Brudzinski II

Refleks fisiologis Patela Trisep Bisep Achiles

Pupil Kornea

Refleks patologis Babinski Chaddock Oppenheim Schaefer

Hoffman

Gerakan involunter:

Lain-lain:

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k. Sistem Muskuloskeletal

Kemampuan pergerakan sendi Bebas Terbatas

Deformitas Ya Tidak Lokasi:

Fraktur Ya tidak Lokasi:

Kekakuan Ya Tidak

Nyeri sendi/otot Ya Tidak

Kekuatan otot :

Lain-lain:

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l. Sistem Imun

Perdarahan Gusi Ya Tidak

Perdarahan lama Ya Tidak

Pembengkakan KGB Ya Tidak Lokasi:

Keletihan/kelemahan Ya Tidak

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m. Sistem Endokrin

Hiperglikemia Ya Tidak Nilai:

Hipoglikemia Ya Tidak Nilai:

Luka gangrene Ya Tidak

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8. PEMERIKSAAN PENUNJANG

a. Data laboratorium yang berhubungan

Komponen Hasil Nilai Normal Interpretasi

b. Pemeriksaan Radiologi

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c. Hasil Konsultasi

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d. Pemeriksaan penunjang diagnostik lain

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