LAPORAN KASUS

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

DI .................. RUMKITAL Dr. RAMELAN SURABAYA
Tanggal .............. s/d ..................

Oleh :
_________________________
NIM ...............................

PROGRAM STUDI ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA
TA. 2012/2013

LEMBAR PENGESAHAN
ASUHAN KEPERAWATAN PADA KLIEN DENGAN ...................................
DI .................. RUMKITAL Dr. RAMELAN SURABAYA
Tanggal .............. s/d ..................

Oleh :
_________________________
NIM ...............................

Mengetahui,

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

Penguji Pendidikan

Penguji Lahan

______________________

______________________

PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN MEDIKAL BEDAH
STIKES HANG TUAH SURABAYA
Nama mahasiswa : ........................................
Tgl/jam pengkajian : ........................................
Diagnosa medis
: ........................................
........................................

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

:
:
:
:
:
:
:
:
:
:
:

Tgl/jam MRS
No. RM
Ruangan/kelas
No.kamar

:
:
:
:

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II. RIWAYAT SAKIT DAN KESEHATAN

1. Keluhan utama :
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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 :
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III. POLA FUNGSI KESEHATAN
1. Persepsi Terhadap Kesehatan (Keyakinan Terhadap Kesehatan & Sakitnya)
.........................................................................................................................................................
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2. Pola Aktivitas Dan Latihan
a. Kemampuan perawatan diri
Aktivitas

SMRS
2
3

MRS
2
3

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

Alat bantu : ( ) tidak ( ) kruk ( ) tongkat

( ) pispot disamping tempat tidur ( ) kursi roda
b. Kebersihan diri
Di rumah
Di rumah sakit
Mandi
: ........................ /hr
Mandi
: ........................ /hr
Gosok gigi
: ........................ /hr
Gosok gigi
: ........................ /hr
Keramas
: .................... /mgg
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

.........................
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.........................
.........................
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5. Pola Eliminasi
a. Buang air besar
Di rumah
Frekuensi : ..................................
Konsistensi : ..................................
Warna
: ..................................

Masalah di RS : ( ) konstipasi ( ) diare

Kolostomi
: ( ) tidak ( ) ya

( ) berkurang
( ) stomatitis

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

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

b. Buang air kecil

Di rumah
Di rumah sakit
Frekuensi : ..................................
Frekuensi : ..................................
Konsistensi : ..................................
Konsistensi : ..................................
Warna
: ..................................
Warna
: ..................................
Masalah di RS : ( ) disuria ( ) nokturia
( ) hematuria
( ) retensi ( ) inkontinen
Kolostomi
: ( ) tidak
( ) ya, kateter ........................... produksi : .................. cc/hari
6. Pola Kognitif Perseptual
Berbicara
: ( ) normal
( ) gagap
( ) bicara tak jelas
Bahasa sehari-hari
: ( ) Indonesia ( ) Jawa
( ) lainnya, ....................................
Kemampuan membaca : ( ) bisa
( ) tidak
Tingkat ansietas
: ( ) ringan
( ) sedang
( ) berat
( ) panik
Sebab, ...................................................................................................
Kemampuan interaksi : ( ) sesuai
( ) tidak, ...................................................................
Vertigo
: ( ) tidak
( ) ya
Nyeri
: ( ) tidak
( ) ya
Bila ya, P
Q
R
S
T

:
:
:
:
:

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7. Pola Konsep Diri

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8. Pola Koping
Masalah utama selama MRS (penyakit, biaya, perawatan diri)
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Kehilangan perubahan yang terjadi sebelumnya
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Kemampuan adaptasi
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9. Pola Seksual Reproduksi
Menstruasi terakhir : .....................................................................................................................
Masalah menstruasi : .....................................................................................................................
Pap smear terakhir : .....................................................................................................................
Pemeriksaan payudara/testis sendiri tiap bulan
: ( ) ya ( ) tidak
Masalah seksual yang berhubungan dengan penyakit : ...............................................................
10. Pola Peran Hubungan
Pekerjaan
Kualitas bekerja
Hubungan dengan orang lain
Sistem pendukung

:
:
:
:

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( ) pasangan ( ) tetangga/teman ( ) tidak ada
( ) lainnya, .................................................................................
Masalah keluarga mengenai perawatan di RS : .............................................................................

11. Pola Nilai Kepercayaan

Agama
Pelaksanaan ibadah
Pantangan agama
Meminta kunjungan rohaniawan

:
:
:
:

................................................................................................
................................................................................................
( ) tidak ( ) ya, ................................................................
( ) tidak ( ) ya

IV. PENGKAJIAN PERSISTEM (Review of System)

1. Tanda-Tanda Vital
a. Suhu
: ................... C
lokasi : ......................
b. Nadi
: ................... /menit irama : ......................
c. Tekanan darah : ................... mmHg
lokasi : ......................
d. Frekuensi nafas : ................... /menit irama : ......................
e. Tinggi badan : ................... cm
f. Berat badan
: SMRS ................... kg MRS .................... kg

pulsasi : ......................

2. Sistem Pernafasan (Breath)

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3. Sistem Kardiovaskuler (Blood)

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4. Sistem Persarafan (Brain)
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5. Sistem Perkemihan (Bladder)
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6. Sistem Pencernaan (Bowel)
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7. Sistem Muskuloskeletal (Bone)
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8. Sistem Integumen
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9. Sistem Penginderaan
Mata
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Hidung
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Telinga
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10. Sistem Reproduksi Dan Genetalia
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V. PEMERIKSAAN PENUNJANG
1. Laboratorium
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2. Photo
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3. Lain-lain
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VI. TERAPI
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Surabaya, .....................
Mahasiswa

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

ANALISA DATA
Nama klien
Umur
No.

: ..............................................
: ..............................................
Data (Symptom)

Ruangan/kamar : ..............................................
No. RM
: ..............................................

Penyebab (Etiologi)

Masalah (Problem)

PRIORITAS MASALAH
Nama klien
Umur
No.

: ..............................................
: ..............................................
Masalah Keperawatan

Ruangan/kamar : ..............................................
No. RM
: ..............................................
Tanggal

Ditemukan

Teratasi

Paraf
(Nama Perawat

RENCANA KEPERAWATAN
No.

Diagnosa Keperawatan

Tujuan Dan Kriteria Hasil

Intervensi

Rasional

RENCANA KEPERAWATAN
No.

Diagnosa Keperawatan

Tujuan Dan Kriteria Hasil

Intervensi

Rasional

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No
DX.

Waktu
Tgl/jam

Tindakan

TT

Waktu
Tgl/jam

Catatan Perkembangan
(SOAP)

TT

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No
DX.

Waktu
Tgl/jam

Tindakan

TT

Waktu
Tgl/jam

Catatan Perkembangan
(SOAP)

TT