LAPORAN KASUS

DENGAN PENYAKIT.........................................................
A.

PENGKAJIAN
1. Identitas Klien
Nama
Umur
Jenis Kelamin
Agama
Pendidikan
Pekerjaan
Suku Bangsa
Status Perkawinan
Tgl Masuk
No. Reg. Medis
Ruang /Kamar
Diagnosa Medis
Tgl Pengkajian
Alamat

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Identitas Penanggung Jawab

Nama
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Umur
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Pekerjaan
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Pendidikan
: ..................................................................
Alamat
: ..................................................................
Hub Dengan Klien
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2. Riwayat Kesehatan.
a). Keluhan Utama
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b). Riwayat Kesehatan Sekarang
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c). Riwayat Kesehatan Dahulu
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d). Riwayat Kesehatan Keluarga

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3. Keadaaan Umum
e). Penampilan
f). Kesadaran
a) BB dan TB
b) TTV

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GCS . ..................................................................................
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:TD....................................., Nadi........................................
suhu...................................., respirasi..................................

4. Pemeriksaan Fisik
a). Kepala dan Rambut
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b). Mata
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c). Hidung
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d). Telinga
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e). Mulut
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f). Leher
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g). Dada
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h). Abdomen
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i). Punggung
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j). Ekstremitas
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k). Integument
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l). System reproduksi
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5. Pola Aktivitas Sehari-hari
No

Aktivitas Sehari-hari

1).

Nutrisi dan Makanan

a) Makanan
Jenis
Frekuensi
Keluhan
b) Minuman
Jenis
Frekuensi
Keluhan

2).

Eliminasi
c) BAK
Frekuensi
Warna
Keluhan
d) BAB
Frekuensi
Konsistensi
Warna
Keluhan

Sebelum Hamil

Sesudah Hamil

3).

Pola Tidur
Malam
Siang

4).

Personal Hygiene
Mandi
Keramas
Gosok gigi
Gunting kuku
Ganti pakaian

6. Data Penunjang
a). Data sosial
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b). Data Spiritual
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c). Data Psikologi
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d). Pemeriksaan Laboratorium tgl.......................................................................
No

Jenis Kelamin

Hasil

Satuan

Nilai normal

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B. ANALISA DATA
NO

DATA

ETIOLOGI

MASALAH

C.

DIAGNOSA KEPERAWATAN
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LEMBAR PENGESAHAN

CI RUANGAN

Ciamis, .....................2014
Mahasiswa

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MENGETAHUI DOSEN

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