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LAPORAN KASUS

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Nama Mahasiswa

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NIM

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Tanggal Pengkajian

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1. Pengkajian
A. Identitas Pasien
Nama

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Umur

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Jenis Kelamin

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Pendidikan

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Suku Bangsa

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Pekerjaan

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Agama

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Status Perkawinan

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Alamat

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No. Medical Record

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Ruang Rawat

: ..........................................................................

B. Penanggung Jawab
Nama

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Umur

: ..........................................................................

Pekerjaan

: ..........................................................................

Alamat

: ..........................................................................

C. Data Saat Masuk RS


Tanggal masuk RS

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Jam masuk RS

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Yang mengirim/merujuk

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Alasan masuk
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Diagnosa medis saat masuk

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Diagnosa Medis Saat Pengkajian : .......................................................................


D. Riwayat Kesehatan Sekarang
1. Kondisi atau keadaan klien saat pengkajian
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Masalah Keperawatan : ................................................................................
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E. Riwayat kesehatan Yang lalu
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F. Riwayat Kesehatan keluarga
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Genogram

Keterangan:

G. Riwayat Psikologis dan Spiritual


a. Psikologis
Suasana hati/ mood
: ..........................................................................
Karakter
: ..........................................................................
Keadaan emosional
: ..........................................................................
Konsep diri
: ..........................................................................
b. Sosial
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c. Spiritual
Pelaksanaan ibadah : ...................................................................................
Aktifitas keagamaan yang dilakukan : ........................................................
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Keyakinan kepada tuhan : ...........................................................................

H. Pola Kesehatan Fungsional


1. Pola Nutrisi dan cairan
a. Makanan
1) Sehat :
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2) Sakit :
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b. Cairan/Minum
1) Sehat :
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2) Sakit :
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2. Pola Eliminasi
a. BAK
1) Sehat :
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2) Sakit :
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b. BAB
1) Sehat :
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2) Sakit :
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3. Pola Aktivitas
1) Sehat :
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2) Sakit :
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4. Pola Istirahat
1) Sehat :

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2) Sakit :
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5. Personal Hygiene
1) Sehat :
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2) Sakit :
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I. Pemeriksaan fisik
Tanggal : .......................................
1. Umum
Keadaan umum
: ......................................................................................
Tingkat kesadaran : ......................................................................................
Tinggi badan
: ......................................................................................
Berat badan
: ......................................................................................
2. Tanda- tanda vital
Suhu
: ......................................................................................
Nadi
: ......................................................................................
Pernafasan
: ......................................................................................
Tekana darah
: ......................................................................................
3. Rambut dan kepala
Inspeksi
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Palpasi
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4. Mata
Inspeksi

5. Telinga
Inspeksi

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6. Hidung dan sinus
Inspeksi
: ..................................................................................................

Palpasi
7. Mulut
Inspeksi

8. Leher
Inspeksi
Palpasi

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9. Thorak
1. Paru
Inspeksi
Palpasi
Perkusi
Auskultasi
2. jantung
Inspeksi
Palpasi
Perkusi

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Auskultasi
10. Abdomen
Inspeksi
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Ausklultasi : ..................................................................................................
Palpasi
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Perkusi
: ..................................................................................................
11. Genetalia
Inspeksi
: ..................................................................................................
12. Ekstremitas
1. Atas
Inspeksi
: ......................................................................................

Palpasi
2. Bawah
Inspeksi
Palpasi

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J. Hasil Pemeriksaan Diagnostik

K. Program Dokter