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

Kebiasaan:

: Ya

Tidak

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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Pola eliminasi
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d.

Pola aktivitas dan latihan

Kemamp
0
1
2
3
4
uan
pera
wata
n diri
Makan/m
inum
Mandi
Toileting
Berpakai
an
Mobilisas
i di
temp
at
tidur
Berpinda
h
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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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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Pola keyakinan-nilai
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7.

RIWAYAT KESEHATAN DAN PEMERIKSAAN FISIK

Keadaan umum

: Baik Sedang

Lemah

Kesadaran:

TTV

: TD:

Nadi :

x/menit

RR :

x/menit

Suhu:
a.

mmHg
C

Kulit, Rambut dan Kuku

Distribusi rambut:
Lesi

Ya

Tidak

Warna kulit

Ikterik

Sianosis

Kemerahan

Pucat

Akral

Hangat

Panas

Dingin kering

Dingin

Oedem

Ya

Tidak

Warna kuku:

Pink

Turgor:
Sianosis

Lokasi:
lain-lain

Lainlain: ....................................................................................................................................
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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

Isokor

Anisokor

Sklera/ konjungtiva

Anemis

Ikterus

Gangguan pendengaran

Ya

Tidak

Visus:
Pupil
Ukuran:

Menggunakan alat bantu dengar Ya

Tes webber

Tes Rinne

Tes Swabach

Tidak

Lain-lain:
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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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Lain-lain:
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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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Lain-lain:
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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

Peristaltik:

x/mnt

Nyeri tekan

Lain-lain
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h.

Sistem Urinarius
Penggunaan alat bantu/ kateter

Ya

Tidak

 Ya

Kandung kencing, nyeri tekan

Gangguan

Anuria

Oliguria

Tidak
Retensi

Inkontinensia

Nokturia
Lain-lain:
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i.

Sistem Reproduksi Wanita/Pria

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j.

Sistem Saraf
GCS:

Eye:

Verbal:

Rangsangan meningeal Kaku kuduk

Motorik:
Kernig

Brudzinski I

Brudzinski II
Refleks fisiologis
Refleks patologis

Patela

Trisep

Bisep

Achiles

Pupil

Kornea

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
Ya

Perdarahan Gusi

Tidak

Perdarahan lama

Ya

Tidak

Pembengkakan KGB

Ya

Tidak

Keletihan/kelemahan

Ya

Tidak

Lokasi:

Lain-lain:
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m.

Sistem Endokrin
Hiperglikemia

Ya

Tidak

Nilai:

Hipoglikemia

Ya

Tidak

Nilai:

Luka gangrene

Ya

Tidak

Lain-lain:
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8.

PEMERIKSAAN PENUNJANG
a.

Data laboratorium yang berhubungan

Komponen

b.

Hasil

Nilai Normal

Interpretasi

Pemeriksaan Radiologi
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c.

Hasil Konsultasi
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d.

Pemeriksaan penunjang diagnostik lain

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