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

DENGAN...................................................
DI RUANG.........................................RSUP SANGLAH
DENPASAR
TANGGAL
.......................................S/D....................................2010

OLEH:
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NIM:................................................

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA

2010

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

DENGAN..................................................................................
....
DI RUANG............................................
RSUP SANGLAH DENPASAR
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

: ......................................................
2. Riwayat keluarga
Genogram (kalau perlu)

pasien

 Keterangan genogram

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:................................................................................
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Riwayat tranfusi :

Ya

Tidak

Ya

Tidak

Kebiasaan :

Merokok

Sejak:..................................................................................
................

Jumlah:................................................................................
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Minum kopi

Ya

Tidak

Sejak:...........................................................................
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Jumlah:.........................................................................
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Penggunaan Alkohol

Ya

Tidak

Sejak:..................................................................................
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Jumlah:................................................................................
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Lain-lain:
Jelaskan:.......................................................................
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4. Riwayat Penyakit Keluarga

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5. Diagnosa Medis dan therapy

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6. Riwayat Penyakit Saat Ini (11 Pola Fungsional Gordon)
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 0

diri
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
Keterangan:
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang
lain dan alat, 4: tergantung total.
Lainlain: .........................................................................................
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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 dan nilai
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7. Riwayat Kesehatan dan Pemeriksaan Fisik
Keadaan umum :

Baik

Sedang

Lemah
Kesadaran:
TTV:
TD:

Nadi :

Suhu:

a. Kulit, Rambut dan Kuku

Distribusi rambut :
Lesi

Ya

Tidak

RR:

Warna kulit

Ikterik

Sianosis Kemerahan

Hangat

Panas

Pucat
Akral

Dingin kering

Dingin
Turgor:
...
.............
...
Oedem

Ya

Tidak

Lokasi:
.
...W
arna kuku:

Pink

Sianosis lain-lain

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

Weber:

.
Tes

Rinne:

.
Tes

Swabach:

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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.
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Lain-lain:

...
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e. Sistem Kardiovaskular :
Nyeri dada

Ya

Palpitasi
CRT

Tidak
Ya

< 3 dtk

Tidak
> 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

Mukosa

Lembab Kering

Pembesaran hepar
Abdomen

Kotor

Ya

Meteorismus

Peristaltik:..

Berbau
Stomatitis
Tidak

Asites

Nyeri tekan

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

Lain-lain:
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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

Oppenheim

Refleks patologis
Babinski

Chaddock

Rossolimo
Gordon

Schaefer Stransky

Gerakan

Gonda

involunter

Lain-lain:

k. Sistem Muskuloskeletal:
Kemampuan pergerakan sendi
Deformitas

Ya

Bebas

Terbatas

Tidak

Lokasi:

Fraktur

Ya

Tidak

Lokasi:

Kekakuan

Ya

Tidak

Nyeri sendi/otot

Ya

Tidak

Kekuatan

otot

Lain-lain

.
...

l. Sistem Imun:
Perdarahan Gusi

Ya

Tidak

Perdarahan lama

Ya

Tidak

Pembengkakan KGB

Ya

Tidak

Lokasi:

Keletihan/kelemahan

Ya

Tidak

Lain-lain:

...

m. Sistem Endokrin:
Hiperglikemia

Ya

Tidak

Hipoglikemia

Ya

Tidak

Luka gangrene

Ya

Tidak

Lain-lain:

8. Pemeriksaan Penunjang
a.

Data laboratorium yang berhubungan

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b.

Pemeriksaan Radiologi

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c.

Hasil Konsultasi

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d.

Pemeriksaan penunjang diagnostik lain

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