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FORMAT LAPORAN ASUHAN KEPERAWATAN

BERDASARKAN FORMAT GORDON

ASUHAN KEPERAWATAN PADA Tn. D


DENGAN DIAGNOSA MEDIS ABSES CEREBRI
DI ...............................................................................................
TANGGAL
I.

PENGKAJIAN
1. Identitas
a. Identitas Pasien
Nama

: Tn. I

Umur

: 34 tahun

Agama

: kong hu cu

Jenis Kelamin

: laki - laki

Status

: menikah

Pendidikan

: d3

Pekerjaan

: swasta

Suku Bangsa

: jawa

Alamat

: jogjakarta

Tanggal Masuk

: 31 desember 2011

Tanggal Pengkajian

: 1 januari 2012

No. Register

:-

Diagnosa Medis

: abses cerebri

2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
Sakit kepala
2) Alasan masuk rumah sakit dan perjalanan penyakit saat ini
Sakit kepala dirasakan selama 2 minggu SMRS dan dirasakan semakin
memberat. Sakit kepala terkadang dirasakan berdenyut dan terasa seperti kepala
sedang diregangkan. Sakit kepala dirasakan di semua bagian kepala terutama
pada kepala bagian belakang. Apabila sakit kepalanya timbul, Os terkadang

sampai menelungkupkan kepalanya dan memegangi kepalanya dengan kedua


tangannya. Sakit kepalanya timbul terus-menerus dan menetap serta lebih
sering terasa semakin memberat pada pagi hari dan menjelang malam hari
sehingga membuat Os tidak dapat beristirahat. Untuk mengurangi sakit
kepalanya, Os lebih senang berbaring pada sisi sebelah kiri.
Awalnya sakit kepala dirasakan 2 minggu yang lalu ketika Os sedang bekerja,
yang membuat Os beristirahat sejenak, kemudian tanpa timbul mual Os
muntah beberapa kali. Muntahnya timbul pada saat Os sedang berbaring dan
terkesan muncrat. Karena tidak ada perbaikan selama beberapa hari berada di
rumah, dan muntah terus-menerus, serta tidak ada perbaikan pada sakit
kepalanya walaupun telah diberikan obat sakit kepala, akhirnya Os dibawa oleh
keluarganya ke rumah sakit.
Di rumah sakit, Os masih sering muntah-muntah, terkadang didahului oleh rasa
mual. Akhir-akhir ini Os merasa gelisah dan susah sekali buat tidur, khususnya
menjelang malam. Lebih banyak diam, dan tampak acuh tak acuh, serta sering
tidak merespon terhadap panggilan serta terkadang berbicara ngelantur ( sering
tidak nyambung ). Bahkan menurut pengakuan istrinya, Os terkadang tidak
mengenali lagi saudara-saudaranya sendiri bahkan kepada istrinya sendiri. Os
seringkali merintih kesakitan.
Ketika berumur sekitar 25 tahun, Os pernah mengalami trauma pada kepalanya
karena tertimpa kayu belian ketika sedang membuat rumah. Pada saat itu, Os
pingsan selama kurang lebih 2 jam dan dibawa oleh keluarganya ke rumah sakit
dan dirawat selama beberapa hari.
Saat ini Os mengalami demam dan tidak pernah mengalami kejang-kejang.
3) Upaya yang dilakukan untuk mengatasinya
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b. Satus Kesehatan Masa Lalu

1) Penyakit yang pernah dialami


Riwayat hipertensi disangkal , riwayat diabetes disangkal, riwayat sakit pada
telinga, gigi disangkal, riwayat sakit pada kulit disangkal. Riwayat kejang
disangkal.
2) Pernah dirawat
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3) Alergi
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4) Kebiasaan (merokok/kopi/alkohol dll)
Merokok sejak remaja, menghabiskan 2 bungkus rokok/hari
Minum kopi 3 gelas/hari
c.

Riwayat Penyakit Keluarga


Tidak ada pada keluarga yang mengalami keluhan yang serupa.

d. Diagnosa Medis dan therapy


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a.

3. Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)


Pola Persepsi dan Manajemen Kesehatan
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b. Pola Nutrisi-Metabolik

Sebelum sakit :
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Saat sakit

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c.

Pola Eliminasi

1) BAB
Sebelum sakit :
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Saat sakit

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2) BAK
Sebelum sakit :
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Saat sakit

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d. Pola aktivitas dan latihan


1) Aktivitas
Kemampuan

Perawatan Diri
Makan dan minum
Mandi
Toileting
Berpakaian
Berpindah
0: mandiri, 1: Alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total

2) Latihan

Sebelum sakit

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Saat sakit
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e.

Pola kognitif dan Persepsi


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f.

Pola Persepsi-Konsep diri


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g.

Pola Tidur dan Istirahat


Sebelum sakit :
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Saat sakit

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h. Pola Peran-Hubungan
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i.

Pola Seksual-Reproduksi
Sebelum sakit :
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Saat sakit

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j.

Pola Toleransi Stress-Koping


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k. Pola Nilai-Kepercayaan
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Status Generalis
Keadaan umum : tampak sakit sedang, gelisah
Kesadaran : Apatis
Status gizi : cukup
Tekanan darah : 130/70 mmHg
Nadi : 88x/ menit, teratur, isi cukup
Nafas : 21x/ menit, teratur, kedalaman cukup
Suhu : 38,50C
Mata : konjungtiva tidak pucat, sklera tidak ikterik
Telinga : sekret (-)
Hidung : sekret (-), deviasi septum (-)
Tenggorokan : faring tidak hiperemis
Jantung : bunyi jantung I/II normal, murmur (-), gallop (-)
Paru : suara dasar vesikuler , rhonki (-/-), wheezing (-/-)
Abdomen : perut datar, lemas, tidak teraba hati maupun limpa
bising usus 3x/menit
Ekstremitas : akral hangat, perfusi perifer baik

Kulit : kering pada kedua tungkai


Status _eurologik
GCS 13 , E4M5V4
Orientasi, jalan pikiran, daya ingat kejadian baru dan lama terganggu.
Kemampuan berbicara tidak terganggu.
Cara berjalan tidak terdapat kelainan
Tidak ada gerakan abnormal
Kepala : bentuk tidak ada kelainan, simetris, dan nyeri tekan (+) pada
daerah belakang kepala sebelah kanan.
Leher : sikap dinamis, gerakan memalingkan kepala ke kiri dan ke kanan
baik
Vertebra : tidak terdapat deformitas
Pemeriksaan Rangsang Meningeal
- Kaku kuduk ( + )
- Lasegue ( - )
- Kernig ( - )
- Brudzinski I/Brudzinskis neck sign ( - )
- Brudzinski II/Brudzinskis contralateral leg sign ( - )
Nervus kranialis
_ N.I : daya pembau baik
_ N.I : daya penglihatan baik
_ N.III : ptosis (-), gerak kedua mata ke medial, atas, dan
bawah baik, pupil bulat isokor, diameter 3 mm,
Refleks pupil +/+, strabismus divergen (-), diplopia
(-)
_ N.IV :gerak kedua mata ke lateral bawah baik,
strabismus konvergen (-), diplopia (-)
_ N.V : sensibilitas baik, motorik baik
_ N.VI : gerak kedua mata ke lateral baik, strabismus
konvergen (-), diplopia (-)
_ N.VII : motorik baik, tidak tampak paresis, salivasi dan

lakrimasi baik.
_ N. VIII : pendengaran suara baik pada telinga kanan dan kiri
_ N.IX & X : arkus faring simetris, bersuara baik, tidak sengau,
menelan baik
_ N.XI : bisa memalingkan kepala dan mengangkat bahu
_ N.XII : artikulasi baik, kekuatan lidah baik, deviasi (-),
tremor (-)
Motorik: Kekuatan : 4 4 4 4 4 4 4 4
44444444
Tonus : N N
NN
Trofi : atrofi - - Sensorik: Eksteroseptif: - Ekstremitas atas: baik
- Ekstremitas bawah: baik
Refleks fisiologis: bisep (+/+)
trisep (+/+)
radius (+/+)
patella (+/+)
achilles (+/+)
Refleks patologis: Hoffman-Trommer (-/-)
Babinsky (-/-)
Oppenheim (-/-)
Gordon (-/-)
Gonda (-/-)
Schaffer (-/-)
Chaddock (-/-)
Otonom: retensio urin (-), inkotinensia alvi (-)
III. PEMERIKSAA_ PE_U_JA_G
1. Laboratorium ( hasil pemeriksaan tanggal 2 April 2010)
Hb : 13,4 g/dL

Ht : 41,6 %
Leukosit : 8.900/JL
Trombosit : 319.000 /JL
2. Radiologi ( hasil pemeriksaan tanggal 7 April 2010 )
Foto thorak : Cor Pulmo tidak tampak kelainan
CT Scan Kepala : Tampak midline shift ke kiri, tampak gambaran hipodens
di temporofrontalis dekstra dan temporooksipitalis sinistra
yang pada pemberian larutan kontras tampak gambaran
ring enhancement di frontalis dekstra dengan ukuran
3,5 x 2,8 cm.
3. Laboratorium (hasil pemeriksaan tanggal 9 April 2010)
Waktu perdarahan : 230
Waktu pembekuan : 730