LAPORAN ASUHAN KEPERAWATAN PADA PASIEN NY.

DENGAN DIAGNOSA CA MAMAE + EFFUSI PLEURA

DI RUANG JANGER RSUD BADUNG
PADA TANGGAL 18 JANUARI 21 JANUARI 2016

DISUSUN OLEH :
KADEK VERLYANITA SEPTIARINI
1302105071

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA
2016

A. Pengkajian
1. Identitas pasien dan Keluarga
Pasien
Nama

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

Umur

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

Jenis kelamin

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

Pendidikan

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

Pekerjaan

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

Status perkawinan

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

Agama

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

Suku

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

Alamat

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

Tanggal masuk

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

Tanggal pengkajian

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

Sumber Informasi

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

Diagnosa masuk

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

Penanggung jawab
Nama

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

Hubungan dengan pasien

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

Riwayat keluarga :

Genogram

Keterangan genogram

2. Riwayat 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 dilkakukan 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

Riwayat tranfusi : Ya

Tidak

Jelaskan :...................................

Tidak

Kebiasaan :

Merokok
Ya
Tidak
Sejak:
Jumlah:
Minum kopi
Ya
Tidak
Sejak:
Jumlah:
Penggunaan Alkohol Ya
Tidak
Sejak:
Jumlah:
Lain-lain: ..................................................................................................................
Jelaskan:......................................................................................................................
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3. Riwayat Penyakit Keluarga :

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4. Diagnosa Medis dan therapy:

Diagnosa medis saat ini :

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Terapi :
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5. Riwayat Kesehatan dan Pemeriksaan fisik
Keadaan umum : Baik
TTV

Sedang

: TD :

Lemah

Nadi :

Kesadaran: ............................

Suhu :

RR:

a. Kulit, Rambut dan Kuku

Distribusi rambut :................................................................................................................
Lesi

Ya

Tidak

Warna kulit

Ikterik

Sianosis

Kemerahan Pucat

Akral

Hangat

Panas

Dingin kering

Dingin

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

Ya

Tidak

Warna kuku:

Pink

Sianosis

Lokasi:
lain-lain

Lain-lain: ..........................................................................................................................
b. Kepala dan Leher
Kepala

Simetris

Asimetris, Lesi:

Deviasi trakea

Ya

Tidak

Pembesaran kelenjar tiroid

Ya

ya

Tidak

Tidak

Lain-lain: ..............................................................................................................................
c. Mata dan Telinga
Gangguan pengelihatan
Menggunakan kacamata

Ya
Ya

Tidak

Tidak

Pupil

Isokor

Sklera/ konjungtiva

Anemis
5

Visus:
Anisokor Ukuran: normal

Ikterus

nornal

Gangguan pendengaran

Ya

Tidak

Menggunakan alat bantu dengar

Ya

Tidak

Tes weber:

Tes Rinne:

Tes Swabach:

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

e. Sistem Kardiovaskular :
Nyeri dada

Ya

Tidak

Palpitasi

Ya

Tidak
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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

Nyeri tekan

Peristaltik: ..................................................................................................................
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Lain-lain : ..................................................................................................................
h. Sistem Urinarius :
Penggunaan alat bantu/ kateter

Ya

Tidak

Kandung kencing, nyeri tekan

Ya

Tidak

Gangguan

Retensi

Anuria

Oliguria

Nokturia

Lain-lain:

Inkontinensia

Jumlah air kencing: .............................................................................................................

i. Sistem Reproduksi Wanita/Pria :
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j. Sistem Saraf:
GCS:

Eye:

Verbal:

Rangsangan meningeal

Motorik:

Kaku kuduk

Kernig

Brudzinski I

Brudzinski II

Refleks fisiologis

Patela

Trisep

Bisep

Refleks patologis

Babinski

Chaddock Oppenheim Rossolimo

Gordon Schaefer

Achiles

Stransky

Gonda
Gerakan involunter : .........................................................................................................
Lain-lain: ...............................................................................................................................
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 :
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Lain-lain: ..............................................................................................................................
l. Sistem Imun:
Perdarahan Gusi

Ya

Tidak

Perdarahan lama

Ya

Tidak

Pembengkakan KGB

Ya

Tidak

Keletihan/kelemahan

Ya

Tidak

Lokasi:

Lain-lain: ..........................................................
m. Sistem Endokrin:
Hiperglikemia

Ya

Tidak

Hipoglikemia

Ya

Tidak

Luka gangrene

Ya

Tidak

Lain-lain: ..........................................................
6. Pemeriksaan Penunjang
a. Data laboratorium yang berhubungan
Tanggal:
Pemeriksaan

Hasil

Pemeriksaan Darah Lengkap (DL)

Nilai normal

Pemeriksaan Kimia Klinik

Pemeriksaan Elektroli

Pemeriksaan imunologi

b. Pemeriksaan Radiologi :
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c. Hasil konsultasi:
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d. Pemeriksaan penunjang diagnostik lain :
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7.
No
1

Pola pengkajian menurut 11 pola fungsional Gordon

Pola Gordon

Hasil Pengkajian

Pola persepsi dan

pemeliharaan

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kesehatan

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Pola nutrisi dan

metabolisme,

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cairan dan

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elektrolit

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Diagnosa
Keperawatan

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..

Pola eliminasi
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Pola aktivitas dan

latihan

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..
5

Pola

tidur

istirahat

dan
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..
6

Pola persepsi dan

kognitif

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14

..
7

Pola persepsi diri ..............................................................................

dan konsep diri

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Pola

peran

dan

hubungan

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Pola

seksualitas

dan reproduksi

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15

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Pola

toleransi

coping- stress

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11

Pola tata nilai dan ..............................................................................

kepercayaan

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8. Analisa Data berdasarkan konsep keluasan diagnosis

No
1

Tangal

Data

Penyebab/Interpretasi

DO:
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DS:
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Masalah

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DO:
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DS:

18

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DO:
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DS:
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9.

Daftar Diagnosa Keperawatan dan masalah PK, Menurut prioritas dan keluasan

diagnosa
10.
Perencanaan Keperawataan
Hari/Tgl 1 No
Dx

Tujuan dan kriteria

Rencana Keperawatan
Intervensi

hasil

21

Rasional

22

23

24

25

26

11.
Hari/Tgl

Pelaksanaan (Implementasi) Keperawatan

No
Dx

Jam

Implementasi Tindakan
Keperawatan

27

Respon Pasien

TTD

28

29

30

12. Evaluasi (Catatan Perkembangan)

31

Hari/Tgl

No

Jam

Evaluasi

Dx
S:

O:

A:

P:

S:

32

Ttd

O:

A:

P:

S:

O:

33

A:

P:

LAPORAN RESUME ASUHAN KEPERAWATAN PADA

PASIEN........................................
DENGAN DIAGNOSA ..............................................................................
DI RUANG OLEG RSUD BADUNG

34

PADA TANGGAL.................................................................................

DISUSUN OLEH:
DEWA AYU DWI SHINTYA ANGGRENI
1302105067

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA
2016
Identitas Pasien
Nama

Umur

35

 Jenis kelamin

No RM

Pendidikan

Pekerjaan

Status perkawinan

Agama

Suku

Alamat

Tanggal masuk

Tanggal pengkajian

Sumber Informasi

Diagnosa Medis

36

S:

O:

A:

P:

37

Mengetahui,

Badung,

Pembimbing

Mahasiswa

(..)

(.)

38