LAPORAN KASUS

ASUHAN KEPERAWATAN PADA KLIEN DENGAN ...................................

DI ..........................................................................................................

Tanggal .............. s/d ..................

Oleh :
_________________________
NIM ...............................

PROGRAM STUDI ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN AN NUR PURWODADI
 TA. 2016/2017
PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN MEDIKAL BEDAH
STIKES AN NUR PURWODADI
Nama mahasiswa : ........................................ Tgl/jam MRS : ........................................
Tgl/jam pengkajian : ........................................ No. RM : ........................................
Diagnosa medis : ........................................ Ruangan/kelas : ........................................
........................................ No.kamar : ........................................

I. IDENTITAS
 1. Nama : .....................................................................................................................
2. Umur : .....................................................................................................................
3. Jenis kelamin : .....................................................................................................................
4. Status : .....................................................................................................................
5. Agama : .....................................................................................................................
6. Suku/bangsa : .....................................................................................................................
7. Bahasa : .....................................................................................................................
8. Pendidikan : .....................................................................................................................
9. Pekerjaan : .....................................................................................................................
10. Alamat dan no. telp : .....................................................................................................................
11. Penanggung jawab : .....................................................................................................................

II. RIWAYAT SAKIT DAN KESEHATAN

1. Keluhan utama :
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2. Riwayat penyakit sekarang :
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3. Riwayat penyakit dahulu :
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4. Riwayat kesehatan keluarga :
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5. Susunan keluarga (genogram) :

6. Riwayat alergi :
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III. POLA FUNGSI KESEHATAN

1. Persepsi Terhadap Kesehatan (Keyakinan Terhadap Kesehatan & Sakitnya)
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2. Pola Aktivitas Dan Latihan

a. Kemampuan perawatan diri
Aktivitas SMRS MRS
 0 1 2 3 4 0 1 2 3 4
Mandi
Berpakaian/berdandan
Eliminasi/toileting
Mobilitas di tempat tidur
Berpindah
Berjalan
Naik tangga
Berbelanja
Memasak
Pemeliharaan rumah
 Skor 0 = mandiri 3 = dibantu orang lain & alat
1 = alat bantu 4 = tergantung/tidak mampu
2 = dibantu orang lain

Alat bantu : ( ) tidak ( ) kruk ( ) tongkat

( ) pispot disamping tempat tidur ( ) kursi roda

b. Kebersihan diri
Di rumah Di rumah sakit
Mandi : ........................ Mandi : ........................
/hr /hr
Gosok gigi : ........................ Gosok gigi : ........................
/hr /hr
Keramas : .................... Keramas : ....................
/mgg /mgg
Potong kuku : .................... Potong kuku : ....................
/mgg /mgg
c. Aktivitas sehari-hari
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d. Rekreasi
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e. Olahraga : ( ) tidak ( ) ya
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3. Pola Istirahat Dan Tidur

Di rumah Di rumah sakit
Waktu tidur : Siang ..............-............... Waktu tidur : Siang ..............-...............
Malam ............-............... Malam ............-...............
Jumlah jam tidur : .................................. Jumlah jam tidur : ..................................
 Masalah di RS : ( ) tidak ada ( ) terbangun dini ( ) mimpi buruk
( ) insomnia ( ) Lainnya, ...............................

4. Pola Nutrisi Metabolik

a. Pola makan
Di rumah Di rumah sakit
Frekuensi : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Porsi : ......................... Porsi : ..................................
Pantangan : ......................... Diit khusus : ..................................
Makanan disukai : .........................
Nafsu makan di RS : ( ) normal ( ) bertambah ( ) berkurang
( ) mual ( ) muntah, .............. cc ( ) stomatitis
Kesulitan menelan : ( ) tidak ( ) ya
Gigi palsu : ( ) tidak ( ) ya
NG tube : ( ) tidak ( ) ya

b. Pola minum
Di rumah Di rumah sakit
Frekuensi : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Jumlah : ......................... Jumlah : ..................................
Pantangan : .........................
Minuman disukai : .........................

5. Pola Eliminasi
a. Buang air besar
Di rumah Di rumah sakit
Frekuensi : .................................. Frekuensi : ..................................
Konsistensi : .................................. Konsistensi : ..................................
Warna : .................................. Warna : ( ) kuning
( ) bercampur darah
( ) lainnya, ..............
Masalah di RS : ( ) konstipasi ( ) diare ( ) inkontinen
Kolostomi : ( ) tidak ( ) ya

b. Buang air kecil

Di rumah
Frekuensi : ..................................
Konsistensi : ..................................
Warna : ..................................
Di rumah sakit
Frekuensi : ..................................
Konsistensi : ..................................
Warna : ..................................
 Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria
( ) retensi ( ) inkontinen
Kolostomi : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari

6. Pola Kognitif Perseptual

Berbicara : ( ) normal ( ) gagap ( ) bicara tak jelas
Bahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya, ....................................
Kemampuan membaca : ( ) bisa ( ) tidak
Tingkat ansietas : ( ) ringan ( ) sedang ( ) berat ( ) panik
Sebab, ...................................................................................................
Kemampuan interaksi : ( ) sesuai ( ) tidak, ...................................................................
Vertigo : ( ) tidak ( ) ya
Nyeri : ( ) tidak ( ) ya

Bila ya, P : .................................................................................................................................

Q : .................................................................................................................................
R : .................................................................................................................................
S : .................................................................................................................................
T : .................................................................................................................................
7. Pola Konsep Diri
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8. Pola Koping
Masalah utama selama MRS (penyakit, biaya, perawatan diri)
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Kehilangan perubahan yang terjadi sebelumnya
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Kemampuan adaptasi
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9. Pola Seksual Reproduksi

Menstruasi terakhir : .....................................................................................................................
Masalah menstruasi : .....................................................................................................................
Pap smear terakhir : .....................................................................................................................
Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidak
Masalah seksual yang berhubungan dengan penyakit : ...............................................................

10. Pola Peran Hubungan

Pekerjaan :
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Kualitas bekerja :
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Hubungan dengan orang lain :
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Sistem pendukung :
( ) pasangan ( ) tetangga/teman ( ) tidak ada
( ) lainnya, .................................................................................
Masalah keluarga mengenai perawatan di RS : .............................................................................

11. Pola Nilai Kepercayaan

Agama : ................................................................................................
Pelaksanaan ibadah : ................................................................................................
 Pantangan agama : ( ) tidak ( ) ya, ................................................................
Meminta kunjungan rohaniawan : ( ) tidak ( ) ya

IV. PENGKAJIAN PERSISTEM (Review of System)

1. Tanda-Tanda Vital
a. Suhu : ................... C lokasi : ......................
b. Nadi : ................... /menit irama : ...................... pulsasi : ......................
c. Tekanan darah : ................... mmHg lokasi : ......................
d. Frekuensi nafas : ................... /menit irama : ......................
e. Tinggi badan : ................... cm
f. Berat badan : SMRS ................... kg MRS .................... kg

2. Sistem Pernafasan (Breath)

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3. Sistem Kardiovaskuler (Blood)

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4. Sistem Persarafan (Brain)

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5. Sistem Perkemihan (Bladder)

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6. Sistem Pencernaan (Bowel)

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7. Sistem Muskuloskeletal (Bone)

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8. Sistem Integumen
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9. Sistem Penginderaan
Mata
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Hidung
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Telinga
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10. Sistem Reproduksi Dan Genetalia

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V. PEMERIKSAAN PENUNJANG
1. Laboratorium
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2. Lain-lain
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VI. TERAPI
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 ANALISA DATA

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. RM : ..............................................
No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)

PRIORITAS MASALAH
Nama klien : .............................................. Ruangan/kamar : ..............................................
Umur : .............................................. No. RM : ..............................................

Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama Perawat
 RENCANA KEPERAWATAN

No. Dx Keperawatan Tujuan Dan Kriteria Hasil Intervensi Rasional

NO DP HARI/TGL/JAM TINDAKAN RESPON HASIL TTD
NO DP HARI/TGL EVALUASI TTD
/JAM