LAPORAN KASUS

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I. DATA DASAR
A. Identitas Pasien
1. Nama ( Inisial Klien ) :.
2. Usia :.
3. Status Perkawinan :.
4. Pekerjaan :.
5. Agama :.
6. Pendidikan :.
7. Suku :.
8. Bahasa Yang Digunakan :.
9. Alamat Rumah :...........................................
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10. Sumber Biaya :.
11. Tanggal Masuk RS :.
12. Diagnosa Medis :.
13. Tanggal Pengkajian :.................................
14. No RM :................................

B. Sumber informasi ( penanggung jawab ) :

1. Nama : ..
2. Umur : ..
3. Hubungan dengan klien : ..
4. Pendidikan :
5. Pekerjaan : ..
6. Alamat : ..
II. RIWAYAT KESEHATAN
A. Keluhan Utama
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B. Riwayat kesehatan saat pengkajian
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C. Riwayat kesehatan masuk RS :

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D. Riwayat Kesehatan Lalu:
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E. Riwayat Kesehatan Keluarga : (Genogram / Penyakit yang pernah
diderita oleh anggota keluarga yang menjadi faktor resiko, 3 generasi)
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F. Riwayat Psikososial spiritual
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G. Pola Kebiasaan sehari-hari sebelum dan saat sakit:

No Pola Aktivitas Dirumah Di Rumah Sakit

1. Pola Nutrisi dan Cairan (sebelum
dan saat sakit) :
a. Pola nutrisi :
Asupan: ( ) Oral
( ) Enteral
( ) TPN
Frekwensi makan
:.x/Hari
Nafsu makan :
( ) Baik
( ) Sedang (Jelaskan
alasannya)
( ) Kurang (Jelaskan
alasannya)
Diit :
Makanan tambahan:

Makanan yang tidak
disukai/alergi/pantangan
:
Kebiasaan makan :
..
Perubahan berat badan 3
bulan terakhir:
( )Bertambah.Kg
( ) Tetap
( ) Berkurang.Kg
b. Pola Cairan :
Asupan cairan:
( ) Oral
( ) Parenteral
Jenis : .
Frekwensi : x/hari
Volume total :cc/hari
2. Pola Eliminasi (sebelum dan saat
sakit) :
a. BAK
Frekwensi :..x/hari
Waktu :
Jumlah :..cc/hari
Warna :
Bau :
Keluhan yang berhubungan
dengan BAK:.
Out put perhari : cc/hari
b. BAB
Frekwensi :..x/hari
Waktu :.
Warna :.
Bau :.
Konsistensi :.
Keluhan :.
Penggunaan laxatif/pencahar
:.
c. IWL ( Insensible Water Lose )
: cc/hari

3. Pola Personal Hygiene (sebelum

dan saat sakit) :
a. Mandi
Frekwensi
:x/hari

b. Oral hygiene
Frekwensi :x/hari
Waktu :
c. Cuci Rambut
Frekwensi:x/minggu

4. Pola istirahat dan tidur (sebelum

dan saat sakit) :
Lama tidur :Jam/hari
 Waktu
- Siang : ..jam
- Malam : ..jam
Kebiasaan sebelum
tidur/pengantar tidur :
( ) Penggunaan obat tidur
( ) Kegiatan lain, Jelaskan
.
Kesulitan dalam hal tidur :
( ) Menjelang tidur
( ) sering/mudah terbangun
( ) Merasa tidak puas setelah
bangun tidur
Jelaskan alasannya ..
5. Pola aktivitas dan latihan (sebelum
dan saat sakit) :
Kegiatan dalam
pekerjaan:
Waktu bekerja :
Kegiatan waktu luang:
Keluhan dalam
beraktivitas:
Olah raga :
Jenis :
Frekwensi :
Keterbatasan dalam hal :
( ) Mandi
( ) Menggunakan pakaian
( ) Berhias

6. Pola kebiasaan yang mempengaruhi

kesehatan
a. Merokok :( ) Ya
( ) Tidak
- Frekwensi : .
- Jumlah :..
- Lama pemakaian :..
 b. Minuman keras :( ) Ya
( ) Tidak
- Frekwensi : .
- Jumlah : .
- Lama pemakaian : .
c. Ketergantungan obat : ( ) Ya
( ) Tidak
Jika Ya : Jelaskan : Jenis,
Lama pemakaian, Frekwensi dan
Alasan

H. Pemeriksaan fisik
1. Pemeriksaan umum
- Kesadaran : .
- Tekanan Darah : .mmHg
- Nadi : .x/Menit
- Pernafasan : .x/Menit
- Suhu : .oC
- TB/BB : .Cm/Kg

2. Pemeriksaan fisik per system

a. Sistem Kardiovaskular
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b. Sistem Pernafasan
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c. Sistem Pencernaan
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d. Sistem Persyarafan
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e. Sistem Muskuloskeletal
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f. Sistem Perkemihan
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g. Sistem Imun dan Hematologi

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h. Sistem Endokrin
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i. Sistem Integumen
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j. Sistem Muskuloskeletal
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I. PEMERIKSAAN PENUNJANG
Pemeriksaan Diagnostik
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Pemeriksaan laboratorium
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J. PENATALAKSANAAN
Penatalaksanaan Medis
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Penatalaksanaan Keperawatan
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III. ANALISA DATA

No Data Masalah
Etiologi
IV. DIAGNOSA KEPERAWATAN SESUAI DENGAN PRIORITAS
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 RENCANA TINDAKAN KEPERAWATAN

Nama Klien : .. Ruang : ..

Dx. Medis : .. No. MR : ..

Diagnosa
No Tanggal Keperawatan dan Tujuan ( SMART) Rencana Tindakan Rasional
Data Penunjang
 CATATAN IMPLEMENTASI
Nama Klien : .. Ruang : ..
Dx. Medis : .. No. MR : ..

No.
Implementasi
No Dx. Tanggal/Jam Paraf Evaluasi ( SOAP) dan paraf
( Respon dan atau Hasil )
Kep
Tanggal :
Jam
 CATATAN PERKEMBANGAN
Nama Klien : .. Ruang : ..
Dx. Medis : .. No. MR : ..

No. Dx.
No Tanggal Evaluasi ( SOAPIER) Paraf
Kep