LAPORAN KASUS MTBS

I. Biodata Klien
A. Identitas Klien
Nama : _______________________________________
Umur : _______________________________________
Jenis Kelamin : _______________________________________
Alamat : _______________________________________
B. Identitas Orang Tua
Nama Ibu : _______________________________________
Umur : _______________________________________
Pendidikan Terakhir : _______________________________________
Nama Ayah : _______________________________________
Umur : _______________________________________
Pendidikan Terakhir : _______________________________________

II. Riwayat Singkat Klien

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
___________________________________________________________________
III. Hasil Penilaian MTBS
(Formulir Terlampir)
IV. Identifikasi Masalah Yang Timbul Terkait Asuhan Keperawatan yang
Dilakukan dan Solusi yang Diberikan
Dari hasil wawancara dan hasil pemeriksaan sesuai dengan format MTBS pada
klien __________, didapatkan keterangan sebagai berikut :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Dari hasil wawancara dan pemeriksaan diatas, dapat diklasifikasikan bahwa
anak saat ini menderita _________________________________________________
Adapun tindakan yang dilakukan pada klien adalah :
1. _________________________________________________________________
2. _________________________________________________________________
3. _________________________________________________________________
4. _________________________________________________________________
5. _________________________________________________________________
6. _________________________________________________________________
7. _________________________________________________________________
8. _________________________________________________________________
9. _________________________________________________________________
10. _________________________________________________________________
 LAPORAN KASUS MTBM

I. Biodata Klien
A. Identitas Klien
Nama : _______________________________________
Umur : _______________________________________
Jenis Kelamin : _______________________________________
Alamat : _______________________________________

B. Identitas Orang Tua

Nama Ibu : _______________________________________
Umur : _______________________________________
Pendidikan Terakhir : _______________________________________
Nama Ayah : _______________________________________
Umur : _______________________________________
Pendidikan Terakhir : _______________________________________

II. Riwayat Singkat Klien

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
_______________________________________________________________
III. Hasil Penilaian MTBM
(Formulir Terlampir)

IV. Identifikasi Masalah Yang Timbul Terkait Asuhan Keperawatan yang

Dilakukan dan Solusi yang Diberikan
Dari hasil wawancara dan hasil pemeriksaan sesuai dengan format MTBM
pada klien __________, didapatkan keterangan sebagai berikut :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Dari hasil wawancara dan pemeriksaan diatas, dapat diklasifikasikan bahwa
anak saat ini menderita _________________________________________________
Adapun tindakan yang dilakukan pada klien adalah :
1. _________________________________________________________________
2. _________________________________________________________________
3. _________________________________________________________________
4. _________________________________________________________________
5. _________________________________________________________________
6. _________________________________________________________________
7. _________________________________________________________________
8. _________________________________________________________________
9. _________________________________________________________________
10. _________________________________________________________________
 PROGRAM STUDI S1 TERAPAN KEPERAWATAN SEMARANG

POLITEKNIK KESEHATAN KEMENKES SEMARANG

Nama Mahasiswa : Eka Ratna Sari Tanggal Pengkajian : _______________

Nim : P1337420615008 Ruang/Puskesmas : Poli KIA
Padangsari

A. IDENTITAS KLIEN
1. Nama : _______________________________________
2. Jenis Kelamin : _______________________________________
3. Tanggal Lahir : _______________________________________
4. Usia : _______________________________________
5. Alamat : _______________________________________
6. Anak ke : _______________________________________
Identitas Orang Tua
1. Nama Ayah : _______________________________________
2. Nama Ibu : _______________________________________
3. Umur Ayah : _______________________________________
4. Umur Ibu : _______________________________________
5. Pekerjaan Ayah : _______________________________________
6. Pekerjaan Ibu : _______________________________________
7. Pendidikan Ayah : _______________________________________
8. Pendidikan Ibu : _______________________________________
9. Hubungan dengan klien : _______________________________________
10. Alamat : _______________________________________

B. ALASAN KE PUSKESMAS

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

C. RIWAYAT PEMBERIAN IMUNISASI DASAR

 No Reaksi Setelah
Waktu Jenis Imunisasi Cara Pemberian
. Pemberian
Imunisasi Dasar
1. HB 0
2. BCG
3. Polio 1
4. DPT 1
5. Polio 2
6. DPT 2
7. Polio 3
8. DPT 3
9. Polio 4
10. IPV
11. Campak
Imunisasi Tambahan
1. DPT
2. Campak

D. RIWAYAT PENGALAMAN YANG TIDAK MENYENANGKAN TENTANG

IMUNISASI SEBELUMNYA.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

E. RIWAYAT KESEHATAN DAHULU

 Prenatal
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
 Natal
________________________________________________________________
________________________________________________________________
________________________________________________________________
 ________________________________________________________________
________________________________________________________________
________________________________________________________________
 Post Natal
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
 Neonatal
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
 Infant
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

F. RIWAYAT KESEHATAN KELUARGA

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
__________________________________________________________________
__________________________________________________________________
G. GENOGRAM
Tidak terkaji secara menyeluruh tapi klien adalah anak______________________
__________________________________________________________________

H. DATA FISIK
KEADAAN UMUM
__________________________________________________________________
TINGKAT KESADARAN
Kesadaran secara umum : _______________________________________
Skala koma Glaslow (Kuantitatif)
Respon motorik : _______________________________________
Respon bicara : _______________________________________
Respon membuka mata : _______________________________________
Jumlah : _______________________________________
Kesimpulan (Kualitatif) : _______________________________________
TANDA-TANDA VITAL
Suhu : _______________________________________
Lokas : _______________________________________
Nadi : _______________________________________
Jenis : _______________________________________
Pernapasan : _______________________________________
Irama : _______________________________________
Jenis : _______________________________________
ANTROPOMETRI
BBL/TBL : _______________________________________
Lingkar Lengan Atas : _______________________________________
Lingkar Kepala : _______________________________________
BB : _______________________________________
Tinggi Badan : _______________________________________
Index Masa tubuh (IMT) : _______________________________________
Kesimpulan Berat Badan : _______________________________________
SURVEI UMUM
Ekspresi wajah mengantuk : _______________________________________
Banyak menguap : _______________________________________
Palpebra inferior berwarna gelap : _______________________________________
Kontak mata : _______________________________________
Edema : _______________________________________
Icterik : _______________________________________
Peradanga : _______________________________________
Lesi : _______________________________________
Postur Tubuh : _______________________________________
Gaya jalan : _______________________________________
Anggota gerak yang cacat : _______________________________________
Tracheostomi : _______________________________________
Perfusi pembuluh perifer kuku : _______________________________________
Aktivitas Harian
Makan : _______________________________________
Mandi : _______________________________________
Pakaian : _______________________________________
Kerapihan : _______________________________________
Buang air besar : _______________________________________
Buang air kecil : _______________________________________
Mobilisasi di tempat tidur : _______________________________________
Kesimpulan : _______________________________________
HEAD TO TOE

 Inspeksi
 Kepala
Keadaan kulit kepala : _____________________________________
Warna rambut : _____________________________________
Jumlah : _____________________________________
Rontok/Tidak : _____________________________________
Ubun-ubun : _____________________________________

 Muka
Kebersihan : _____________________________________
Pucat : _____________________________________
Oedema : _____________________________________
 Mata
Bentuk : _____________________________________
Conjungtiva : _____________________________________
Sklera : _____________________________________
Palpebra : _____________________________________

 Mulut
Bentuk : _____________________________________
Bibir : _____________________________________
Gigi : _____________________________________
Lidah : _____________________________________

 Abdomen
Kebersihan : _____________________________________
 Pembesar Abdomen : _____________________________________

 Anus
Varices : _____________________________________
Oedema : _____________________________________
Kelainan : _____________________________________
 Palpasi

 Abdomen
Nyeri Tekan : _____________________________________
Turgor Kulit : _____________________________________
Kembung : _____________________________________

 Auskultasi
 Abdomen
Bising Usus : _____________________________________

I. DATA PERKEMBANGAN
 Kembang
 Motorik Halus
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

 Motorik Kasar
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

 Sistem Neuorologi
Reflek Moro : ____________________________________________
 Reflek Rooting : ____________________________________________
Reflek Graphs / Plantar : ____________________________________________
Reflek Sucking : ___________________________________________
Reflek Tonic Neck : ___________________________________________
Reflek Swallowing : ___________________________________________
Reflek Babynsky : ____________________________________________

J. DATA PSIKO, SOSIAL, SPIRITUAL KELUARGA

1) Sosial keluarga
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2) Psikologis keluarga
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

3) Spiritual
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
K. KEBUTUHAN PENDIDIKAN KESEHATAN
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
L. ANALISA DATA

Tgl/Jam Data yang menyimpang Etiologi Masalah TTD

DS : __________ ___________ Eka
_________________________ _ ___________
_ __________ ___________
_________________________ _ ___________
_ __________ ___________
_________________________ _ ___________
_ __________ ___________
_________________________ _
_ __________
_________________________ _
_ __________
_
DO : __________
_________________________ _
_
_________________________
_
_________________________
_
_________________________
_
_________________________
_

DS : __________ Eka
_________________________ _ ___________
_ __________ ___________
_________________________ _ ___________
_ __________ ___________
_________________________ _ ___________
 _ __________ ___________
_________________________ _
_ __________
_________________________ _
_ __________
_
DO : __________
_________________________ _
_
_________________________
_
_________________________
_
_________________________
_
_________________________
_

M. DIAGNOSA KEPERAWATAN
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

N. RENACANA ASUHAN KEPERAWATAN

N Diagnosa
Tgl/jam Tujuan Intervensi Rasional TTD
o Keperawatan
1 _______ ___________ ______________ ______________ __________ Eka
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
2 _______ ___________ ______________ ______________ __________ Eka
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
 _______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________
_______ ___________ ______________ ______________ __________

O. IMPLEMENTASI
N Dx.
Waktu Impelementasi
o Kep
1 _______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
T
Evaluasi T
D
_________________________ E
k
_________________________
a
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
 _______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
2 _______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________ E
k
_________________________
a
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
 _______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_________________________
_________________________
_________________________
_________________________
_________________________

P. CATATAN PERKEMBANGAN
No Tgl/Jam Dx. Kep Evaluasi Ttd
1. _______ _________________________ _________________________ Eka
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
_______ _________________________ _________________________
2. _______ _________________________ _________________________ Eka
_______ _________________________ _________________________
_______ _________________________ _________________________
 _______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
_______ _________________________
PEMBERIAN IMUNISASI
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________

Tanggal :
Imunisasi yang diberikan hari ini :

A. IDENTITAS KLIEN
Nama : _______________________________________
Jenis Kelamin : _______________________________________
Tanggal Lahir : _______________________________________
Usia : _______________________________________
Alamat : _______________________________________
Anak ke : _______________________________________
Identitas Orang Tua
Nama Ayah : _______________________________________
 Nama Ibu : _______________________________________
Umur Ayah : _______________________________________
Umur Ibu : _______________________________________
Pekerjaan Ayah : _______________________________________
Pekerjaan Ibu : _______________________________________
Pendidikan Ayah : ______________________________________
Pendidikan Ibu : _______________________________________
Hubungan dengan klien : _______________________________________
Alamat : _______________________________________

B. ANTROPOMETRI
BBL/TBL : _________ gram / _________ cm
Berat Badan : _________ gram
Tinggi Badan : _________ cm
Lingkar Lengan Atas : _________ cm
Lingkar Kepala : _________ cm

C. RIWAYAT PEMBERIAN IMUNISASI

No Reaksi Setelah
Waktu Jenis Imunisasi Cara Pemberian
. Pemberian
Imunisasi Dasar
1. HB 0
2. BCG
3. Polio 1
4. DPT 1
5. Polio 2
6. DPT 2
7. Polio 3
8. DPT 3
9. Polio 4
10. IPV
11. Campak
Imunisasi Tambahan
1. DPT
2. Campak