16.2 Format Askep

LAPORAN KASUS
ASUHAN KEPERAWATAN PADA ....................

.DENGAN...................................................................................
DI .................................................................................................................
.................................................................................................
Tanggal .............. s/d ..................
Oleh :
_________________________
JURUSAN KEPERAWATAN
SEKOLAH MENENGAH KEJURUAN ROUDLOTUL HIKMAH
UJUNGPANGKAH GRESIK
LEMBAR PENGESAHAN
ASUHAN KEPERAWATAN PADA ....................

.DENGAN...................................................................................
DI .................................................................................................................
.................................................................................................
Tanggal .............. s/d ..................
Oleh :
_________________________
Mengetahui, Ujungpangkah, ................ 20.....

Penguji Pendidikan Penguji Lahan
______________________ ______________________
FOMAT ASUHAN KEPERAWATAN KEBUTUHAN MANUSIA
SEKOLAH MENENGAH KEJURUAN ROUDLOTUL HIKMAH
UJUNGPANGKAH
JURUSAN KEPERAWATAN
Nama siswa : ........................................ 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 : .....................................................................................................................
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. Riwayat alergi :
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Masalah keperawatan :..........................................................................................................

III. POLA FUNGSI KESEHATAN
1. Pola Aktivitas Dan Latihan
a. Kemampuan perawatan diri
SMRS MRS
Aktivitas
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 : ........................  /hr Mandi : ........................  /hr
Gosok gigi : ........................  /hr Gosok gigi : ........................  /hr
Keramas : ....................  /mgg Keramas : ....................  /mgg
Potong kuku : ....................  /mgg Potong kuku : ....................  /mgg
2. Pola Istirahat Dan Tidur

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, ...............................
Masalah keperawatan:.......................................................................................................
3. Pola Nutrisi – Metabolik

a. Pola makan
Frekuensi : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Porsi : ......................... Porsi : ..................................
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
Jumlah : ......................... Jumlah : ..................................
4. Pola Eliminasi
a. Buang air besar
Frekuensi : .................................. Frekuensi : ..................................
Konsistensi : .................................. Konsistensi : ..................................
Warna : .................................. Warna : ( ) kuning
( ) bercampur darah
( ) lainnya, ..............
Masalah di RS : ( ) konstipasi ( ) diare ( ) inkontinen
Kolostomi : ( ) tidak ( ) ya
b. Buang air kecil

Frekuensi : .................................. Frekuensi : ..................................
Jumlah : .................................. Jumlah : ..................................
Warna : .................................. Warna : ..................................
Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria
( ) retensi ( ) inkontinen
Kateter : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari
5. Pola Kognitif Perseptual

Nyeri : ( ) tidak ( ) ya
Bila ya, P : .................................................................................................................................

Q : .................................................................................................................................
R : .................................................................................................................................
S : .................................................................................................................................
T : .................................................................................................................................
IV. PENGKAJIAN HEAD TO TOE

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. Keadaan Umum
Kesadaran :.........................................................................................................................
3. Kulit, rambut, kuku
Inspeksi Palpasi
Warna kulit ............................... Suhu ...............................
Jaringan parut ............................... Kelembapan ...............................
LESI ............................... Tekstur ..............................
Jumlah rambut ............................... Turgor ...............................
Wana kuku ............................... Edema ..............................
Bentuk kuku ................................ Lain lain ...............................
4. Kepala
Inspeksi Palpasi
Kesimetrisan wajah ............................... Kulit kepala ...............................
Tengkorak ............................... Deformitas ...............................
Rambut ...............................
Kulit kepala ...............................
5. Mata
Inspeksi Palpasi
Konjungtiva ............................... Tekanan bola mata ...............................
Pupil kanan : ............................... ...............................
Pupil kiri ............................... ..............................
...............................
..............................
...............................
6. Telinga
Inspeksi Palpasi
Daun telinga ............................... Nyeri tekan tragus ...............................
Liang ............................... Uji pendengaran ...............................
............................... ..............................
7. Hidung dan sinus

Inspeksi Palpasi
Bagian luar ............................... Septum ...............................
Bagian dalam ............................... Sinus ...............................
Ingus ...............................
Perdarahan ...............................
penyumbatan ...............................
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8. Mulut
Inspeksi Palpasi
Bibir ............................... Pipi ...............................
Gigi ............................... Palatum ...............................
Gusi ............................... Dasar mulut ..............................
Lidah ............................... Lidah ...............................
Membrane mukosa ............................... ..............................
Faring ................................ ...............................
Tonsil
9. Leher
Inspeksi Palpasi
Bentuk leher ............................... Trakea ...............................
Warna kulit ............................... lain-lain ...............................
Bengkak ...............................
Tumor ...............................
...............................
10. Dada
Inspeksi
Bentuk ...............................
Retraksi ...............................
Kulit ...............................
payudara ...............................
11. Paru paru

Inspeksi
Kiri ............................... Kanan ...............................
Palapasi
Kiri ............................... Kanan ...............................
Perkusi
Kiri ............................... Kanan ...............................
Auskultasi
Kiri ............................... Kanan ...............................
12. Jantung
Inspeksi ....................................................................................................................................
Palapasi ....................................................................................................................................
Perkusi ....................................................................................................................................
Auskultasi ....................................................................................................................................
13. Abdomen
Inspeksi Palpasi
Bentuk ............................... Ringan ..............................
Retraksi ............................... Dalam ...............................
Kandung kemih ...............................
Lain-lain ................................
...............................
Auskultasi Perkusi
........................................ ......................................
14. Anus dan rektum

Inspeksi .............................................................................................................................
Palapasi.............................................................................................................................
15. Muskulus skeletal

Otot
Inspeksi Palpasi
Kontraktur ................................. Kelemahan .................................
Kekuatan ................................. Gerakan .................................
Tulang
Inspeksi Palpasi
Susunan tulang ................................. Nyeri tekan ................................
deformitas ................................. Edema ..................................
pembengkakan .................................
Persendian
Inspeksi Palpasi
Kaku ................................. Nyeri tekan .................................
Rentang gerak ................................. Bengkak .................................
Krepitasi .................................
Lain-lain .................................
V. DAFTAR MASALAH KEPERAWATAN

1. .....................................................................................................................................
2. .....................................................................................................................................
3. .....................................................................................................................................
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5. .....................................................................................................................................
6. .....................................................................................................................................
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8. .....................................................................................................................................
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10. .....................................................................................................................................
11. .....................................................................................................................................
VI. PEMERIKSAAN PENUNJANG
1. Laboratorium
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2. Photo
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3. Lain-lain
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VII. TERAPI
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Ujungpangkah, .....................
siswa
(...............................)
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. Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi Rasional

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN
Waktu Waktu Catatan Perkembangan

No. Tindakan TT TT
Tgl/jam Tgl/jam (SOAP)

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LAPORAN KASUS

ASUHAN KEPERAWATAN PADA ....................

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

ASUHAN KEPERAWATAN PADA ....................

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

Mengetahui, Ujungpangkah, ................ 20.....

Nama siswa : ........................................ Tgl/jam MRS : ........................................

II. RIWAYAT SAKIT DAN KESEHATAN

Masalah keperawatan :..........................................................................................................

Skor 0 = mandiri 3 = dibantu orang lain & alat

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

2. Pola Istirahat Dan Tidur

3. Pola Nutrisi – Metabolik

b. Buang air kecil

5. Pola Kognitif Perseptual

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

IV. PENGKAJIAN HEAD TO TOE

7. Hidung dan sinus

11. Paru paru

14. Anus dan rektum

15. Muskulus skeletal

V. DAFTAR MASALAH KEPERAWATAN

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

No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)

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

No. Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi Rasional

Waktu Waktu Catatan Perkembangan

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