BAB III

TINJAUAN KASUS

A. BIODATA

1. IDENTITAS PASIEN
Nama :
Jenis Kelamin :
Umur :
Status Perkawinan :
Agama :
Pendidikan :
Pekerjaan :
Alamat :
No.Register :
Ruangan/Kamar :
Golongan Darah :
Tanggal Pengkajian :
Tanggal Oprasi :
Diagnosa Medis :

2. PENANGGUNG JAWAB
Nama :
HubunganDenganPasien :
Umur :
Pekerjaan :
Pendidikan :
Suku bangsa :
Alamat :
B. KELUHAN UTAMA

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C. RIWAYAT KESEHATAN SEKARANG

1. Provocative / Palliative
a. Apa penyebabnya
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b. Hal-hal yang memperbaiki keadaan
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2. Quantity / Quality
a. Bagaimana dirasakan
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b. Bagaimana dilihat
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3. Ragion
a. Dimana lokasinya
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b. Apakah menyebar
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4. Savetity (menggunakan aktivitas)
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5. Time (kapan mulai timbul dan bagaimana terjadinya)

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D. RIWAYAT KESEHATAN MASA LALU

1. Penyakit yang pernah dialami

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2. Pengobatan / tindakan yang dilakukan
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3. Pernah dirawat / dioperasi
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4. Lamanya
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5. Alergi
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6. Imunisasi
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E. RIWAYAT KESEHATAN KELUARGA

A. Orang Tua
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B. Saudara Kandung
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C. Penyakit keturunan yang ada
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D. Anggota keluarga yang meninggal
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E. Penyebab meninggal
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F. Genogram

53 thn

Keterangan :
Laki –laki hidup Umur / umur : Pasien
Perempuan hidup ------------------: Tinggal serumah
Laki-laki meninggal
Perempuan meninggal
F. RIWAYAT / KEADAAN PSIKOSOSIAL

1. Bahasa yang digunakan

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2. Persepsi pasien tentang penyakitnya
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3. Konsep diri :
1. Body Image :
2. Ideal diri :
3. Harga diri :
4. Personal diri :
5. Personal Identity :

4. Keadaan Emosi
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5. Perhatian terhadap orang lain/lawan bicara
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6. Hubungan dengan keluarga
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7. Hubungan dengan orang lain
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8. Kegemaran
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9. Mekanisme pertahanan diri
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G. PEMERIKSAAN FISIK

A. Keadaan Umum
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TB :
BB :

B. Tanda-tanda Vital
Suhu Tubuh :
TD :
Nadi :
RR :

C. Pemeriksaan Kepala dan Leher

1. Kepala, rambut dan leher
a. Kepala :
- Bentuk :
- Ubun-ubun :
- Kulit kepala:
b. Rambut :
- Penyebaran dan keadaan rambut :
- Bau :
- Warna kulit :
c. Wajah :
- Warna kulit :
2. Mata
a. Kelengkapan dan kesimetrisan :
b. Pelbera :
c. Konjungtiva :
d. Selera :
e. Pupil :
f. Cornea dan iris :
g. Visus :
h. Tekanan bola mata :

3. Hidung
a. Tulang hidung dan posisi septum :
b. Lubang hidung :
c. Cuping hidung :
d. Fungsi penciuman :

4. Telinga
a. Bentuk telinga :
b. Ukuran telinga :
c. Lubang telinga :
d. Ketajaman pendengaran :

5. Mulut dan Faring

1. Keadaan bibir :
2. Keadaan gusi dan gigi :

6. Leher
a. Posisi trachea :
b. Thyroid :
c. Suara :
 d. Kelenjar limfe :
e. Vena jugularis :
f. Denyut nadi karotis :

D. Pemeriksaan Integuman
1. Kebersihan :
2. Kehangatan :
3. Warna :
4. Turgor :
5. Kelembaban :
6. Kelainan pada kulit :

E. Pemeriksaan Payudara dan Ketiak

1. Ukuran dan bentuk payudara :
2. Warna payudara dan areola :
3. Kelainan payudara dan puting :
4. Aksila dan clavikula :

F. Pemeriksaan Thoraks dan Dada

1. Infeksi Thoraks
a. Bentuk Thoraks :
b. Pernafasan :
- Frekuensi :
- Irama :
c. Tanda kesulitan :
2. Pemeriksaan paru
a. Palpasi getaran suara :
b. Perkusi :
c. Auskultasi
- Suara nafas :
- Suara tambahan :
 3. Pemeriksaan jantung
a. Infeksi :
b. Palpasi :
- Pulsasi :
- Ictus cordis :
c. Perkusi :
- Batas jantung :
d. Auskultasi
- Bunyi jantung I :
- Bunyi jantung II :
- Bunyi jantung tambahan :
- Mur-mur :
- Frekuensi :

G. Pemeriksaan Abdomen
1. Infeksi :
a. Bentuk abdomen :
b. Benjolan / massa :
c. Bayangan pembuluh darah :
2. Auskultasi :
a. Peristaltik usus :
3. Palpasi :
a. Benjolan / massa :
b. Tanda ascites :
c. Hepar :
d. Lien :
e. Titik mc. Burney :
4. Perkusi :
a. Suara abdomen :
b. Pemeriksaan ascites :
H. Pemeriksaan Kelamin dan Daerah Sekitarnya
1. Genitalia :
a. Rambut pubis :
b. Lubang uretra :
c. Kelainan pada genetalia eksterna :
2. Anus
a. Lubang Anus :
b. Kelainan pada lubang anus :
c. Perineum :

I. Pemeriksaan Muskulosklrtal/Ekstremitas
1. Ekstremitas Atas :
a. Kesimetrisan otot :
Kiri Kanan
b. Edema (derajat) :
c. Kekuatan Otot :
d. Kelainan pada ekstremitas :

2. Ekstremitas bawah :
a. Kesimetrisan Otot :
Kiri Kanan
b. Edema :
c. Kekuatan Otot :
e. Kekuatan pada ekstremitas :
d. Varises :

J. Pemeriksaa Neurologi
1. Tingkat kesadaran :
GCS 15 E6 M5 V4
2. Meninggealsign
3. Status mental

a. Kondisi emosi dan perasaan

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b. Orientasi
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c. Proses berfikir (ingatan, keputusan, perhitungan)
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d. Motivasi
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e. Bahasa
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4. Nervus Craniallis
a. Nervus Ollaktorius / N I / Penciuman (hidung)
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b. Nervus Optikus / N II / Penglihatan (mata)
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c. Nervus Okulomotoris / N III, Trochlearis / N IV, Abdusen / N VI /
bergeraknya bola mata
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 d. Nervus Trigeminus / N V / Sentuhan Halus (dengan kapas)
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e. Nervus Fasialis / N VII / Wajah / (otot wajah)
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f. Nervus Vestibulocochlearis / N VIII / Acusticus (pendengaran)
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g. Nervus Glossopharingeus / N IX, Vagus / N X / Menelan

(tenggorokan)
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h. Nervus Asesorius / N XI / Bahu
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i. Nervus Hipoglosus / N XII / Lidah
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5. Fungsi motorik
a. Cara berjalan
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b. Romberg Test
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c. Test jari Hidung
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d. Pronasi Suvinasi Test
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e. Heel to Shim Test
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6. Fungsi sensorik
a. Identifikasi sentuhan ringan
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b. Test Tajam Tumpul
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c. Tes Panas Dingin
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d. Test Getaran
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e. Sreognosis Test
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7. Reflek
a. Reflek Bisep
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b. Reflek Trisep
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c. Reflek Brachioradialis
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d. Reflek patelar
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e. Reflek Tendon Achiles
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f. Reflek Plantar
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H. POLA KEBIASAAN SEHARI-HARI

A. Pola Tidur :
 a. Sebelum Sakit
- Waktu tidur :
- Waktu bangun :
- Masalah tidur :
- Hal-hal yang memperngaruhi tidur :
- Hal-hal yang mempermudah tidur :
b. Selama Sakit
- Waktu tidur :
- Waktu bangun :
- Masalah tidur :
- Hal-hal yang memperngaruhi tidur :
- Hal-hal yang mempermudah tidur :

B. Pola Eliminasi
a. Sebelum sakit
1. BAB
- Pola BAB :
- Karakteristik Fases
 Warna :
 Konsistensi :
 Bau :
- Penggunaan Laksatif :
- BAB terakhir :
- Riwayat perdarahan :
2. BAK
- Pola BAK :
- Karaketer urine :
- Nyeri/kesulitan BAK :
- Inkontinentia :
- Penggunaan deuretik :
 - Riwayat penyakit ginjal :
- Berat Jenis :

b. Selama sakit
1. BAB
- Pola BAB :
- Karakteristik Fases :
 Warna :
 Kosistensi :
 Bau :
- Penggunaan Laksatif :
- BAB terakhir :
- Riwayat pendarahan :
2. BAK
- Pola BAK :
- Karakter urine :
- Nyeri/kesulitan BAK :
- Inkontinentia :
- Retensi :
- Penggunaan deuretik :
- Riwayat penyakit ginjal :
- Berat jenis :

C. Pola Makan dan Minum

a. Sebelum sakit
1. Pola makan
- Diet (type) :
- Jumlah / porsi :
- Pola diet :
- Anoreksia :
 - Mual- muntah :
- Nyeri ulu hati :
- Alergi makanan :
- BB biasa (Sebelumnya) :
2. Tanda objek
- BB sekarang :
- TB :
- Bentuk Tubuh :
3. Waktu pemberian makanan :
4. Masalah makanan :
- Kesulitan mengunyah :
- Kesulitan menelan :
- Tidak dapat makan sendiri:
5. Pola minum :
- Jumlah / porsi :
- Kesulitan menelan :
b. Selama sakit
1. Pola makan :
- Diet (type) :
- Jumlah/porsi :
- Pola diet :
- Anoreksida :
- Mual muntah :
- Nyeri ulu hati :
- Alergi makanan :
- BB biasa (Sebelumnya) :
2. Tanda Objek
- BB sekarang :
- TB :
- Bentuk tubuh :
 3. Waktu pemberian makanan :
4. Masalah makanan
- Kesulitan mengunyah :
- Kesulitan menelan :
- Tidak dapat makan sendiri:
5. Pola minum
- Jumlah/porsi :
- Kesulitan menelan :

D. Kebersihan Diri / Personal Hygiene

a. Sebelum sakit
1. Pemeliharaan badan :
2. Pemeliharaan gigi dan mulut :
3. Pemeliharaan kuku :
b. Selama sakit
1. Pemeliharaan badan :
2. Pemeliharaan gigi dan mulut :
3. Pemeliharaan kuku :

E. Pola Kegiatan / Aktivitas

a. Sebelum sakit
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b. Selama sakit
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F. Kebiasaan Ibadah
a. Sebelum sakit
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 b. Selama sakit
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I. PEMERIKSAAN PENUNJANG/DIAGNOSIK
1. Laboratorium

No Nilai Nilai Rujukan

2. USG

3. EKG

4. Rongent

5. Lain-lain
J. PENATALAKSANAAN DANTERAPI

NO NAMA OBAT DOSIS EFEK SAMPING HARI

K. ANALISI DATA

NO DATA PENYEBAB MASALAH

L. PERIORITAS MASALAH
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2. ..............................................................................................................
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4. ..............................................................................................................
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6. ..............................................................................................................

M. RENCANA ASUHAN KEPERAWATAN

Diagnosa Tujuan/kriteria Intervensi
No Rasionalisasi
Keperawatan Hasil keperawatan
No Diagnossa Keperawwatan Implementasi Evaluasi (SOAP)

N. IMPLEMENTASI

O. EVALUASI
 Catatan Perkembangan (SOAP-
No Tanggal/hari/jam Paraf
SOAPIE)