Laporan Kasus Ruang OK

Di Rumah Sakit...............................................................................

Laporan kasus pada ..........dengan diagnosa medik ...............................................

Tanggal pengkajian     : ………………….

Tanggal Operasi          : …………………
Tempat Praktek           : Ruangan OK RS………..

1.      Post operasi care

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a.       Identitas
Nama pasien          : ................
Jenis kelamin         : ................
Usia                       : ................
Status perkwinan  : ................
Agama                   : ................
Suku                      : ................
Pekerjaan               : ................
Alamat                  : ................
Diagnosa medik    : ................

2.      Keluhan utama

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3.      Riwayat penyakit
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4.      Pemeriksaan fisik
Keadaan umum           : ...........
Tingkat kesadaran       : ...........
GCS                            : E ...........
                                      V ...........
                                      M ...........
Nilai normal GCS       : ...........
Vital Sign                    : Tekanan darah : ...........
                                     Nadi               : ...........
                                     Suhu               : ...........
                                      Pernafasan      : ...........

Inspeksi                       : ...........

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Palpasi                          : ............................................................

Klien dipindahkan keruangan RR pukul ...................dengan kesadaran ........., klien terpasang
..................................... Hasil TTV yaitu :
a.       TTV (Post operasi) jam......
Tekanan darah       : ......
Nadi                      : ......
Suhu                      : ......
Pernafasan             : ......
b.      TTV (Post operasi) jam......
Tekanan darah       : ......
Suhu                      : ......
Nadi                      : ......
Pernafasan             : ......
c.       Instruksi dokter
Bedrest                  : ......
Diit                        : ......
d.      Terapi medis
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Analisa data
No Data Etiologi Problem
1.

2.

3.
 FORMAT ASKEP RUANG ICU

I.         PENGKAJIAN
Tanggal masuk                 : ……………………………….
Tanggal pengkajian          : …………………….
A.       Identitas Pasien
1.            N a m a                                    : ……….                      
2.            U m u r                                    : ……..
3.            Jenis Kelamin                          : ...........
4.            Agama                                     : …………
5.            Pekerjaan                                 : ………
6.            Alamat                                     : ……..
7.            Diagnosa Medis                      : …………
8.            No. Register                            : …………
         Identitas Penanggung Jawab
1.            N a m a                                    : ……….
2.            U m u r                                    : …………                                          
3.            Alamat                                     : ……..
4.            Hubungan                                : ………..

B.       Riwayat 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 Penyakit Keluarga

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II.      PENGKAJIAN PRIMER

a.       Airway
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b.      Breathing
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c.       Circulation
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 d.      Disability
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e.       Exposure
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III.   PENGKAJIAN SEKUNDER

A.       Tanda-tanda Vital
Tanggal TD MAP HR SaO2 RR Suhu

B.                 Pemeriksaan Fisik

1.        Kepala
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2.        Mata
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3.        Telinga
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4.        Hidung
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5.        Mulut
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6.        Leher
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7.        Thoraks
a.         Jantung
Inspkesi       : ......................................
Palpasi         : ......................................
Perkusi        : ......................................
 Auskultasi   : ......................................
b.        Paru-paru
Inspkesi       : ......................................
Palpasi         : ......................................
Perkusi        : ......................................
Auskultasi   : ......................................

8.        Abdomen
Inspeksi              : ......................................
Auskultasi          : ......................................
Perkusi               : ......................................
Palpasi                : ......................................

9.        Ekstremitas
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10.    Genitalia
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C.    Pola Eliminasi

a)      Urin/shift
Tgl Frek BAK Warna Retensi Inkontinensia Jumlah

         Pemeriksaan lab urin : ......................................

b)      Fekal
Tgl Frek BAB Warna Konsistensi

D.    Tingkat Kesadaran

1.      GCS
Tgl Eye (e) Motorik (m) Verbal (v) Total

2.      Status Kesadaran

Tgl Composmentis Apatis Somnolen Sopor Soporocoma Coma

E.     Tingkat ketergantungan

Tingkat Ketergantungan Klien Menurur Indeks KATZ
Aktivitas
Hygiene Berpakaian Eliminasi Mobilisasi Kontinen Makan Kategori
Tgl

F.     Status Nutrisi dan Cairan

1.      Asupan Nutrisi
Tgl Hari ke- Jumlah porsi Jumlah buah Kalori buah Kalori Total
makanan

Status nutrisi perhari               : F x A

                                                  ( BB x 30 kkal ) x indeks aktivitas
                                                  ( 60 x 30 kkal ) x 0,9
                                                  1620 kkal/hari         
Aminovel/comafusin hepar     : 200 kkal/botol
Total nutrisi yang diterima      : Sonde + 1 botol aminovel/comafusin hepar
                        1620 kkal/hari : sonde + 200 kkal
                         Jadi sonde/hari: 1420 kkal             @ shift : 473.3 kkal

2.      Cairan/24 jam

Tanggal Intake Output Balance Cairan

G.    Pemeriksaan Penunjang

1)        Laboratorium
Pemeriksaan Nilai Satuan Tgl..... Tgl..... Tgl.....
Nilai Nilai Nilai

2)        Hasil EKG

Kesan :
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 3)        Hasil Rontgen
Kesan :
-       ..........................................................

4)        Pemeriksaan fundoskopi

Kesan :
Tidak ada

5)        Lain-lain.
 Tidak ada

H.    Therapy
Terapi Tgl..... Tgl..... Tgl.....
 ANALISA DATA
Nama   : ...........                                                           No ..............
Usia     : ..............                                                        Diagnosa Medis       : ..............
NO TGL/JAM DATA FOKUS MASALAH ETIOLOGI
 PRIORITAS DIAGNOSA KEPERAWATAN

Nama   : .........                                                           No : .........

Usia     : .........                                                        Diagnosa Medis       : .........
DX. KEPERAWATAN
NO TTD
 RENCANA ASUHAN KEPERAWATAN

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