LAPORAN KASUS ASUHAN KEPERAWATAN Tn.

I.       PENGKAJIAN
1.       Identitas
a.      Identitas Pasien
Nama                         : Tn. P
Umur                         : 28 Tahun
Agama                       : Islam
Jenis Kelamin            : Laki-laki
Status                         : Belum menikah
Pendidikan                 : SMA
Pekerjaan                   : Pegawai swasta
Suku Bangsa :
Alamat  : Handil Bakti, Kecamatan Batola
Tanggal Masuk          : 27 Pebruari 2021
Tanggal Pengkajian : 28 Pebruari 2021
No. Register               : 2040579
Diagnosa Medis         :

b.      Identitas Penanggung Jawab

Nama                         :
Umur                         :
Hub. Dengan Pasien  :
Pekerjaan                   :
Alamat                       :

2.      Status Kesehatan
a.      Status Kesehatan Saat Ini
1)      Keluhan Utama (Saat MRS dan saat ini)
Nyeri di daerah perut kuadran kanan atas dan dibelakang tengah, faktor pencetus berubah posisi
dan melakukan aktivitas sedang seperti berjalan, karakteristik nyeri panas dengan skala nyeri 8,
intensitas 30 menit, timbulkeluhan mendadak. Nyeri semakin berat bila klien beraktivitas sedang
seperti berjalan dan berkurang saat klien tiduran dengan posisi semi fowler dan setelah diberikan
obat Paracetamol 2 x 500 mg via oral.

2)      Riwayat Penyakit Sekarang

Klien merasa mual, tidak selera makan, perut terasa begah, berat badan turun 2kg, makanan
habis ½ porsi. Klien mengatakan minuman dalam sehari kurang lebih 1 ½ liter.

b.      Satus Kesehatan Masa Lalu

1)      Penyakit yang pernah dialami
Tidak ada keterangan mengenai status Kesehatan pasien di masa lalu.

2)      Pernah dirawat
Tidak ada keterangan data mengenai klien pernah dirawat sebelumnya.

3)     Alergi
Tidak ada keterangan mengenai alergi obat terhadap pasien.

4)      Kebiasaan (merokok/kopi/alkohol dll)

Tidak ada keterangan mengenai kebiasaan tersebut dalam data kasus klien.
c.       Riwayat Penyakit Keluarga
Tidak ada data mengenai riwayat penyakit keluarga klien.

d.      Diagnosa Medis dan therapy

Diagnosa : .............................
Therapy : ............................

3.      Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)

a.       Pola Persepsi dan Manajemen Kesehatan

b.      Pola Nutrisi-Metabolik
   Sebelum sakit          :
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   Saat sakit                 :
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c.       Pola Eliminasi
1)   BAB
   Sebelum sakit          :
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   Saat sakit                 :
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2)   BAK
      Sebelum sakit       :
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      Saat sakit              :
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d.      Pola aktivitas dan latihan
1)   Aktivitas
Kemampuan 0 1 2 3 4
Perawatan Diri
Makan dan minum
Mandi
Toileting
Berpakaian
Berpindah
0: mandiri, 1: Alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total

2)  Latihan
       Sebelum sakit
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    Saat sakit          
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e.       Pola kognitif dan Persepsi
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f.       Pola Persepsi-Konsep diri
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g.       Pola Tidur dan Istirahat
 Sebelum sakit          :
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 Saat sakit                 :
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h.      Pola Peran-Hubungan
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i.        Pola Seksual-Reproduksi
   Sebelum sakit     :
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   Saat sakit                        :
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j.        Pola Toleransi Stress-Koping

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k.      Pola Nilai-Kepercayaan
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4.       Pengkajian Fisik
a.       Keadaan umum : sedang
Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma
GCS           : verbal 5 Psikomotor: 6 Mata : 4
b.      Tanda-tanda Vital : Nadi = 128 x/menit, Suhu = 36.3oC, TD = 100/70 mmHg, RR = 22 x/menit
c.       Keadaan fisik

a.       Kepala  dan leher       :
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b.      Dada  :
   Paru
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   Jantung
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c.       Payudara dan ketiak   :

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d.      abdomen        :
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e.       Genetalia        :
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f.       Integumen :
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g.       Ekstremitas     :
         Atas
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         Bawah
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h.      Neurologis      :
         Status mental da emosi :
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         Pengkajian saraf kranial :
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         Pemeriksaan refleks :
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b.      Pemeriksaan Penunjang
1.      Data laboratorium yang berhubungan
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2.      Pemeriksaan radiologi
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 3.      Hasil konsultasi
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4.      Pemeriksaan penunjang diagnostic lain

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5.         ANALISA DATA
A.     Tabel Analisa Data
DATA Etiologi MASALAH

B.     Tabel Daftar  Diagnosa Keperawatan /Masalah Kolaboratif Berdasarkan Prioritas

NO TANGGAL / DIAGNOSA KEPERAWATAN Ttd

JAM
DITEMUKAN
1

Dst

C.     Rencana Tindakan  Keperawatan
Hari Rencana Perawatan TTD
No
/
Dx Tujuan dan Kriteria Hasil Intervensi
Tgl
 D.    Implementasi Keperawatan

Hari/ Evaluasi proses/ Respon Ttd

No Dx Tindakan Keperawatan
Tgl/Jam Tindakan

      

E.           Evaluasi Keperawatan
Hari/Tgl TT
No. DX Evaluasi
Jam d
1 S:

O:

A:

P: