LAPORAN KASUS KEPERAWATAN PADA NY.....

DENGAN……………………………………………………………

DI RUANG KEMUNING BRSU TABANAN

TANGGAL…………….

OLEH :

NI MADE CANDRA ASRI

20121110006

PROGRAM STUDI S1 KEPERAWATAN

STIKES ADVAITA MEDIKA TABANAN

TAHUN AJARAN 2022

 ASUHAN KEPERAWATAN PADA Ny......

DENGAN………………………………………………

DI RUANG ……………………………………………

TANGGAL ............................................

A. PENGKAJIAN

I. IDENTITAS PASIEN PENANGGUNG/SUAMI

Nama : …………………… Nama : …………..........

Umur : …………………… Umur :…………..........

Pendidikan : .………………….. Pendidikan :…………..........

Pekerjaan :……………………. Pekerjaan :…………..........

Status Perkawinan :……………..... Alamat :…………..........

Agama : …………………… Hub.dgn klien : ………..........

Suku : ……………………

Alamat : ……………………

No. CM : ……………………

Tgl MRS : …………………….

Tgl Pengkajian : …………………….

Sumber informasi : ………………......

II. RIWAYAT PENYAKIT

Keluhan Utama

- Saat MRS
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

- Saat Pengkajian
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Riwayat Penyakit Sekarang

....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

III. RIWAYAT OBSTETRI DAN GINEKOLOGI

A. Riwayat Menstruasi :

 Menarche : ................. Siklus : teratur ( ) tidak( )

 Banyaknya :………….. Lamanya : ……………...
 Keluhan :…………...
 HPHT :…………...

B. Riwayat pernikahan :

 Menikah :……..kali Lama :………..tahun

C. Riwayat kehamilan, persalinan, nifas yang lalu :

Anak ke Kehamilan Persalinan Komplikasi nifas Anak

Umur Jenis BB Pj
No Th Penyakit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan
Kehamilan Kelamin (gr) (cm)

D. Riwayat Keluarga Berencana :

 Akseptor KB : jenis ………… Lama : ……..............

 Masalah :
....................................................................................................................................

E. Riwayat Penyakit Klien dan Keluarga

………………………………………………………………………………………....
…................................................................................................................................................................
....................................................................................................................................................................
............................
IV. POLA FUNGSIONAL KESEHATAN

1. Pemeliharaan dan persepsi terhadap kesehatan

…………………………………………………………………………………….........................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

2. Nutrisi/metabolik

……………………………………………………………………………………….....................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

3. Pola eliminasi

……………………………………………………………………………………….....................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

4. Pola aktivitas dan latihan

Kemampuan perawatan diri 0 1 2 3 4

Makan/Minum

Mandi

Toileting

Berpakaian

Mobilisasi di tempat tidur

Berpindah

Ambulasi ROM

0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung tota

Simpulan:
 ............................................................................................................................................................

C. Oksigenasi:
……………………………………………………………………........................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

D. Pola tidur dan istirahat

………………………………………………………………………………........................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

E. Pola perseptual
…………………………………………………………………………………....................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

F. Pola persepsi diri

…………………………………………………………………………………....................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

G. Pola seksual dan reproduksi

…………………………………………………………………………………....................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
H. Pola peran-hubungan
…............................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

I. Pola manajemen koping stress

…………………………………………………………………………………....................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

J. Sistem nilai dan keyakinan

………………………………………………………………………………...................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

V. PEMERIKSAAN FISIK

Keadaan umum

 GCS : ...………………….
 Tingkat kesadaran : ……………………
 Tanda-tanda vital : TD……...… N…...….... RR…........... T……......
 BB : ………….... TB:……..... LILA……….

Head to toe

Kepala wajah :

 Inspeksi :
…………………….......................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
..........................................................................................................................................
 ..........................................................................................................................................
..........................................................................................................................................

 Palpasi :
…………………...........................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Mata

 Inspeksi:
..........
…...................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.............................................................................................................................................

 Palpasi :
…………………….......................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Leher

 Inspeksi:
..........
…...................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.............................................................................................................................................

 Palpasi:
…………………….......................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

Dada

 Inspeksi:
.
…………………….......................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
......................................................................................................................................................

 Palpasi :
 .
……………………..................................................................................................................... .
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
......................................................................................................................................................

 Perkusi:
.
…………………….......................................................................................................................
......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

 Auskultasi:
.……………………......................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

Abdomen

 Inspeksi:
.
…………………….......................................................................................................................
......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

 Auskultasi:
.……………………......................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

 Perkusi:
.
…………………….......................................................................................................................
.......................................................................................................................................................
......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

 Palpasi:
.……………………......................................................................................................................
.......................................................................................................................................................
 .......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

Genetalia dan Perineum

 Kebersihan : ………………….
 Keputihan :………………….. Karakteristik :…………………
 Hemoroid :…………………..
 Pendarahan : ………………….

Ektremitas

 Atas :
Oedema :………………..

Varises :………………..

CRT :………………..

 Bawah:
Oedema :………………..

Varises :………………..

CRT :………………...

Reflek :………………..

VI. DATA PENUNJANG

A. Pemeriksaan Laboratorium :

.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
 .......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Pemeriksaan Radiologik :
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

VII. Diagnosa Medis

.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

VIII. Pengobatan

.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
B. ANALISA DATA

Tanggal/
No Data Fokus Etiologi Masalah
Jam
Diagnosa keperawatan berdasarkan prioritas:
………………………………………………………................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
C. RENCANA KEPERAWATAN

N DIAGNOSA RENCANA KEPERAWATAN

O
TUJUAN INTERVENSI RASIONAL
D. IMPLEMENTASI

HARI, NO. IMPLEMENTASI EVALUASI/ PARAF/

TGL DX RESPON KLIEN NAMA
JAM
E. EVALUASI/ CATATAN

HARI, NO.
TGL DIAGNOS EVALUASI PARAF
JAM A
 SEKOLAH TINGGI ILMU KESEHATAN
ADVAITA MEDIKA TABANAN
SK. MENDIKNAS NO : 110/D/O/2009
Sekretariat : Jl. Perkutut No. 25 Pasekan Belodan Tabanan
Website : http//www.advaitamedika.ac.id
Telp. : (0361)814242, Email : stikes_ameta@yahoo.co.id

LEMBAR PENGESAHAN
Tabanan, Juli 2022
Mahasiswa

(Ni Made Candra Asri)

NIM. 20121110006

Mengetahui

Pembimbing Clinical Instructor Pembimbing Clinical Teacher

( G. N. Sri Armini, S.ST ) (Ns. Desak Gede Yenny Apriani, S.Kep, M.Kes)
NIP.196711211988072005 NIK. 090803.0.044