LAPORAN KASUS

ASUHAN KEPERAWATAN PADA Tn/Ny ……

DENGAN MASALAH …………………………………
DI DESA ………………. WILAYAH KERJA PUSKESMAS SUKAMERANG

Disusun untuk memenuhi salah satu tugas

Praktek Profesi Keperawatan Kesehatan Jiwa (PPKKJ)

Disusun oleh:
Nama : ……………………………
NIM : ……………………………

PROGRAM STUDI PROFESI NERS ANGKATAN XIII

SEKOLAH TINGGI ILMU KESEHATAN KARSA HUSADA GARUT
TAHUN AKADEMIK 2024
 LAPORAN KASUS
ASUHAN KEPERAWATAN PADA Tn/Ny ……
DENGAN MASALAH …………………………………
DI DESA ………………. WILAYAH KERJA PUSKESMAS SUKAMERANG

Nama mhs/klp :
Tgl/jam pengkajian :
Sumber data :
Metode :
Alat/bahan :
I. IDENTITAS
Identitas Klien
Nama :......................................................................................................
Umur :......................................................................................................
Jenis Kelamin :......................................................................................................
Pekerjaan :......................................................................................................
Pendidikan :......................................................................................................
Suku/Bangsa :
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Alamat :.......................................................................................................
Status Marital :......................................................................................................
No Register :.......................................................................................................
Diagnosa medis :........................................................................................................

II. POLA PERSEPSI KESEHATAN ATAU PENANGANAN KESEHATAN

1. Keluhan Utama :
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2. Riwayat penyakit sekarang :
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3. Lamanya keluhan
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4. Faktor yang Memperberat

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5. Upaya yang Dilakukan Untuk Mengatasi Keluhan
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6. Riwayat penyakit dahulu :
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7. Persepsi klien tentang status kesehatan dan kesejahteraan
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8. Riwayat kesehatan keluarga :
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9. Susunan keluarga (genogram) :
 Keterangan:
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10. Riwayat alergi
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III.POLA NUTRISI DAN METABOLIK

1. Pola makan
Frekuensi : ....................................................................................................
Jenis : ....................................................................................................
Porsi : ....................................................................................................
Pantangan : ....................................................................................................
Makanan disukai : ....................................................................................................
Nafsu makan : ( ) normal ( ) bertambah ( ) berkurang
( ) mual ( ) muntah, .............. cc ( ) stomatitis
Kesulitan menelan : ( ) tidak ( ) ya
Gigi palsu : ( ) tidak ( ) ya

2. Pola minum
Frekuensi : ....................................................................................................
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Jenis : ....................................................................................................
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Jumlah : ....................................................................................................
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Pantangan : ....................................................................................................
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Makanan disukai
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IV. POLA ELIMINASI

1. Buang air besar
 Frekuensi :
Konsistensi :
Warna :
2. Buang air kecil
Frekuensi :
Jumlah :
Warna :

V. POLA AKTIVITAS DAN LATIHAN

1. 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

2. Kebersihan diri
Mandi :
Gosok gigi :
Keramas :
Potong kuku :
3. Aktivitas sehari-hari
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4. Rekreasi
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5. Olahraga :
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VI. POLA ISTIRAHAT DAN TIDUR
Waktu tidur
Siang :
Malam :

VII. POLA KOGNITIF DAN PERSEPTUAL

Berbicara : ( ) normal ( ) gagap ( ) bicara tak jelas
Bahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya, sunda
Kemampuan membaca : ( ) bisa ( ) tidak
Tingkat ansietas : ( ) ringan ( ) sedang ( ) berat ( ) panik

Kemampuan interaksi : ( ) sesuai ( )

Vertigo : ( ) tidak ( ) ya
Nyeri : ( ) tidak ( ) ya

Bila ya, P:

Q:.......................................................................................................................................
R:.......................................................................................................................................
S:.......................................................................................................................................
T:.......................................................................................................................................
VIII. POLA PERSEPSI DIRI / KONSEP DIRI
1. Body image/gambaran diri
( ) cacat fisik ( ) pernah operasi
( ) perubahan ukuran fisik ( ) proses patologi penyakit
( ) fungsi alat tubuh terganggu ( ) kegagalan fungsi tubuh
( ) keluhan karena kondisi tubuh ( ) gangguan struktur tubuh
( ) transplantasi alat tubuh ( ) menolak berkaca
( ) prosedur pengobatan yang mengubah fungsi alat tubuh
( ) perubahan fisiologis tumbuh kembang
Jelaskan :
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Masalah keperawatan :
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2. Role/peran
( ) overload peran ( ) perubahan peran ( ) transisi peran karena
( ) konflik peran ( ) keraguan peran sakit
Jelaskan :
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Masalah keperawatan :
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3. Identity/identitas diri
( ) kurang percaya diri ( ) merasa kurang memiliki potensi
( ) merasa terkekang ( ) kurang mampu menentukan pilihan
( ) tidak mampu menerima perubahan ( ) menolak menjadi tua
Jelaskan :
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Masalah keperawatan :
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4. Self esteem/harga diri
( ) mengkritik diri sendiri dan orang ( ) menyangkal kepuasan diri
lain ( ) polarisasi pandangan hidup
( ) merasa jadi orang penting ( ) mencemooh diri
( ) menunda tugas ( ) mengecilkan diri
( ) merusak diri ( ) keluhan fisik
( ) menyangkal kemampuan pribadi ( ) menyalahgunakan zat
( ) rasa bersalah
Jelaskan :
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Masalah keperawatan :
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5. Self ideal/ideal diri
( ) masa depan suram ( ) tidak ingin berusaha
( ) terserah pada nasib ( ) tidak memiliki cita-cita
( ) merasa tidak memiliki kemampuan ( ) merasa tidak berdaya
( ) tidak memiliki harapan ( ) enggan membicarakan masa depan
Jelaskan :
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Masalah keperawatan :
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IX. POLA PERAN DAN HUBUNGAN

Pekerjaan :
Kualitas bekerja :
Hubungan dengan orang lain :
Sistem pendukung : ( ) pasangan ( ) tetangga/teman ( ) tidak ada
( ) lainnya,

Masalah keluarga mengenai perawatan di RS :

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X. POLA SEKSUALITAS / REPRODUKSI
 Menstruasi terakhir :
Masalah menstruasi :
Pap smear terakhir :
Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidak
Masalah seksual yang berhubungan dengan penyakit :
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XI. POLA KOPING / TOLERANSI STRESS

1. Masalah utama yang berhubungan dengan (penyakit, biaya, perawatan diri)
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2. Kehilangan perubahan yang terjadi sebelumnya
a. Tahap Denial/Penolakan
( ) penolakan terhadap situasi ( ) merasa tertekan
( ) tidak percaya pada orang lain ( ) wawasan sempit
Jelaskan :
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Masalah keperawatan :
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b. Tahap Anger/Marah
( ) marah pada diri sendiri
( ) marah pada orang lain
( ) meningkatnya kesadaran klien pada realita
Jelaskan :
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Masalah keperawatan :
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 3. Kemampuan adaptasi
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XII. POLA NILAI / KEPERCAYAAN

Agama : .................................................................................
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Pelaksanaan ibadah
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Pantangan agama : ( ) tidak ( ) ya, ...........................................................

XIII. PENGKAJIAN PERSISTEM (Review of System)

1. Tanda-Tanda Vital
a. Suhu :
b. Nadi :
c. Tekanan darah :
d. Frekuensi nafas :
e. Tinggi badan :
f. Berat badan :
2. Sistem Pernafasan (Breath)
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3. Sistem Kardiovaskuler (Blood)
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4. Sistem Persarafan (Brain)
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5. Sistem Perkemihan (Bladder)
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6. Sistem Pencernaan (Bowel)

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7. Sistem Muskuloskeletal (Bone)

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8. Sistem Integumen
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9. Sistem Penginderaan
Mata
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Hidung
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Telinga
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10. Sistem Reproduksi Dan Genetalia
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XIV. PEMERIKSAAN PENUNJANG
1. Laboratorium

2. Terapi medis :
No Nama dan Dosis Cara Indikasi
Sediaan obat pemberian
I. DAFTAR MASALAH KEPERAWATAN
Data maladaptif
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Masalah keperawatan
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II. DIAGNOSA KEPERAWATAN
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RENCANA TINDAKAN KEPERAWATAN
Diagnosa Perencanaan
No Rasional
Keperawatan Tujuan Kriteria Hasil Intervensi
 Diagnosa Perencanaan
No Rasional
Keperawatan
 Diagnosa Perencanaan
No Rasional
Keperawatan
IMPLEMENTASI DAN EVALUASI KEPERAWATAN
No Diagnosis Hari/Tanggal
Implementasi Evaluasi Paraf
Kep Jam
No Diagnosis Hari/Tanggal
Implementasi Evaluasi Paraf
Kep Jam