LAPORANASUHANKEPERAWATAN

PRAKTIKKLINIKKEPERAWATANDASAR

JUDUL:

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NAMA :..............................................................
TK/SMT :..............................................................
NIM :..............................................................

PROGRAM STUDI D3 KEPERAWATAN

 HALAMANPENGESAHAN

Laporanasuhankeperawataninidiajukan oleh:
Nama :………………………………………………………………..
NIM :………………………………………………………………..
Tingkat/smt :………………………………………………………………..
Programstudi :………………………………………………………………..
Judulasuhankeperawatan:……………………………………………………………………..
…………………………………………………………………………………………………….

Telahdiperiksadandisetujuisebagaibagiandaripersyaratanyangdiperlukanuntukmemenuhicapaian
pembelajaran Praktik Klinik Keperawatan Dasar pada Program Studi D3 Keperawatan

...........................,....................

Pembimbingruangan, Pembimbingpendidikan,

(..........................................................) (........................................................)

Mengetahui,
Kepalaruangan

(..............................................................)
 PENGKAJIANKEPERAWATANDASARPENDEKATAN11POLAGORDON

A. PENGKAJIAN

Rumah Sakit :.......................................

Ruang :.......................................
I. BIODATA

Nama :....................................... Status :.......................................

perkawinan
Register :....................................... Pendidikan :.......................................
JenisKelamin :....................................... Agama :.......................................
Pekerjaan :....................................... MRStanggal :.......................................
Alamat :....................................... Diagnosamasuk :.......................................
Tanggalpengkajian :....................................... Oleh :.......................................

II. POLAKESEHATANFUNGSIONAL
1. Polapersepsikesehatan/penanganankesehatan
a.KeluhanUtama
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b.RiwayatPenyakitSekarang(RPS)
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c.Riwayat PenyakitDahulu(RPD)
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d.RiwayatPenyakitKeluarga(RPK)
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2. PolaNutrisi/Metabolisme
a. DataSubyektif:
Intakenutrisi(frekuensi,jumlah&komposisi)
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Intakecairan( frekuensi,jumlah &jenis)
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Nafsumakan :........................................................................................
Masalahdenganmakan :…………………………………………………………
Makanankesukaan :........................................................................................
Alergimakanan :........................................................................................
b. DataObyektif:
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3. Pola Eliminasi
EliminasiUri
a. DataSubyektif:
PolaBAK( frekuensi,waktu,jumlah ) :................................................................
Karakteristik(warna, kejernihan,bau,endapan ):................................................................
Faktoryg mempengaruhiBAK :................................................................
Masalaheliminasiuri :................................................................
b. DataObyektif:
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Eliminasialvi
a. DataSubyektif:
PolaBAB( frekuensi,waktu) :................................................................
Karakteristikkeluaranfeses(bau,jumlah) :................................................................
MasalahdenganBAB :................................................................
Faktoryangmempengaruhi BAB :................................................................
Penggunaanlaksantif :................................................................
b. DataObyektif:
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4. Pola Aktivitas – LatihanMobilitas/aktivitas

a. DataSubyektif
Polaaktivitasygdilakukan :………………………………………………………....
Aktivitasdiwaktuluang :……………………………………………………........
Masalahdalamaktivitas :……………………………………………………........
Penggunaanalatbantu :………………………………………............................
Aktivitassejaksakit :........................................................................................
b. DataObyektif:
Kemampuanperawatandiri
Jeniskemampuan 0 1 2 3 4
Makan/minum
Berpakaian
Mandi
Toileting
Mobilisasiditempattidur
Berjalan
0 : Mandiri 3 :Bantuanperalatandanoranglain
1 :Denganbantuan oranglain 4 :Tidak mampu
2 :Menggunakanalatbantu

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Respirasi
a.DataSubyektif
Masalahdalampernafasan :……………………………………………………........
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Adakahkeluhanbatuk :………………………………………............................
Keluhanlainnya :........................................................................................

c.DataObyektif:
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Sirkulasi
a.DataSubyektif
Masalahdalamsirkulasi :……………………………………………………........
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b. DataObyektif:
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5. PolaIstirahat Tidur
a.DataSubyektif
Kebiasaanpolatidur (waktu, jumlah,kualitas ) :................................................................
Dampakpolaistitrahattidurterhadapaktivitassehari–hari:....................................................
Kesulitantidur :........................................................................................
Alatbantu tidur :........................................................................................
b.DataObyektif:
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6. PolaKognitifPerseptual
a.DataSubyektif
Kemampuanpancaindra(pendengaran,penglihatan, penghidu/penciuman)
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Pemakaianalatbantupendengaran,penglihatan :................................................................
Masalahsensoriperseptual :........................................................................................
Perubahanmemori :........................................................................................
PresepsiNyeri &penanganan nyeri(P, Q, R,S, T ) :................................................................
b. DataObyektif:
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 7. PolaPresepsi–Diri /KonsepDiri
a. Data Subyektif
Konsepdiri
a. BodyImage :........................................................................................
b.SelfIdeal :........................................................................................
c. Selfesteem :.......................................................................................
d.Role :.......................................................................................
e. Identitas :.......................................................................................
b. DataObyektif:
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8. PolaPeran–hubungan
a.DataSubyektif
Keefektifanperan :........................................................................................
Hubungandenganorang terdekat :........................................................................................
Efekperubahanperanterhadaphubungan :............................................................................
b. DataObyektif:
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9. PolaSeksualitas–Reproduksi
a.Datasubyektif
Dampaksakitterhadapseksualitas :.......................................................................................
Riwayathaid :.......................................................................................
Tindakanpengendaliankelahiran :.......................................................................................
Riwayatpenyakithubunganseksual:.......................................................................................
b. DataObyektif:
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10. PolaKoping–ToleransiStress
a.DataSubyektif
Penggunaansistempendukung :...........................................................................
Stressorsebelumsakit :...........................................................................
Metodekopingyg biasa digunakan :...........................................................................
Faktor–faktor ygmempengaruhikoping:...........................................................................
Efekpenyakitterhadaptingkatstress :...........................................................................
Penggunaanalkohol&obatlainuntukmengatasistres :...................................................
b. DataObyektif:
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11. PolaNilai –Kepercayaan
a. Datasubyektif
Agama:spiritualitas :...........................................................................
Kegiatankeagamaan&budaya :...........................................................................
b. DataObyektif:
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III. PEMERIKSAAN FISIK

KeadaanUmum : …………………………………………………………………………
Kesadaran, GCS :………………………………………………………………………..
Tandavital :TD : …………… Nadi : ……………
Suhu :…………… RR : ……………

Secara khusus (Chepalo – Caudal)

1. Kepala
Kebersihan : () Bersih ( )Kotor
Warna rambut : ()Hitam ( ) Putih ( ) Lainnya
Rambut rontok : ()Ya ( )Tidak
Jejas : ( )Ada ( ) Tidak ada
Hematom : ( )Ada ( ) Tidak ada
Lain-lain : ……………………………………………………………………………

2. Mata
Simetris : ( )Ya ( )Tidak
Konjungtiva : ( ) Merah muda ( ) Anemis ( ) Hiperemi
Pupil : () Isokhor ( )Anisokhor
Palpebra : () Edema ( )Tidak
TIO : ()Normal ( )Meningkat
Lain-lain : ……………………………………………………………………………

3. Hidung : ( ) Simetris ()Sianosis ( ) Epistaksis

Lain-lain :………………………………………………………………………
4. Telinga
Simetris : ( )Ya ( ) Tidak
Kebersihan : () Bersih ( )Kotor
Gangguanpendengaran: ( )Ya ( )Tidak
Lain-lain : ……………………………………………………………………………..

5. Mulut
Mukosabibir : ( ) Lembab () Kering ( ) Pecah-pecah ( ) Simetris () Sianosis
( ) Stomatitis
Lidah : () Kotor ( )Bersih
Lain-lain : ………………………………………………………..
Leher : ( )Normal
( ) Peningkatan tekanan vena jugularis
 ( ) Pembesaran kelenjar limfe
( ) Pembesaran tiroid
Lain-lain : ………………………………………………………..
6. Paru
Inspeksi
Bentuk thorak : ()Simetris ( ) Barrelcest
( ) Pigeon cest ( ) Funnelcest
Bntk punggung : () Simetris () Lordosis ( ) Skoliosis
Penggunaan otot bantu nafas: ( ) Ada,……… ( ) Tidak ada
Pola nafas : () Reguler ( )Takipnea
( ) Bradipnea ( ) Apnea
Retraksi : () Ada ( ) Tidak ada
Palpasi
Ekspansiparu: Dekstra Sinistra
Upper Upper

………… …………
Midle Midle

………… …………
Lower Lower

………… ………
Vokal fremitus: Dekstra Sinistra

Upper Upper

………… …………
Midle Midle

………… …………
Lower Lower

………… ……
Perkusi ( ) Sonor ( ) Hipersonor
( ) Pekak ( ) Redup
Auskultasi :
Vesikuler / Dekstra Sinistra
ronkhi /  Upper  Upper
wheezing / …………… ……………
rales / amforik
 Midle  Midle
…………… ……………
 Lower  Lower
…………… ……………
7.Jantung
Inspeksi Ictuscordis ( ) Terlihat ( ) Tidak terlihat
Palpasi : Thrill ( ) Teraba ( ) Tidak teraba
Perkusi : ( ) Redup ( ) Pekak
Auskultasi : ( ) S1 S2 tunggal () Gallop ( )Murmur
Lain-lain : ………………………………………………………..

8. Abdomen
Inspeksi : ()Simetris () Asimetris ( )Strie
( ) Spider navi
Auskultasi :Peristaltikusus.............x/mnt
Palpasi : () Normal ( ) Nyeritekan
()Hepatomegali ( )Splenomegali
( )Pembesaranginjal ( )Skibala
Perkusi : ( ) Timpani ( ) Hipertimpani
( ) Redup ( ) Nyeri ketuk pada ginjal
( )Shiftingdullness ( )Pekak
Lain-lain :……………………………………………..

9. Ekstremitas :Kekuatanotot Dekstra Sinistra

........./......... ........./.........
()Fraktur ( )Dislokasi ( )Kontraktur

Lain-lain :…………………………………………………………

10. Syaraf
Reflek fisiologis : () Bisep ( ) Trisep
() Pronator ( )Patella
()Brakhioradialis ( ) Achilles
Reflekpatologi : ( )Babinski
() Gordon ( )Chaddok
( ) Schaeffer ( ) Openheim
Lain-lain :…………………………………………………

11. Integumen
Akral : ()Dingin ( )Hangat
Turgor : ( ) Normal () Meningkat ( ) Turun
CRT :.................detik
Luka : ( ) Ya, ………… ( )Tidak
Lain-lain :………………………………………………………..
IV. DATA PENUNJANG
V. TERAPI MEDIS

Mojokerto,.................

(......................................)

CTT:
- Datasubyektif:diperolehmelaluiwawncara
- Dataobyektifdiperolehdaripemeriksaanfisik, penunjang:hasillab, fotothorak(dll)
- Dataobyektifterintegrasipadamasing-masingpola
 B. ANALISADATA

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