LAPORAN KASUS

ASUHAN KEPERAWATAN MATRA DAN HIPERBARIK PADA KLIEN

DENGAN DIAGNOSA MEDIS .................................................................
DI ................................................... RUMKITAL Dr. RAMELAN
SURABAYA
Tanggal .............. s/d ..................

Oleh :
_________________________
NIM ...............................

PROGRAM STUDI PENDIDIKAN PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA
TA. 2011/2012

LEMBAR PENGESAHAN
Asuhan

keperawatan

matra

dan

hiperbarik

terhadap

masalah

keperawatan ........................................................................................ di .....................................................

sesuai dengan praktik yang dilaksanakan oleh mahasiswa :
Nam

: .....................................................................................................................................................

NIM

: .....................................................................................................................................................

Semester

: .....................................................................................................................................................

Prodi

: .....................................................................................................................................................
Sebagai syarat pemenuhan tugas praktik profesi keperawatan matra dan hiperbarik Program

Profesi Ners STIKES Hangtuah Surabaya yang dilaksanakan tanggal ......................................... telah
disyahkan dan disetujui pada :
Hari

: .....................................................................................................................................................

Tanggal

: .....................................................................................................................................................

Surabaya, ................ 20.....

Mahasiswa

______________________

Mengetahui,
Penguji Pendidikan

Penguji Lahan

______________________

______________________

PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN MATRA DAN HIPERBARIK
STIKES HANG TUAH SURABAYA

PENGKAJIAN
1. Identitas
Nama
:
Usia

Agama

Pekerjaan

Pendidikan

Alamat

Keluhan Utama :
....................................................................................................................................................................
....................................................................................................................................................................
2. Riwayat Penyakit
a. Riwayat Penyakit Sekarang
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
b. Riwayat Penyakit Yang Pernah Diderita
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
c. Riwayat Kesehatan Keluarga
..............................................................................................................................................................
..............................................................................................................................................................
d. Riwayat Pembedahan
..............................................................................................................................................................
..............................................................................................................................................................
e. Riwayat Alergi
..............................................................................................................................................................
..............................................................................................................................................................
3. Pengkajian Sistem
a. Kepala, Mata, Telinga, Hidung dan Tenggorokan
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................

b. Neurologis
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................

c. Pernafasan
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
d. Kardiovaskuler
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
e. Pencernaan
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
f. Perkemihan
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
g. Musculoskeletal
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
h. Integumen
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
4. Pengkajian Pemenuhan Kebutuhan Dasar Manusia
a. Universal Self Care
1) Kebutuhan Oksigenasi
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
2) Kebutuhan Cairan
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
3) Kebutuhan Nutrisi
........................................................................................................................................................
........................................................................................................................................................

........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
4) Kebutuhan Eliminasi
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
5) Interaksi Sosial
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
6) Istirahat dan Tidur
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
7) Konsep Diri
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
b. Development Self Care
1) Persepsi terhadap penyakitnya dan terapi hiperbarik oksigen
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
2) Pengetahuan terhadap penyakit dan terapi hiperbarik oksigen
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
c. Health Deviation
1) Tindakan preventif yang dilakukan untuk mengatasi masalah kesehatannya
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
2) Halangan untuk melakukan tindakan preventif untuk mengatasi masalah kesehatannya
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................

ANALISA DATA
No.

Data (Symptom)

Penyebab (Etiologi)

Masalah (Problem)

Diagnosa Keperawatan yang Muncul :

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

RENCANA KEPERAWATAN
No.

Penuh / Wholly

Sebagian / Partial

Suportif / Edukatif

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No.

Waktu
Tgl/jam

Tindakan

TT

Waktu
Tgl/jam

Catatan Perkembangan
(SOAP)

TT