LAPORAN KASUS

ASUHAN KEPERAWATAN PADA KLIEN DENGAN ...................................

DI .................. RUMKITAL Dr. RAMELAN SURABAYA

Tanggal .............. s/d ..................

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

PROGRAM STUDI ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA
TA. 2009/2010
 LEMBAR PENGESAHAN

ASUHAN KEPERAWATAN PADA KLIEN DENGAN ...................................

DI .................. RUMKITAL Dr. RAMELAN SURABAYA

Tanggal .............. s/d ..................

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

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

Penguji Pendidikan Penguji Lahan

______________________ ______________________
 PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN MEDIKAL BEDAH
STIKES HANG TUAH SURABAYA

Nama mahasiswa : ........................................ Tgl/jam MRS : ........................................

Tgl/jam pengkajian : ........................................ No. RM : ........................................
Diagnosa medis : ........................................ Ruangan/kelas : ........................................
........................................ No.kamar : ........................................

I. IDENTITAS
1. Nama : .....................................................................................................................
2. Umur : .....................................................................................................................
3. Jenis kelamin : .....................................................................................................................
4. Status : .....................................................................................................................
5. Agama : .....................................................................................................................
6. Suku/bangsa : .....................................................................................................................
7. Bahasa : .....................................................................................................................
8. Pendidikan : .....................................................................................................................
9. Pekerjaan : .....................................................................................................................
10. Alamat dan no. telp : .....................................................................................................................
11. Penanggung jawab : .....................................................................................................................

II. RIWAYAT SAKIT DAN KESEHATAN

1. Keluhan utama :
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2. Riwayat penyakit sekarang :
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3. Riwayat penyakit dahulu :
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4. Riwayat kesehatan keluarga :
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5. Susunan keluarga (genogram) :
 6. Riwayat alergi :
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III. POLA FUNGSI KESEHATAN

1. Persepsi Terhadap Kesehatan (Keyakinan Terhadap Kesehatan & Sakitnya)
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2. Pola Aktivitas Dan Latihan

a. 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

b. Kebersihan diri
Di rumah Di rumah sakit
Mandi : ........................  Mandi : ........................ 
/hr /hr
Gosok gigi : ........................  Gosok gigi : ........................ 
/hr /hr
Keramas : ....................  Keramas : .................... 
/mgg /mgg
Potong kuku : ....................  Potong kuku : .................... 
/mgg /mgg
c. Aktivitas sehari-hari
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d. Rekreasi
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e. Olahraga : ( ) tidak ( ) ya
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3. Pola Istirahat Dan Tidur

Di rumah Malam ............-...............
Waktu tidur : Siang ..............-............... Jumlah jam tidur : ..................................
 Di rumah sakit Malam ............-...............
Waktu tidur : Siang ..............-............... Jumlah jam tidur : ..................................
Masalah di RS : ( ) tidak ada ( ) terbangun dini ( ) mimpi buruk
( ) insomnia ( ) Lainnya, ...............................

4. Pola Nutrisi – Metabolik

a. Pola makan
Di rumah Di rumah sakit
Frekuensi : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Porsi : ......................... Porsi : ..................................
Pantangan : ......................... Diit khusus : ..................................
Makanan disukai : .........................
Nafsu makan di RS : ( ) normal ( ) bertambah ( ) berkurang
( ) mual ( ) muntah, .............. cc ( ) stomatitis
Kesulitan menelan : ( ) tidak ( ) ya
Gigi palsu : ( ) tidak ( ) ya
NG tube : ( ) tidak ( ) ya

b. Pola minum
Di rumah Di rumah sakit
Frekuensi : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Jumlah : ......................... Jumlah : ..................................
Pantangan : .........................
Minuman disukai : .........................

5. Pola Eliminasi
a. Buang air besar
Di rumah Di rumah sakit
Frekuensi : .................................. Frekuensi : ..................................
Konsistensi : .................................. Konsistensi : ..................................
Warna : .................................. Warna : ( ) kuning
( ) bercampur darah
( ) lainnya, ..............
Masalah di RS : ( ) konstipasi ( ) diare ( ) inkontinen
Kolostomi : ( ) tidak ( ) ya

b. Buang air kecil

Di rumah Di rumah sakit
Frekuensi : .................................. Frekuensi : ..................................
Konsistensi : .................................. Konsistensi : ..................................
Warna : .................................. Warna : ..................................
Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria
( ) retensi ( ) inkontinen
Kolostomi : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari

6. Pola Kognitif Perseptual

Berbicara : ( ) normal ( ) gagap ( ) bicara tak jelas
Bahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya, ....................................
Kemampuan membaca : ( ) bisa ( ) tidak
Tingkat ansietas : ( ) ringan ( ) sedang ( ) berat ( ) panik
Sebab, ...................................................................................................
Kemampuan interaksi : ( ) sesuai ( ) tidak, ...................................................................
Vertigo : ( ) tidak ( ) ya
 Nyeri : ( ) tidak ( ) ya

Bila ya, P : .................................................................................................................................

Q : .................................................................................................................................
R : .................................................................................................................................
S : .................................................................................................................................
T : .................................................................................................................................
7. Pola Konsep Diri
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8. Pola Koping
Masalah utama selama MRS (penyakit, biaya, perawatan diri)
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Kehilangan perubahan yang terjadi sebelumnya
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Kemampuan adaptasi
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9. Pola Seksual – Reproduksi

Menstruasi terakhir : .....................................................................................................................
Masalah menstruasi : .....................................................................................................................
Pap smear terakhir : .....................................................................................................................
Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidak
Masalah seksual yang berhubungan dengan penyakit : ...............................................................

10. Pola Peran – Hubungan

Pekerjaan :
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Kualitas bekerja :
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Hubungan dengan orang lain :
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Sistem pendukung :
( ) pasangan ( ) tetangga/teman ( ) tidak ada
( ) lainnya, .................................................................................
Masalah keluarga mengenai perawatan di RS : .............................................................................

11. Pola Nilai – Kepercayaan

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

IV. PENGKAJIAN PERSISTEM (Review of System)

1. Tanda-Tanda Vital
a. Suhu : ................... °C lokasi : ......................
b. Nadi : ...................  /menit irama : ...................... pulsasi : ......................
c. Tekanan darah : ................... mmHg lokasi : ......................
d. Frekuensi nafas : ...................  /menit irama : ......................
e. Tinggi badan : ................... cm
f. Berat badan : SMRS ................... kg MRS .................... kg
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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V. PEMERIKSAAN PENUNJANG
1. Laboratorium
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2. Photo
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3. Lain-lain
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VI. TERAPI
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Surabaya, .....................
Mahasiswa

(...............................)
 ANALISA DATA

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. RM : ..............................................

No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)

 PRIORITAS MASALAH

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. RM : ..............................................

Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama Perawat
 RENCANA KEPERAWATAN

No. Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi Rasional

 TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

Waktu Waktu Catatan Perkembangan

No. Tindakan TT TT
Tgl/jam Tgl/jam (SOAP)