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 pengkajian : ........................................
Diagnosa medis
: ........................................
........................................

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

:
:
:
:
:
:
:
:
:
:
:

Tgl/jam MRS
No. RM
Ruangan/kelas
No.kamar

:
:
:
:

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

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

II. RIWAYAT SAKIT DAN KESEHATAN

1. Keluhan utama :
.........................................................................................................................................................
2. Riwayat penyakit sekarang :
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
3. Riwayat penyakit dahulu :
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
4. Riwayat kesehatan keluarga :
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
5. Susunan keluarga (genogram) :

6. Riwayat alergi :
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
III. POLA FUNGSI KESEHATAN
1. Persepsi Terhadap Kesehatan (Keyakinan Terhadap Kesehatan & Sakitnya)
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
2. Pola Aktivitas Dan Latihan
a. Kemampuan perawatan diri
Aktivitas

SMRS
2
3

MRS
2
3

Mandi
Berpakaian/berdandan
Eliminasi/toileting
Mobilitas di tempat tidur
Berpindah
Berjalan
Naik tangga
Berbelanja
Memasak
Pemeliharaan rumah
Skor

0 = mandiri
1 = alat bantu
2 = dibantu orang lain

3 = dibantu orang lain & alat

4 = tergantung/tidak mampu

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
...................................................................................................................................................
d. Rekreasi
...................................................................................................................................................
e. Olahraga : ( ) tidak ( ) ya
...................................................................................................................................................
3. Pola Istirahat Dan Tidur
Di rumah
Waktu tidur : Siang ..............-...............
Malam ............-...............

Jumlah jam tidur : ..................................

Di rumah sakit
Waktu tidur : Siang ..............-...............

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

4. Pola Nutrisi Metabolik

a. Pola makan
Di rumah
Frekuensi
: .........................
Jenis
: .........................
Porsi
: .........................
Pantangan
: .........................
Makanan disukai : .........................
Nafsu makan di RS : ( ) normal
( ) mual
Kesulitan menelan : ( ) tidak (
Gigi palsu
: ( ) tidak (
NG tube
: ( ) tidak (
b. Pola minum
Di rumah
Frekuensi
Jenis
Jumlah
Pantangan
Minuman disukai

:
:
:
:
:

Di rumah sakit
Frekuensi : ..................................
Jenis
: ..................................
Porsi
: ..................................
Diit khusus : ..................................
( ) bertambah
( ) muntah, .............. cc
) ya
) ya
) ya

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

5. Pola Eliminasi
a. Buang air besar
Di rumah
Frekuensi : ..................................
Konsistensi : ..................................
Warna
: ..................................
Masalah di RS : ( ) konstipasi ( ) diare
Kolostomi
: ( ) tidak ( ) ya

( ) berkurang
( ) stomatitis

Di rumah sakit
Frekuensi : ..................................
Jenis
: ..................................
Jumlah
: ..................................

Di rumah sakit
Frekuensi : ..................................
Konsistensi : ..................................
Warna
: ( ) kuning
( ) bercampur darah
( ) lainnya, ..............
( ) inkontinen

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
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
8. Pola Koping
Masalah utama selama MRS (penyakit, biaya, perawatan diri)
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
Kehilangan perubahan yang terjadi sebelumnya
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
Kemampuan adaptasi
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
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
Kualitas bekerja
Hubungan dengan orang lain
Sistem pendukung

:
:
:
:

......................................................................................................
......................................................................................................
......................................................................................................
( ) pasangan ( ) tetangga/teman ( ) tidak ada
( ) lainnya, .................................................................................
Masalah keluarga mengenai perawatan di RS : .............................................................................

11. Pola Nilai Kepercayaan

Agama
Pelaksanaan ibadah
Pantangan agama
Meminta kunjungan rohaniawan

:
:
:
:

................................................................................................
................................................................................................
( ) tidak ( ) ya, ................................................................
( ) tidak ( ) ya

IV. PENGKAJIAN PERSISTEM (Review of System)

1. Tanda-Tanda Vital
a. Suhu :
................... C
lokasi : ......................
b. Nadi :
................... /menit irama : ......................
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)

pulsasi : ......................

.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
3. Sistem Kardiovaskuler (Blood)
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
4. Sistem Persarafan (Brain)
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
5. Sistem Perkemihan (Bladder)
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
6. Sistem Pencernaan (Bowel)
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
7. Sistem Muskuloskeletal (Bone)
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
8. Sistem Integumen
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
9. Sistem Penginderaan
Mata
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
Hidung
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
Telinga
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
10. Sistem Reproduksi Dan Genetalia

.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
V. PEMERIKSAAN PENUNJANG
1. Laboratorium
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
2. Photo
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
3. Lain-lain
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
VI. TERAPI
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................

Surabaya, .....................
Mahasiswa

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

ANALISA DATA
Nama klien
Umur
No.

: ..............................................
: ..............................................
Data (Symptom)

Ruangan/kamar : ..............................................
No. RM
: ..............................................

Penyebab (Etiologi)

Masalah (Problem)

PRIORITAS MASALAH
Nama klien
Umur
No.

: ..............................................
: ..............................................
Masalah Keperawatan

Ruangan/kamar : ..............................................
No. RM
: ..............................................
Tanggal

Ditemukan

Teratasi

Paraf
(Nama Perawat

RENCANA KEPERAWATAN
No.

Diagnosa Keperawatan

Tujuan Dan Kriteria Hasil

Intervensi

Rasional

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No.

Waktu
Tgl/jam

Tindakan

TT

Waktu
Tgl/jam

Catatan Perkembangan
(SOAP)

TT