LAPORAN KASUS

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

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 PADA KLIEN DENGAN ...................................
DI .................. RUMKITAL Dr. RAMELAN SURABAYA
Tanggal .............. s/d ..................

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

Mengetahui,

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

Penguji Pendidikan

Penguji Lahan

______________________

______________________

PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN PSIKOSOSIAL
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
:
11. Penanggung
:

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

dan

no.

telp
jawab

II. POLA PERSEPSI KESEHATAN ATAU PENANGANAN KESEHATAN

1. Keluhan utama :
.........................................................................................................................................................
.........................................................................................................................................................
2. Riwayat penyakit sekarang :
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
3. Lamanya keluhan
.........................................................................................................................................................
.........................................................................................................................................................
4. Faktor yang Memperberat
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
5. Upaya yang Dilakukan Untuk Mengatasi Keluhan

.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
6. Riwayat penyakit dahulu :
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
7. Persepsi klien tentang status kesehatan dan kesejahteraan
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

8. Riwayat kesehatan keluarga :

.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
9. Susunan keluarga (genogram) :

10. Riwayat alergi :

.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
III. POLA NUTRISI DAN METABOLIK
1. 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 (
2. Pola minum
Di rumah
Frekuensi
Jenis
Jumlah
Pantangan
Minuman disukai

:
:
:
:
:

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

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

IV. POLA ELIMINASI

1. Buang air besar
Di rumah
Frekuensi
: ..................................
Konsistensi
: ..................................
Warna
: ..................................
Masalah di RS
Kolostomi

: ( ) konstipasi ( ) diare
: ( ) tidak ( ) ya

:
:
:
:

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

( ) berkurang
( ) stomatitis

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

Di rumah sakit
Frekuensi
Konsistensi
Warna
(
(
( ) inkontinen

: ..................................
: ..................................
: ( ) kuning
) bercampur darah
) lainnya, ..............

2. Buang air kecil

Di rumah
Di rumah sakit
Frekuensi
: ..................................
Frekuensi
: ..................................
Jumlah
: ..................................
Jumlah
: ..................................
Warna
: ..................................
Warna
: ..................................
Masalah di RS
: ( ) disuria ( ) nokturia
( ) hematuria
( ) retensi ( ) inkontinen
Kateter
: ( ) tidak
( ) ya, kateter ........................... produksi : .................. cc/hari
V. POLA AKTIVITAS DAN LATIHAN
1. Kemampuan perawatan diri
Aktivitas

SMRS
1
2
3

MRS
1
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
2. 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
3. Aktivitas sehari-hari
.........................................................................................................................................................
4. Rekreasi
.........................................................................................................................................................
.........................................................................................................................................................
5. Olahraga : ( ) tidak ( ) ya
.........................................................................................................................................................
VI. POLA ISTIRAHAT DAN TIDUR
Di rumah
Di rumah sakit
Waktu tidur
: Siang ..............-...............
Waktu tidur
: Siang ..............-...............
Malam ............-...............
Malam ............-...............
Jumlah jam tidur : .......................................
Jumlah jam tidur : .......................................
Masalah di RS :
( ) tidak ada ( ) terbangun dini ( ) mimpi buruk

insomnia

VII. POLA KOGNITIF DAN PERSEPTUAL

Berbicara
: ( ) normal
( ) gagap
Bahasa sehari-hari
: ( ) Indonesia ( ) Jawa
Kemampuan membaca
Tingkat ansietas

: ( ) bisa
: ( ) ringan
Sebab,

( ) tidak
( ) sedang

Kemampuan interaksi

: ( ) sesuai

Vertigo
Nyeri

: ( ) tidak
: ( ) tidak

( ) ya
( ) ya

( ) bicara tak jelas

(
)
( ) berat

Lainnya,

lainnya,

( ) panik
)

tidak,

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
:
.........................................................................................................................................
Masalah
keperawatan
:
............................................................................................................................................................
2. Role/peran
( ) overload peran
( ) perubahan peran
( ) transisi peran karena sakit
( ) konflik peran
( ) keraguan peran
Jelaskan
:
........................................................................................................................................
Masalah
keperawatan
:
..................................................................................................................................................................
3. Identity/identitas diri
( ) kurang percaya diri
( ) merasa terkekang

( ) tidak mampu menerima perubahan

( ) merasa kurang memiliki potensi
Jelaskan

( ) kurang mampu menentukan pilihan

( ) menolak menjadi tua
:

........................................................................................................................................
Masalah
keperawatan
:
..................................................................................................................................................................
4. Self esteem/harga diri
( ) mengkritik diri sendiri dan orang lain
( ) menyangkal kepuasan diri
( ) merasa jadi orang penting
( ) polarisasi pandangan hidup
( ) menunda tugas
( ) mencemooh diri
( ) merusak diri
( ) mengecilkan diri
( ) menyangkal kemampuan pribadi
( ) keluhan fisik
( ) rasa bersalah
( ) menyalahgunakan zat
Jelaskan
:
........................................................................................................................................
Masalah
keperawatan
:
..................................................................................................................................................................
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 :
...........................................................................................................................................
Masalah
keperawatan
:
.....................................................................................................................................................................
IX. POLA PERAN DAN HUBUNGAN
Pekerjaan
:
Kualitas bekerja

Hubungan dengan orang lain

Sistem pendukung

:
: ( ) pasangan
(

Masalah

keluarga

mengenai

( ) tetangga/teman
perawatan

( ) tidak ada
)
di

RS

lainnya,
:

X. POLA SEKSUALITAS / REPRODUKSI

Menstruasi terakhir
:
Masalah menstruasi

Pap smear terakhir

Pemeriksaan payudara/testis sendiri tiap bulan

Masalah seksual yang berhubungan dengan penyakit

: ( ) ya
:

( ) tidak

XI. POLA KOPING / TOLERANSI STRESS

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

.........................................................................................................................................................
.........................................................................................................................................................
XII. POLA NILAI / KEPERCAYAAN
Agama
:
Pelaksanaan ibadah
:
Pantangan agama
:
Meminta kunjungan rohaniawan
:

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

XIII. 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 ................... kgMRS ....................
kg
2. Sistem Pernafasan (Breath)
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
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
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

XIV. PEMERIKSAAN PENUNJANG

1. Laboratorium
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
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.........................................................................................................................................................
2. Photo
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3. Lain-lain
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
XV. TERAPI
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
...............................................................................................................................................................
XVI. POHON MASALAH

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