LAPORAN KASUS

ASUHAN KEPERAWATAN PADA KLIEN DENGAN ...................................
DI ..................
Tanggal .............. s/d ..................

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

PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS LAMBUNG MANGKURAT
2011

....... Mengetahui....... Surabaya...... s/d ................................ 20..... Tanggal .................. .... Oleh : _________________________ NIM ..... DI ............... Penguji Pendidikan Penguji Lahan ______________________ ______________________ ...................................LEMBAR PENGESAHAN ASUHAN KEPERAWATAN PADA KLIEN DENGAN ......

.............................. ........................................................ Pekerjaan 10.... Susunan keluarga (genogram) : ......................................................................... ........................................ IDENTITAS 1....................... ................................................................................................................ Riwayat penyakit dahulu : ..................................... telp 11.................................................................................. Alamat dan no............. .....kamar : : : : ....................... Riwayat kesehatan keluarga : ............................................................................................................................. .................................................................... ............................................................................................................................................. ....................................................................................................................................................... ......................... 3................................................ 4........................................................................................................................................................... I....................................................................................................................................................................................................................... 5..................................................................... .... .................... .................. ....................................... Status 5.................................................. .. 2........................................................................................................................................ ............................................................................ Umur 3..................................................................................................... ........................................................................................................................................................ .................................................................. ......... Suku/bangsa 7............................................................................................................................. Jenis kelamin 4.................................................................................. .......................................................................................................................... ...............................................................PENGKAJIAN KEPERAWATAN ASUHAN KEPERAWATAN MEDIKAL BEDAH PSIK UNLAM Nama mahasiswa : ................................................................................................... ...................................................................................................................... Nama 2.................................................................................................................................................................................. II........................................................................................................................... ..................... ............................................................................................................................................ Pendidikan 9........................................ Riwayat penyakit sekarang : ................................................................................................................... RIWAYAT SAKIT DAN KESEHATAN 1....................................... Diagnosa medis : ......... ....................................................................... .................................. Penanggung jawab : : : : : : : : : : : Tgl/jam MRS No...................................... Keluhan utama : ............................ .................................................................................................................................................................................................................................................. Agama 6.................... ................... Tgl/jam pengkajian : ....................... RM Ruangan/kelas No................................. .......................................................................... Bahasa 8.....................................................

......................................................................................... .......... POLA FUNGSI KESEHATAN 1......................... Rekreasi .......................................-................ Pola Istirahat Dan Tidur Di rumah Di rumah sakit Waktu tidur : Siang ............................. ........................ Jumlah jam tidur : .... d..................................................................................................... Aktivitas sehari-hari ............... Olahraga : ( ) tidak ( ) ya ....... III................................................. ......................................................................... Waktu tidur : Siang ... Kemampuan perawatan diri Aktivitas 0 1 SMRS 2 3 4 0 1 MRS 2 3 4 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... .........................................................  /hr Mandi : .............................. Pola Aktivitas Dan Latihan a..............  /mgg Potong kuku : ...... e............................ Riwayat alergi : ........ 3............................................. Masalah di RS : ( ) tidak ada ( ) terbangun dini ( ) mimpi buruk ( ) insomnia ( ) Lainnya............................................................. 2..............  /hr Gosok gigi : .......................................... ....................................................................................................... Persepsi Terhadap Kesehatan (Keyakinan Terhadap Kesehatan & Sakitnya) ....................... ........................................................................  /mgg Potong kuku : ......  /hr Keramas : ................................................................-............................................................................................................................................................................................................................................................................... Malam ....................... Kebersihan diri Di rumah Di rumah sakit Mandi : .............................................................................................................................................. Malam ................................................  /mgg c...................-..................................................................................  /mgg Keramas : ........6.................................. Jumlah jam tidur : ..................................................... .........................................................................................................................-.............................  /hr Gosok gigi : .....................

..................... Pola minum Di rumah Frekuensi Jenis Jumlah Pantangan Minuman disukai : : : : : Di rumah sakit Frekuensi : .. 5.............. Porsi : .................... Diit khusus : ...... .. cc/hari 6.... Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria ( ) retensi ( ) inkontinen Kolostomi : ( ) tidak ( ) ya.................... Konsistensi : ................................... Jenis : ................... P Q R S T : : : : : ............ Jumlah : ............................................................................................................................................................. Warna : ( ) kuning ( ) bercampur darah ( ) lainnya....... .. Warna : .. ........... ...... ....... Porsi : .......................... Pola makan Di rumah Frekuensi : ............................4............................... ............................................................................ .......................................... Vertigo : ( ) tidak ( ) ya Nyeri : ( ) tidak ( ) ya Bila ya. ........................................................ ...................................................... ( ) inkontinen b............................................................. Kemampuan interaksi : ( ) sesuai ( ) tidak................. Pola Kognitif Perseptual Berbicara : ( ) normal ( ) gagap ( ) bicara tak jelas Bahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya................................................................... ( ) bertambah ( ) muntah................................................... cc ) ya ) ya ) ya ............ Nafsu makan di RS : ( ) normal ( ) mual Kesulitan menelan : ( ) tidak ( Gigi palsu : ( ) tidak ( NG tube : ( ) tidak ( b.............................................. Masalah di RS : ( ) konstipasi ( ) diare Kolostomi : ( ) tidak ( ) ya ( ) berkurang ( ) stomatitis Di rumah sakit Frekuensi : ........... produksi : ........................ ............................. Makanan disukai : ........................................................................................................... Warna : ...................................................... ...................................... ........................ Konsistensi : ... Jenis : ............... Frekuensi : ......................................................................................... ................... Buang air besar Di rumah Frekuensi : .............. Pola Eliminasi a................. Warna : ............................................ Buang air kecil Di rumah Di rumah sakit Frekuensi : .............................................................................................. Konsistensi : ..................................................... ...................... Kemampuan membaca : ( ) bisa ( ) tidak Tingkat ansietas : ( ) ringan ( ) sedang ( ) berat ( ) panik Sebab.......... kateter .......................... Pola Nutrisi – Metabolik a.... Konsistensi : .... Di rumah sakit Frekuensi : .................................................................................... Pantangan : ................. Jenis : ................................................................................

................................................................................................................................................................................................................................................................. ............................................................ e............................. ......  /menit irama : ............................................................. ( ) tidak ( ) ya IV.......................................................................................................................................... ........... Masalah keluarga mengenai perawatan di RS : ................................................. 2.................................................................................... ................. Pola Nilai – Kepercayaan Agama Pelaksanaan ibadah Pantangan agama Meminta kunjungan rohaniawan : : : : ........................................................................................................................................................................ ................................................................................. c....................................................................................................................................................................7............................................................................................................................................ biaya.............................. .................. ( ) tidak ( ) ya............................................................. 11............. Berat badan : SMRS ............................................................................... mmHg lokasi : ......................................................................... ........................ ......................... Tanda-Tanda Vital a.............................................................................................................................  /menit irama : ..................................... .............................. perawatan diri) ......................... d................................................ kg pulsasi : .................. ........................... ...... Masalah menstruasi : . 8........................................................................................... Kehilangan perubahan yang terjadi sebelumnya ............................. °C lokasi : ............................... .................................... 9............................................................... Pola Peran – Hubungan Pekerjaan Kualitas bekerja Hubungan dengan orang lain Sistem pendukung : : : : ................................................................................................................................................................................... . 10.................... Suhu : ......................................................................................................... ............................................................................................................................................................................... kg MRS ............................................... Pola Koping Masalah utama selama MRS (penyakit................... b.......................................................................................... cm f................................................................ Pola Konsep Diri .................................................... Nadi : .......................................................................... Tinggi badan : ............................................................................................................................................ .............................................................................................................................................................................................................. ................................................................................................................... Sistem Pernafasan (Breath) ..................................................................................................................................................................................... ....... Frekuensi nafas : ............... Pola Seksual – Reproduksi Menstruasi terakhir : ........ Pap smear terakhir : ..................................... ( ) pasangan ( ) tetangga/teman ( ) tidak ada ( ) lainnya........... .. Tekanan darah : ............................................................................................................................................................................................................................... Kemampuan adaptasi ........................... PENGKAJIAN PERSISTEM (Review of System) 1............ Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidak Masalah seksual yang berhubungan dengan penyakit : .................................

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

................................................................... ............................................................................................................................................................................................................................................................ ............................... .......................................................................... Mahasiswa (........................................................................................... .. Photo rontgen ................................................................................. .................................... ... ................................................................................................................................................................... ................................................................. .............. ............................................................................................................................ ....................................................................................................................................................................................................................................................................................................... ................. .......................................... Laboratorium ....................................................................................................................................................................................................... PEMERIKSAAN PENUNJANG 1................................................................................................................... .............. 2...................................................... ............................................................................. ............................................................................................................................................................................................................................................ ....................... .......................................................................................................) ....................................................................................................................................................................................................................... ..................... ................................................................................................................................................................................. Surabaya.................................................................................................................................................................................................... .................................................................. VI........................................................................................................................................................................................................V............................................................................................................................................................. 3.. TERAPI .................................................................................................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................................................................................................................................................................................... Lain-lain ........................................................................................................................................................................................................................ ....................................................................... ........................................................................................................................................................................................ .....

................ RM : ............. Data (Symptom) Ruangan/kamar : ....... Penyebab (Etiologi) Masalah (Problem) ...............ANALISA DATA Nama klien Umur No............................................... : ....................................................... No................. : .................

. No.........PRIORITAS MASALAH Nama klien Umur No......................................... Masalah Keperawatan Ruangan/kamar : ....................................................................... : ..................... Tanggal Ditemukan Teratasi Paraf (Nama Perawat .. RM : ....................................... : ...

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 .