LAPORAN KASUS

LAPORAN KASUS

ASUHAN KEPERAWATAN PADA KLIEN DENGAN

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

Oleh :_________________________NIM ...............................

PROGRAM STUDI PROFESI NERS KEPERAWATANSEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYATA. 2014/2015LEMBAR PENGESAHAN

ASUHAN KEPERAWATAN PADA KLIEN DENGAN

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

Oleh :_________________________NIM .............................

Surabaya, November 2014Menyetujui,Penguji Pendidikan

_______________________Penguji Lahan

_________________________

Mengetahui,Penanggung Jawab Ruang Perawatan Mutiara

___________________________

PENGKAJIAN KEPERAWATANASUHAN KEPERAWATAN MEDIKAL BEDAHSTIKES HANG TUAH SURABAYA

Nama mahasiswa:......................................Tgl/jam pengkajian:......................................Diagnosa medis:............................................................................Tgl/jam MRS:......................................No. RM:......................................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 KESEHATAN1. Keluhan utama :...........................................................................................................................................2. Riwayat penyakit sekarang :.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................ ............................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Riwayat penyakit dahulu :...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................4. Riwayat kesehatan keluarga :....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................5. Susunan keluarga (genogram) :

6. Riwayat alergi :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

III. POLA FUNGSI KESEHATAN1. Persepsi Terhadap Kesehatan (Keyakinan Terhadap Kesehatan & Sakitnya)............................................................................................................................................................................................................................................................................................................................................................................................................................................................

2. Pola Aktivitas Dan Latihana. Kemampuan perawatan diriAktivitasSMRSMRS

0123401234

Mandi

Berpakaian/berdandan

Eliminasi/toileting

Mobilitas di tempat tidur

Berpindah

Berjalan

Naik tangga

Berbelanja

Memasak

Pemeliharaan rumah

Skor

0 = mandiri1 = alat bantu2 = dibantu orang lain3 = dibantu orang lain & alat4 = tergantung/tidak mampu

Alat bantu : ( ) tidak ( ) kruk ( ) tongkat( ) pispot disamping tempat tidur ( ) kursi roda

b. Kebersihan diri

Di rumah

Mandi :.............../hr

Gosok gigi:.............../hr

Keramas:................../mgg

Potong kuku:................./mggDi rumah sakit

Mandi :.............../hr

Gosok gigi:.............../hr

Keramas:................./mgg

Potong kuku:................../mggc.

d. Aktivitas sehari-hari..............................................................................................................................................e. Rekreasi..............................................................................................................................................f. Olahraga : ( ) tidak ( ) ya..............................................................................................................................................

3. Pola Istirahat Dan Tidur

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

4. Pola Nutrisi Metabolika. b. Pola makan

Di rumahFrekuensi:.......................Jenis:......................Porsi:......................Pantangan:....................Makanan disukai:.......................Di rumah sakitFrekuensi:.......................Jenis:.......................Porsi:.......................Diit khusus:.......................Nafsu makan di RS:( ) normal ( ) bertambah ( ) berkurang( ) mual ( ) muntah, .............cc ( ) stomatitisKesulitan menelan:( ) tidak ( ) yaGigi palsu:( ) tidak ( ) yaNG tube:( ) tidak ( ) ya

c. Pola minum

Di rumahFrekuensi:.......................Jenis:.......................Jumlah:......................Pantangan:.......................Minuman disukai:.......................Di rumah sakitFrekuensi:.........................Jenis:...............................Jumlah:..............................

5.

6. Pola Eliminasia. Buang air besar

Di rumahFrekuensi:............................Konsistensi:..............................Warna:...............................

Di rumah sakitFrekuensi:................................Konsistensi:...............................Warna:( ) kuning ( ) bercampur darah ( ) lainnya, ...........Masalah di RS:( ) konstipasi ( ) diare ( ) inkontinenKolostomi :( ) tidak ( ) ya

b. Buang air kecil

Di rumahFrekuensi:..............................Konsistensi:...............................Warna:...............................Di rumah sakitFrekuensi:..............................Konsistensi:..............................Warna:...............................

Masalah di RS:( ) disuria( ) nokturia( ) hematuria( ) retensi( ) inkontinenKolostomi :( ) tidak( ) ya, kateter ................... produksi : ............... cc/hari

7. Pola Kognitif PerseptualBerbicara:( ) normal( ) gagap( ) bicara tak jelasBahasa sehari-hari:( ) Indonesia( ) Jawa( ) lainnya, .........................Kemampuan membaca:( ) bisa( ) tidakTingkat ansietas:( ) ringan( ) sedang( ) berat( ) panikSebab, ............................................................................................Kemampuan interaksi:( ) sesuai( ) tidak, ..........................................................Vertigo:( ) tidak( ) yaNyeri:( ) tidak( ) ya

Bila ya, P:............................................................................................................................Q:............................................................................................................................R:............................................................................................................................S:............................................................................................................................T:............................................................................................................................8. Pola Konsep Diri................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9. Pola KopingMasalah utama selama MRS (penyakit, biaya, perawatan diri)........................................................................................................................................................................................................................................................................................................Kehilangan perubahan yang terjadi sebelumnya........................................................................................................................................................................................................................................................................................................Kemampuan adaptasi............................................................................................................................................................................................................................................................................................................................................................................................................................................................10. Pola Seksual ReproduksiMenstruasi terakhir:................................................................................................................Masalah menstruasi:...............................................................................................................Pap smear terakhir:..............................................................................................................Pemeriksaan payudara/testis sendiri tiap bulan: ( ) ya ( ) tidakMasalah seksual yang berhubungan dengan penyakit:..........................................................

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

12. Pola Nilai Kepercayaan Agama:.........................................................................................Pelaksanaan ibadah:......................................................................................Pantangan agama:( ) tidak ( ) ya, ...........................................................Meminta kunjungan rohaniawan:( ) tidak ( ) ya

IV. PENGKAJIAN PERSISTEM (Review of System)1. Tanda-Tanda Vitala. Suhu:....... Clokasi : ............b. Nadi:......./menitirama : .............pulsasi : ...................c. Tekanan darah:......mmHg lokasi : .............d. Frekuensi nafas:....../menit irama : ..............e. Tinggi badan:......cmf. 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 PenginderaanMata............................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hidung............................................................................................................................................................................................................................................................................................................................................................................................................................................................

Telinga............................................................................................................................................................................................................................................................................................................................................................................................................................................................

10. Sistem Reproduksi Dan Genetalia........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

V. PEMERIKSAAN PENUNJANG1. Laboratorium........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Photo........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................3. Lain-lain............................................................................................................................................................................................................................................................................................................................................................................................................................................................

VI. TERAPI......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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

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

Nama klien:........................................Umur:........................................Ruangan/kamar:.........................................No. RM:.........................................

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

PRIORITAS MASALAH

Nama klien:.......................................Umur:.......................................Ruangan/kamar:..........................................No. RM:..........................................

No.Masalah KeperawatanTanggalParaf(Nama Perawat

DitemukanTeratasi

RENCANA KEPERAWATAN

No.Diagnosa KeperawatanTujuan Dan Kriteria HasilIntervensiRasional

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No.WaktuTgl/jamTindakanTTWaktuTgl/jamCatatan Perkembangan(SOAP)TT