LAPORAN KASUS

PENGKAJIAN KEPERAWATAN

ASUHAN KEPERAWATAN MEDIKAL BEDAH

STIKES HANG TUAH SURABAYA

Nama mahasiswa:......................................Tgl/jam pengkajian:......................................Diagnosa medis:......................................

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

I. IDENTITAS1. 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 KESEHATAN

1. 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 mampuAlat bantu : ( ) tidak ( ) kruk ( ) tongkat

( ) pispot disamping tempat tidur ( ) kursi roda

b. Kebersihan diriDi rumah

Mandi :....................../hrGosok gigi:....................../hrKeramas:................../mggPotong kuku:................../mggDi rumah sakit

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

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

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

Potong kuku:................../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:.......................Di rumah sakit

Frekuensi:................................Jenis:................................Porsi:................................Diit khusus:................................

Nafsu makan di RS:( ) normal ( ) bertambah ( ) berkurang

( ) mual ( ) muntah, .............. cc ( ) stomatitisKesulitan menelan:( ) tidak ( ) yaGigi palsu:( ) tidak ( ) yaNG tube:( ) tidak ( ) yab. Pola minum

Di rumahFrekuensi:.......................

Jenis:.......................

Jumlah:.......................

Pantangan:.......................

Minuman disukai:.......................

Di rumah sakit

Frekuensi:................................

Jenis:................................

Jumlah:................................

5. Pola Eliminasi

a. Buang air besar

Di rumah

Frekuensi:................................Konsistensi:................................Warna:................................Di rumah sakit

Frekuensi:................................Konsistensi:................................Warna:( ) kuning ( )bercampur darah ( ) lainnya, ...........

Masalah di RS:( ) konstipasi ( ) diare ( ) inkontinenKolostomi :( ) tidak ( ) yab. Buang air kecil

Di rumah

Frekuensi:................................

Konsistensi:................................

Warna:................................

Di rumah sakit

Frekuensi:................................

Konsistensi:................................

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 jelasBahasa sehari-hari:( ) Indonesia( ) Jawa( ) lainnya, .................................Kemampuan membaca:( ) bisa( ) tidakTingkat ansietas:( ) ringan( ) sedang( ) berat( ) panik

Sebab, ..............................................................................................

Kemampuan interaksi:( ) sesuai( ) tidak, ..............................................................Vertigo:( ) tidak( ) yaNyeri:( ) tidak( ) yaBila 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 ( ) tidakMasalah 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:( ) tidak ( ) ya, ...........................................................Meminta kunjungan rohaniawan:( ) tidak ( ) yaIV. PENGKAJIAN PERSISTEM (Review of System)1. Tanda-Tanda Vital

a. Suhu:...................Clokasi : ......................b. Nadi:...................

/menitirama : ......................pulsasi : .................c. Tekanan darah:...................mmHg lokasi : ......................d. Frekuensi nafas:...................

/menit irama : ......................e. Tinggi badan:...................cmf. Berat badan:SMRS ................... kgMRS .................... kg2. Sistem Pernafasan (Breath)

Irama pola napas: ( ) Reguler ( ) Irreguler

Ket: ..........................................Jenis

: ( ) Normal ( ) Kusmaul( ) Cepat dangkal

Suara napas

: ( ) Vesikuler ( ) Bronkovesikuler

( ) Wheezing ( ) Stidor

( ) Ronkhi

Ket: ...................................................................................................

Sesak napas: ( ) Tidak ada( ) Ada

Jika ada ( ) ada ketika aktivitas( ) ada ketika istirahat

( ) orthopnea

Alat bantu napas: ( ) Tidak ada( ) Ada

Jenis

: ..............................................................................................................

Lain-lain

: ...........................................................................................................

Masalah Keperawatan : .............................................................................................................3. Sistem Kardiovaskuler (Blood)

Irama jantung: ( ) Reguler

( ) IrregulerNyeri dada: ( ) Tidak ada( ) Ada

Bunyi jantung: ( ) S1, S2 tunggal( ) Murmur( ) Gallop

CRT

: ( ) 2detik

Akral

: ( ) HKM

( ) Dingin( ) Lembab( ) Basah

Masalah Keperawatan : .............................................................................................................4. Sistem Persarafan (Brain)

GCS

: ( ) Eye( ) Verbal( ) MotorikRefleks Fisiologis : ( ) Patella( ) Kremaster

( ) Trisep

( ) Bisep

( ) Cahaya : /

Refleks Patologis : ( ) Babinsky( ) Brudzunky( ) Kernig

Istirahat tidur: ....... jam/hari

Gangguan tidur : ( ) Insomnia( ) Lain-lain ...............

Ket: ................................................................................................................

Pupil

: ( ) Isokor( ) Anisokor

Sklera konjungtiva: ( ) Anemis( ) Ikterus

Gangguan penglihatan : ( ) Ya( ) Tidak

Gangguan pendengaran : ( ) Ya( ) Tidak

Gangguan penciuman : ( ) Ya( ) Tidak

Masalah Keperawatan: ..............................................................................................................5. Sistem Perkemihan (Bladder)

Kebersihan: ( ) Bersih( ) KotorJumlah urine: ........ cc/hari

Alat bantu: ( ) Kateter( ) Pispot( ) Tidak ada

Kandung kemih : ( ) Membesar( ) Nyeri tekan( ) Normal

Gangguan miksi : ( ) Anuria

( ) Disuria

( ) Hematuria

( ) Inkontinensia( ) Retensi

( ) Nokturia

Masalah Keperawatan : .............................................................................................................6. Sistem Pencernaan (Bowel)

Nafsu makan: ( ) Baik ( ) MenurunFrekuensi: .......... kali/hari

Porsi

: ( ) Habis( ) TidakKet: .................................................................

Minum

: ........... cc/hariMulut dan TenggorokanMulut

: ( ) Bersih( ) Kotor

Mukosa: ( ) Lembab( ) Kering( ) Stomatitis

Abdomen

Perut

: ( ) Tegang( ) Kembung( ) Acites( ) Nyeri tekan

Peristaltik: ........ kali/menit

Pembesaran Hepar : ( ) Ya( ) Tidak

Pembesaran Lien : ( ) Ya( ) Tidak

BAB

: ....... kali/hari

( ) Teratur( ) Tidak

Konsistensi : .........................Warna: ..................................

Bau: ...................................

Hematesesis : ( ) Ada( ) Tidak

Melena : ( ) Ada( ) Tidak

Masalah Keperawatan : .............................................................................................................7. Sistem Muskuloskeletal (Bone)

Kemampuan pergerakan sendi : ( ) Bebas( ) TerbatasKekuatan otot :

8. Sistem Integumen

Turgor

: ( ) Baik( ) Sedang( ) JelekEdema

: ( ) Ada( ) Tidak ada

Lokasi : .....................................................................................

Warna kulit: ( ) Ikterus( ) Sianotik( ) Hiperpigmentasi

( ) Pucat( ) Bersisik( ) Kemerahan

( ) Normal

Masalah Keperawatan : ........................................................................................................9. Sistem Penginderaan

Mata................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Hidung

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

................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................10. EndokrinPembesaran tyroid : ( ) Ya( ) Tidak

Hiperglikemia

: ( ) Ya( ) Tidak

Hipoglikemia

: ( ) Ya( ) Tidak

Luka gangren

: ( ) Ada( ) Tidak ada

Lokasi : ...............................................................................................

Lain-lain : ............................................................................................11. Sistem Reproduksi dan Genetalia....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................V. PEMERIKSAAN PENUNJANG

1. 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.Waktu

Tgl/jamTindakanTTWaktu

Tgl/jamCatatan Perkembangan

(SOAP)TT

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No.Waktu

Tgl/jamTindakanTTWaktu

Tgl/jamCatatan Perkembangan

(SOAP)TT

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No.Waktu

Tgl/jamTindakanTTWaktu

Tgl/jamCatatan Perkembangan

(SOAP)TT

_1338661286.unknown

_1338661308.unknown

_1339135512.unknown

_1338661235.unknown

_1338661257.unknown