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