LAPORAN KASUS (ASUHAN KEPERAWATAN)

Nama mahasiswa : …………………………………………

Hari, Tgl, Jam pengkajian : …………………………………………

Sumber data : ................................................................

I. Identitas
a. Pasien
Nama (Inisial) : ........................................................................................

Umur/tgl lahir : ........................................................................................

Jenis kelamin : ........................................................................................

Status perkawinan : ........................................................................................

Agama : ........................................................................................

Pekerjaan : ........................................................................................

Alamat : ........................................................................................

Tanggal masuk : ........................................................................................

Diagnosis medis : ........................................................................................

b. Penanggung jawab
Nama (Inisial) : ........................................................................................

Umur : ........................................................................................

Alamat : ........................................................................................

Pekerjaan : ........................................................................................

Hubungan dg pasien : ........................................................................................

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II. Riwayat Kesehatan
a. Keluhan utama
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b. Alasan dibawa ke RS
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c. Riwayat Penyakit Sekarang

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d. Riwayat Kesehatan Dahulu

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e. Riwayat Kesehatan Keluarga

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 Genogram

f. Riwayat Kesehatan Lingkungan

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g. Riwayat Psikososial dan Kultur

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III. Pemeriksaan Fisik

a. Keadaan umum : ................................
Tingkat kesadaran : ......................., GCS: E... M... V...

Suhu tubuh : ............ 0C per aksila/ rektal/ oral

Nadi : .......................................................................................

Pernafasan : .......................................................................................

Tekanan darah : ......../.......... mmHg

BB / TB : ......................................................................................

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b. Pemeriksaan Fisik (Head to Toe)
i. Kepala: ..........................................................................................................
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ii. Mata: ..............................................................................................................
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iii. Hidung: ..........................................................................................................
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iv. Telinga: ..........................................................................................................
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v. Mulut: ............................................................................................................
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vi. Leher: ............................................................................................................
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vii. Thorak: ..........................................................................................................
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Paru:
Inspeksi: .................................................................................................

Palpasi: ..................................................................................................

Perkusi: ...................................................................................................

Auskultasi: .............................................................................................

Jantung :

Inspeksi: ...............................................................................................

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 Palpasi: ....................................................................................................

Perkusi: ....................................................................................................

Auskultasi: ...............................................................................................

Payudara: .......................................................................................................
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Punggung: ......................................................................................................
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viii. Abdomen (Inspeksi, auskultasi, perkusi dan palpasi)

Inspeksi: ........................................................................................................
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Auskultasi: .....................................................................................................

Perkusi: ..........................................................................................................

Palpasi: ..........................................................................................................
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ix. Inguinal
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x. Genital
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xi. Ekstremitas (termasuk keadaan kulit, kuku dan kekuatan)

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IV. Pengkajian Pola Fungsional (11 pola fungsional Gordon)

a. Pola Persepsi dan Managemen terhadap Kesehatan
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b. Pola Nutrisi dan Metabolik (sebelum dan selama sakit)

1. Program Diit di RS: ..................................................................................

2. Intake
Makanan: .................................................................................................
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3. Intake cairan: ............................................................................................

4. Berat badan 6 bulan terakhir: ..................................................................

c. Pola Eliminasi
a. BAB (Buang Air Besar)
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b. BAK (Buang Air Kecil)
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d. Pola Aktifitas dan Latihan

Kemampuan perawatan diri 0 1 2 3 4

Makan /minum

Mandi

Toileting

Berpakaian

Mobilitas di tempat tidur

Berpindah

Ambulasi / ROM

0 : mandiri, 1: alat bantu, 2 : dibantu orang lain, 3 : dibantu orang lain dan alat,

4 : tergantung total
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 Oksigenasi : ........................................................................................................

e. Pola Istirahat dan Tidur

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f. Pola Persepsi dan Kognitif

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g. Pola Persepsi dan Konsep diri

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h. Pola Peran dan Hubungan

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i. Pola Seksual dan reproduksi

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j. Pola Koping dan Toleransi terhadap Stress

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k. Pola Nilai dan Kepercayaan

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V. Data Penunjang
a. Program terapi (tulis mulai dr masuk RS, nama obat dan dosisnya)
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b. Hasil pemeriksaan laborat, radiologi dan penunjang lainnya

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VI. Analisa Data (berdasarkan SDKI)
Hari/tanggal/ D a t a Fokus Problem Etiologi Nama dan
Jam Tanda
tangan

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Prioritas Masalah:

1. ……………………………………………………………………………………………………………………………………………

2. ……………………………………………………………………………………………………………………………………………

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4. ……………………………………………………………………………………………………………………………………………

5. ……………………………………………………………………………………………………………………………………………

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VII. RENCANA TINDAKAN KEPERAWATAN

Nama : No Reg :
Diagnosa Medis : Ruang :
Rencana Tindakan Nama &
No Hr/tgl/jam Diagnosa Kep Tujuan (SLKI) Intervensi (SIKI) Tanda
tangan

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 IMPLEMENTASI DAN EVALUASI

Tanggal / jam No Implementasi Evaluasi Nama dan

Diagnosa Tanda tangan
Kep

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