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LAPORAN KASUS
ASUHAN KEPERAWATAN
PADA KLIEN DENGAN_____________________
DI RUANG ______________RS_______________________
Oleh:
______________________
NIM. P17420612______
POLITEKNIK KESEHATAN KEMENKES SEMARANG
JURUSAN KEPERAWATAN
PROGRAM STUDI DIV KEPERAWATAN KARDIOVASKULER
SEMARANG 2013
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ASUHAN KEPERAWATAN PADA Ny. /Tn.
DENGAN
DI RUANG ___________________ RS_____________________________SEMARANG
Tanggal Masuk : _____________ Tanggal Pengkajian : _____________
Jam : _____________ Jam : _____________
No. RM : _____________ Diagnosa Medis : _____________
IDENTITAS KLIEN
Nama : _____________________
Usia : _____________________ tahun
Jenis Kelamin : Laki-laki / Perempuan
Agama : _____________________
Suku/Bangsa : _____________________
Pendidikan : _____________________
Pekerjaan : _____________________
Alamat : _____________________
IDENTITAS PENANGGUNG JAWAB
Nama : _____________________
Usia : _____________________
Agama : _____________________
Suku/Bangsa : _____________________
Pekerjaan : _____________________
Alamat : _____________________
Hub. dengan klien : _____________________
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RIWAYAT KESEHATAN
Keluhan Utama
________________________________________________________________________
Riwayat Kesehatan Sekarang
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Riwayat Kesehatan Dahulu
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Riwayat Kesehatan Keluarga
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
GENOGRAM ( 3 GENERASI )
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POLA FUNGSIONAL GORDON1. Manajemen Kesehatan
Sebelum Sakit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Selama Sakit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. Nutrisi MetabolikSebelum Sakit________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Selama Sakit
A : BB : _______________ kgTB : _______________ cmLiLA : _______________ cm
B : Hb : _______________Albumin : _______________Transferin : _______________
C : Rambut : ________________________________________Tonus otot : ________________________________________
D : _____________________________________________________ _____3. Eliminasi
Sebelum SakitBAB : Frekuensi : ________________ kali
Konsistensi : ________________Warna : ________________Bau : ________________
BAK : Frekuensi : ________________ kaliWarna : ________________Jumlah : ________________Bau : ________________
Selama SakitBAB : Frekuensi : ________________ kali
Konsistensi : ________________Warna : ________________Bau : ________________
BAK : Frekuensi : ________________ kaliWarna : ________________Jumlah : ________________
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Bau : ________________4. Aktivitas dan Latihan
Sebelum Sakit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Selama Sakit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5. Istirahat dan TidurSebelum Sakit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Selama Sakit_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
6. Kognitif & SensoriSebelum Sakit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Selama Sakit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7. Konsep Diri
a. Identitas :
____________________________________________________________________________________________________________________________________
b. Body image :________________________________________________________________________________________________________________________________________________
c. Ideal diri :________________________________________________________________________________________________________________________________________________
d. Harga diri :________________________________________________________________________________________________________________________________________________
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e. Peran diri :________________________________________________________________________________________________________________________________________________
8. PeranSebelum Sakit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Selama Sakit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9. Mekanisme KopingSebelum Sakit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Selama Sakit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
10. Reproduksi dan Seksualitas________________________________________________________________________
11. Nilai Kepercayaan________________________________________________________________________
PEMERIKSAAN FISIKKeadaan Umum:Suhu : ________ oCTD : ___________ mmHgRR : ___________x/menitNadi : __________ x/menitKepala_____________________________________________________________________________________________________________________________________________________________Mata___________________________________________________________________________________________________________________________________________________________Hidung___________________________________________________________________________________________________________________________________________________________
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Mulut____________________________________________________________________________________________________________________________________________________________Telinga___________________________________________________________________________________________________________________________________________________________Leher___________________________________________________________________________________________________________________________________________________________JantungI : ________________________________________________________________P : ________________________________________________________________P : ________________________________________________________________A : ________________________________________________________________Paru-ParuI : ________________________________________________________________P : ________________________________________________________________P : ________________________________________________________________A : ________________________________________________________________AbdomenI : ________________________________________________________________A : ________________________________________________________________P : ________________________________________________________________P : ________________________________________________________________
Ekstremitas____________________________________________________________________________________________________________________________________________________________Genitalia___________________________________________________________________________________________________________________________________________________________
PEMERIKSAAN LABORATORIUM
Tanggal Jenis Pemeriksaan Hasil Satuan Nilai Normal
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PEMERIKSAAN DIAGNOSTIK_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PROGRAM TERAPI
Cara Masuk Jenis Obat Dosis
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DAFTAR MASALAH
No Data Fokus Etiologi Masalah Paraf
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RENCANA KEPERAWATAN
No.DP Tgl/Jam Diagnosa Kep. Tujuan Intervensi Paraf
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CATATAN KEPERAWATAN
Diagnosa Kep. Tgl/Jam Tindakan Respon Paraf
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16
CATATAN PERKEMBANGAN
Tanggal Diagnosa Keperawatan Evaluasi Paraf
17
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