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

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Riwayat Kesehatan Sekarang

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Riwayat Kesehatan Dahulu

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Riwayat Kesehatan Keluarga

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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

12

13

14

CATATAN KEPERAWATAN

Diagnosa Kep. Tgl/Jam Tindakan Respon Paraf

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16

CATATAN PERKEMBANGAN

Tanggal Diagnosa Keperawatan Evaluasi Paraf

17