Laporan Asuhan Keperawatan Dan Resume

Program Studi Ilmu Keperawatan B Tahun 2012

LAPORAN ASUHAN KEPERAWATAN
PADA ......… DENGAN……………………………………………
DI RUANG .............................................. RSUP SANGLAH DENPASAR
TANGGAL………………………2012

OLEH:
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PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA
2012

Program Studi Ilmu Keperawatan B Tahun 2012
ASUHAN KEPERAWATAN PADA ..............
DENGAN ....................................................................................
DI RUANG ..................................... RSUP SANGLAH DENPASAR
TANGGAL...........................2011
A. Pengkajian
1. Identitas

 Pasien
 Nama
 Umur
 Jenis kelamin
 Pendidikan
 Pekerjaan
 Status perkawinan
 Agama
 Suku
 Alamat
 Tanggal masuk
 Tanggal pengkajian
 Sumber Informasi
 Diagnosa masuk
 Penanggung
 Nama
 Hubungan dengan pasien
2. Riwayat keluarga
 Genogram (kalau perlu)

 Keterangan genogram

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Program Studi Ilmu Keperawatan B Tahun 2012
3. Status kesehatan

a. Status Kesehatan Saat Ini
 Keluhan utama (saat MRS dan saat ini)
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 Alasan masuk Rumah Sakit dan perjalanan penyakit saat ini
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 Upaya yang dilakukan untuk mengatasinya
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b. Status Kesehatan Masa Lalu
 Penyakit yang pernah dialami
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 Pernah dirawat
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 Riwayat alergi
:
 Ya
 Tidak
Jelaskan : ...................................................................................................................
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 Riwayat tranfusi
:
 Ya
 Tidak
 Kebiasaan :
 Merokok

 Ya
 Tidak
Sejak: ................................................ Jumlah: .....................................................
 Minum kopi
 Ya
 Tidak
Sejak: ................................................ Jumlah: .....................................................
 Penggunaan Alkohol
 Ya
 Tidak
Sejak: ................................................ Jumlah: ....................................................
 Lain-lain: .............................................................................................................
 Jelaskan : .............................................................................................................

Program Studi Ilmu Keperawatan B Tahun 2012
4. Riwayat Penyakit Keluarga
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5. Diagnosa Medis dan Therapy
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6. Pola Fungsi Kesehatan
a. Pemeliharaan dan persepsi terhadap kesehatan
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b. Nutrisi/ metabolic
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c. Pola eliminasi
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Program Studi Ilmu Keperawatan B Tahun 2012
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d. Pola aktivitas dan latihan
Kemampuan perawatan diri
0
1
2
3
4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4:
tergantung total.
Oksigenasi
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e. Pola tidur dan istirahat
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f. Pola kognitif-perseptual
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g. Pola persepsi diri/konsep diri
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h. Pola seksual dan reproduksi
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Program Studi Ilmu Keperawatan B Tahun 2012
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i. Pola peran-hubungan
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j. Pola manajemen koping stress
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k. Pola keyakinan-nilai
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7. Riwayat Kesehatan dan Pemeriksaan fisik
Keadaan umum
TTV

:  Baik
: TD:

 Sedang
Nadi :

 Lemah
Kesadaran:
Suhu:
RR:

a. Kulit, Rambut, dan Kuku
Distribusi rambut :
Lesi
 Ya
 Tidak
Warna kulit  Ikterik
 Sianosis
 Kemerahan  Pucat
Akral
 Hangat
 Panas
 Dingin kering
 Dingin
Turgor:
Oedem
 Ya
 Tidak
Lokasi:
Warna kuku:
 Pink
 Sianosis
 lain-lain
Lain-lain: .........................................................................................................................
b. Kepala dan Leher
Kepala
 Simetris
 Asimetris, Lesi:  ya
 Tidak
Deviasi trakea
 Ya
 Tidak
Pembesaran kelenjar tiroid
 Ya
 Tidak
Lain-lain: .........................................................................................................................

Program Studi Ilmu Keperawatan B Tahun 2012
c. Mata dan Telinga
Gangguan pengelihatan
 Ya
 Tidak
Menggunakan kacamata
 Ya
 Tidak
Visus:
Pupil
 Isokor
 Anisokor Ukuran:
Sklera/ konjungtiva
 Anemis
 Ikterus
Gangguan pendengaran
 Ya
 Tidak
Menggunakan alat bantu dengar
 Ya
 Tidak
Tes weber:
Tes Rinne:
Tes Swabach:
Lain-lain: .........................................................................................................................
d. Sistem Pernafasan:
Batuk:
 Ya
 Tidak
Sesak:
 Ya
 Tidak
 Inspeksi: ..........................................................................................................................
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 Palpasi: ............................................................................................................................
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 Perkusi: ..........................................................................................................................
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 Auskultasi: ......................................................................................................................
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Lain-lain: ...............................................................................................................................
e. Sistem Kardiovaskular :
Nyeri dada
 Ya
 Tidak
Palpitasi
 Ya
 Tidak
CRT
 < 3 dtk
 > 3 dtk
 Inspeksi: ..........................................................................................................................
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 Palpasi: ............................................................................................................................
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 Perkusi: ...........................................................................................................................
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Program Studi Ilmu Keperawatan B Tahun 2012
Auskultasi: ......................................................................................................................
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Lain-lain: ...............................................................................................................................
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f. Payudara Wanita dan Pria:
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g. Sistem Gastrointestinal:
Mulut
 Bersih
 Kotor
 Berbau
Mukosa
 Lembab
 Kering
 Stomatitis
Pembesaran hepar
 Ya
 Tidak
Abdomen
 Meteorismus
 Asites
 Nyeri tekan
Peristaltik: x/mnt
Lain-lain : ........................................................................................................................
h. Sistem Urinarius :
Penggunaan alat bantu/ kateter
Kandung kencing, nyeri tekan
Gangguan
 Anuria
 Oliguria
 Nokturia  Lain-lain:

 Ya
 Ya
 Retensi

 Tidak
 Tidak
 Inkontinensia

i. Sistem Reproduksi Wanita/Pria :
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j. Sistem Saraf:
GCS:
Eye:
Rangsangan meningeal

Verbal:
Motorik:
 Kaku kuduk
 Kernig
 Brudzinski I
 Brudzinski II
Refleks fisiologis
 Patela
 Trisep
 Bisep
 Achiles
Refleks patologis
 Babinski  Chaddock  Oppenheim
 Rossolimo  Gordon
Schaefer
 Stransky  Gonda
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Lain-lain: .........................................................................................................................
k. Sistem Muskuloskeletal:
Kemampuan pergerakan sendi
Deformitas
 Ya
Fraktur
 Ya
Kekakuan
 Ya
Nyeri sendi/otot
 Ya
Kekuatan otot :

 Bebas
 Tidak
 Tidak
 Tidak
 Tidak

 Terbatas
Lokasi:
Lokasi:

Program Studi Ilmu Keperawatan B Tahun 2012
Lain-lain: .........................................................................................................................
l. Sistem Imun:
Perdarahan Gusi
 Ya
 Tidak
Perdarahan lama
 Ya
 Tidak
Pembengkakan KGB
 Ya
 Tidak
Lokasi:
Keletihan/kelemahan
 Ya
 Tidak
Lain-lain: .........................................................................................................................
m. Sistem Endokrin:
Hiperglikemia
 Ya
 Tidak
Hipoglikemia
 Ya
 Tidak
Luka gangrene
 Ya
 Tidak
Lain-lain: .........................................................................................................................
8. Pemeriksaan Penunjang
a. Data laboratorium yang berhubungan
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Program Studi Ilmu Keperawatan B Tahun 2012
b. Pemeriksaan Radiologi
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Program Studi Ilmu Keperawatan B Tahun 2012
c. Hasil Konsultasi
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Program Studi Ilmu Keperawatan B Tahun 2012
d. Pemeriksaan penunjang diagnostik lain
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Program Studi Ilmu Keperawatan B Tahun 2012
9. Analisa Data
No.
Tgl

Data

Penyebab/Interpretasi

Masalah

Program Studi Ilmu Keperawatan B Tahun 2012

B. Diagnosa Keperawatan (berdasarkan prioritas)

Program Studi Ilmu Keperawatan B Tahun 2012
No
Dx

Tgl
Muncul
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C. Perencanaan

Dx Keperawatan

Tgl teratasi

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