1
LAPORAN KASUS ASUHAN KEPERAWATAN
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RUMAH SAKIT UMUM PUSAT DR. HASAN SADIKIN BANDUNG
A. PENGKAJIAN
1. Identitas Pasien
Nama (inisial)
: ______________________________________
No RM
: ______________________________________
Usia
: ___________________ (lahir: ____, _________, _____)
Jenis Kelamin
:
laki-laki
perempuan
Status Marital
:
duda/janda
:
belum menikah
menikah
Pekerjaan
______________________________________
Suku Bangsa
: ______________________________________
Alamat Rumah
: ______________________________________
Sumber biaya
: ______________________________________
Diagnosa Medis
: ______________________________________
Tanggal MRS
: ______________________________________
Tanggal Pengkajian
: ______________________________________
2. Identitas Penanggung Jawab
Nama (inisial): ______________________________________
Usia: ______________________________________
Hubungan dgn pasien : ______________________________________
Pendidikan: ______________________________________
Alamat: ______________________________________
Riwayat Kesehatan
Keluhan Utama
__________________________________________________________________
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Riwayat Penyakit Saat Ini
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2
Riwayat Kesehatan Masa Lalu
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Riwayat Kesehatan Keluarga
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Genogram:
Pengukuran
a. Tanda-tanda Vital
Blood Pump
: _____________
mmHg
Heart Rate
: _____________
x/menit
Respiration
: _____________
x/menit
Temperature
: _____________
oC
b. Fisiologis
Berat Badan
: _____________
Kg
Tinggi Badan
: _____________
Cm
IMT
:
(
)
(
)
= ______
Klasifikasi IMT:
< 18,5
: BB Kurang
18,5 22,9
: BB Normal
> 23,0
: BB Lebih
23,0 24,9
: BB Pra Obes
25,0 29,9
: BB Obesitas I
> 30,0
: BB Obesitas II
Klasifikasi IMT : ____________
BB Ideal: (TB 100) ((TB-100)x10%)
( _____ - 100) (( _____ -100) x 10%) ( _____ ) ( _____ )
= ________
3
5. Pola Pemenuhan Kebutuhan Dasar Manusia
NILAI RUJUKAN NORMAL
KH
: 60 75 % energi total
Prot
: 10 15 % energi total
Lemak : 10 25 % energi total
Rujukan:
1 gr KH
= 4 Kkal
1 gr Prot
= 4 Kkal
1 gr Lemak
= 9 Kkal
Keb. Total Kalori Normal (TK):
TK = KB + AF KU
Keb. Basal Kalori (KB)
Pria
= BBI x 30
Wanita
= BBI x 25
Aktivitas Fisik (AF)
-
Ringan
= 10 % x KB
-
Sedang
= 20 % x KB
NUTRISI
-
Berat
= 40 % x KB
Koreksi Usia (KU)
-
< 40 tahun
= 0 % x KB
-
40 59 tahun = 5 % x KB
-
60 69 tahun = 10 % x KB
-
> 70 tahun
= 20 % x KB
Keb. Cairan Normal (KC):
KC = 30-50 cc/KgBB/24 jam
CAIRAN
POLA
KEADAAN PASIEN SAAT INI
KEBUTUHAN
Asupan Nutrisi BBI Pasien
= ________
Kg
KB Pasien
= BBI x ____
= ____ x ____
= _________
Kkal
AF Pasien
= ___% x KB
= ___% x ___
= _________
Kkal
KU Pasien
= ___% x KB
= ___% x ___
= _________
Kkal
TK = KB + AF KU
= _____ + _____ - _____
= _________ Kkal
Kebutuhan Yang Diberikan Saat Ini:
Frekuensi
Cara
Alergi
Keterangan lainnya
Asupan Cairan Tranfusi
Makanan
Parenteral
Keterangan
Lainnya
4
Output Berdasarkan GFR:
BAK
Rata-rata Output Dlm 24 jam
Warna
: _____________
Keluhan
: _____________
Keterangan Lain
ELIMINASI
Rumus dari Cockcroft-gault
Produksi Urine Normal:
BAB
Warna
: ______________
Rata-rata Output Dlm 24 jam
PU = 1 2 cc/KgBB/Jam
Konsistens : ______________
IWL normal:
Keluhan
: ______________
IWL =
(
)
Keterangan Lain
IWL dgn kenaikan suhu tubuh:
(10% CM) kenaikan suhu tubuh
24 jam
+ 37,5 cc
IWL
Pelaksanaan
personal
Frekuensi
: ____________ / hari
HYGIENE
hygiene secara umum jika
Mandi
Cara
: ______________
tidak ada
kolom,
uraikan
Keterbatasan : ______________
di bawah ini:
Frekuensi
: ____________ / hari
Oral Hygiene
Cara
: ______________
PERSONAL
Keterbatasan : ______________
Keramas / Cuci
Frekuensi
: ______________
Cara
: ______________
Rambut
Keterbatasan : ______________
Keterangan
Lainnya
Siang
: _____________ jam
ISTIRAHAT
Durasi Tirus
Malam
: _____________ jam
Total
: ___________ jam/hr
Kebiasaan
Gangguan
INFO LAIN
5
6.
Pemeriksaan Fisik
NILAI RUJUKAN
HASIL PEMERIKSAAN PASIEN SAAT INI
Kuantitatif (GCS):
Eye (4)
Verbal (5)
Motor (6)
spontan
orientasi baik
ikut perintah
dengan suara
kacau/bingung
lokalisir nyeri
dengan nyeri
tidak teratur
fleksi normal
tidak respon
mengerang
fleksi abnormal
KESADARAN
tidak ada
ekstensi abnormal
tidak ada
Kualitatif:
Compos mentis
: kesadaran penuh
Apatis
: tampak segan atau acuh tak acuh terhadap lingkungan
Somnolent
: mengantuk
yang masih dapat
pulih bila dirangsang, tetapi bila
Sopor/Stupor
rangsangan berhenti pasien kembali tidur
: mengantuk yang dalam, pasien dapat
dibangunkan
dengan rangsang
Soporo Coma
yang kuat
: penurunan
kesadaran dimana
tidak
memberikan
respon terhadap
rangsang verbal, tidak dapat dibangunkan, tetapi reflek (korne, pupil)
Coma
masih baik, respon terhadap rangsang nyeri tidak adekuat.
: penurunan kesadaran sangat dalam, tidak ada gerakan spontan, tidak
ada respon terhadap rangsang nyeri.
Masukkan info lainnya:
Simetris
Ikterus
Nistagmus
Lesi
MATA
Ptosis
Xantelasma
Konjungtiva
: __________________
Reflek Pupil
: __________________
Kesimetrisan
: __________________
Ukuran Pupil
: Ka
_________ mm
Ki
_________ mm
KEPALA-LEHER
Masukkan info lainnya:
Simetris
: _______________
HIDUNGTELINGA
Serumen
: _______________
Peradangan
: _______________
Gg. Pndengaran
: _______________
Alat Bantu
: _______________
Cairan Telinga
: _______________
Masukkan info lainnya:
Terpasang NGT
: _______________
Kebersihan
: _______________
Sumbatan
: _______________
Program O2
: _______________
Masukkan info lainnya:
Gigi tanggal
: _______________
MULUT
Gigi Berlubang
: _______________
Stomatitis
: _______________
Keadaan Lidah
: _______________
Mukosa Bibir
: _______________
Gg. Menelan
: _______________
6
LEHER
Masukkan info lainnya:
Deviasi trakea
: _______________
Kelenjar thiroid
: _______________
Reflek menelan
: _______________
JVP
: _______________
Sirkulasi Perifer
Frekuensi Nadi
: _____________ x/menit
Irama Nadi
: _____________
Temperatur Kulit : _____________
Warna Kulit
: _____________
CRT
: _____________
JANTUNG
Flebitis
: _____________
Varises
: _____________
Sirkulasi Central
Ictus cordis
: _____________
Keluhan
: _____________
Bunyi Jantung
: S1 _____________
S2 _____________
DADA
Kelainan BJ
: _____________
CVP
: _____________
Gerakan Dada
Irama
: ________________________
Frekuensi
: ________________________
Kedalaman
: Ka
: __________________
Ki
: __________________
Retraksi Intercostae
: __________________
PARU
Suara sumbatan
: __________________
Suara Nafas
Suara auskultasi
: __________________
Suara Perkusi Dada
: __________________
Pengg. Alat Bantu Nafas
Keterangan Lain
GERAK)
Nilai Kekuatan Otot
5
: melawan gravitasi dengan
Kekuatan otot
full resistensi
4
: melawan gravitasi dengan
(ALAT
resistensi sedikit
3
: melawan gravitasi tanpa
IV Line (Flebitis)
resistensi
2
: tidak bisa melawan gravitas
EKSTREMITAS
1
: ada kontraksi, gerakan
hanya pada jari
Edema
0
: tidak ada kontrasi otot
Kontraktur Sendi
7
Nyeri Sendi
Tanda Fraktur
Pencernaan
Masa pada abdomen
Kekakuatan otot abdomen (distensi)
Ascites
ABDOMEN
Bising Usus
: ________________ x/mnt
Mual/Muntah
: __________ / __________
Fisiologis
Nyeri tekan abdomen
Nyeri lepas abdomen
Perkusi Hepar
_______________________________________
Perkusi Gaster
_______________________________________
Fisiologis
Testis
: Ka
: _________________
Ki
: _________________
Kelamin
: ______________________
URIGENITAL
Keadaan
: ______________________
Kelainan
Distensi Bladder
: _________________
Urinaria
Terpasang Folley Catheter
Kelainan Urine
Anuria
Disuria
Hematuria
Poliuria
Olfaktorius
Kanan
Kiri
KRANIAL
Optikus
Kanan
Kiri
Okulomotorius
SYARAF
Kanan
Kiri
Troklearis
Trigeminus
ENDOKRIN
TEMUAN FISIK LAINNYA
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Abdussen
Fasialis
Akustikus
Glosopharingeus
Vagus
Aksesorius
Hipoglosus
Bau Nafas
Kondisi Luka (jika ada gambarkan)
Tanda Peningkatan GD
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7. Pemeriksaan Penunjang
Jenis
Tanggal
Hasil
8.
Pemeriksaan Laboratorium
TGL
Pemeriksaan
Hasil
Nilai
Normal
Nilai
PemeriksaanHasil
Normal
10
9. Tindakan Medis
Jenis
Tanggal
Keterangan
10. Teraphy Farmakologi
Nama Obat
Dosis
Rute
Nama Obat
Dosis
Rute
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B. ANALISA DATA
No
Data Senjang
Etiologi
Problem
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C. DIAGNOSA DAN INTERVENSI KEPERAWATAN
N
Diagnosa Keperawatan Tujuan dan Kriteria HasilRencana TindakanRasional
o
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D. IMPLEMEN DAN EVALUASI KEPERAWATAN
TGL
DiagnosaImplementasi KeperawatanEvaluasi
& Jam
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