LAPORAN ASUHAN KEPERAWATAN PADA PASIEN “……” DENGAN ……………………………. ……………………………….
DI RUANGAN …………………………… RS. ……………………………………….
OLEH: NAMA
:
NIM
:
PROGRAM STUDI S1 KEPERAWAT KEPERAWATAN AN SEKOLAH TINGGI ILMU KESEHATAN (STIKes) BINA SEHAT PPNI KAB. MOJOKERTO MOJOKERTO
LEMBAR PENGESAHAN
Pengesahan laporan Asuhan Keperawatan (ASKEP) praktik Praktik laboratorium klinik Rumah Sakit (RS), yang disusun oleh, Nama : Nim : elah melaksanakan praktik laboratorium klinik Rumah Sakit pada: anggal : Ruang : Adapun rin!ian asuhan keperawatan terangkum dalam laporan ini"
#o$okerto, #ahasiswa
%%%%%%%%%%%%%%%%%%" N&#"
Pre!eptor Akademik
Pre!eptor Ruangan
%%%%%%%%%%%%%%%%%%" N&K"
%%%%%%%%%%%%%%%%%%" N&K'N&P"
Kepala Ruangan
%%%%%%%%%%%%%%%%%%" N&K'N&P"
ASUHAN KEPERAWATAN PADA PASIEN “……” DENGAN ………………………… ..………………………. DI RUANGAN …………………………… RS. ………………………………………. A. IDENTITAS PASIEN " NA#A +" #R /" SK' 0angsa 1" SAS PERKA2&NAN 3" A*A#A 4" PEN-&-&KAN 5" A6A#A 7" *6 #RS 8" *6 PEN*KA9&AN
: : : : : : : : :
%%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%% %%%%%%%%%%%
N" RE*: -." #edis:
B. POLA FUNGSI KESEHATAN 1. POLA PERSEPSI PEMELIHARAAN KESEHATAN
a" Keluhan utama %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " b" Riwayat penyakit sekarang %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " !" Riwayat penyakit dahulu %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " d" Riwayat penyakit keluarga
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""" " !. POLA NUTRISI" METABOLISME
#enggambarkan masukan nutrisi keseimbangan !airan a" &ntake nutrisi (;rekuensi, $umlah komposisi) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" b" &ntake !airan (;rekuensi,$umlah $enis ) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" !" Na;su makan %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" d" #asalah dengan makan %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" e" #akanan kesukaan %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" ;" Alergi makanan %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" #. POLA ELIMINASI E$%&%'s% U%
Pola 0AK (;rekuensi, waktu, $umlah ) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Karakteristik (warna, ke$ernihan, bau, endapan ) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
Pola 0A0 (;rekuensi,waktu) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Karakteristik keluaran ;eses (bau , padat'!air ) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" #asalah dengan 0A0 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
+. POLA AKTI,ITAS - LATIHAN
Pola akti=itas yg dilakukan %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Akti=itas diwaktu luang %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" #asalah dalam akti=itas %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Penggunaan alat bantu %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Akti=itas se$ak sakit %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
. POLA ISTIRAHAT TIDUR
Kebiasaan pola tidur (waktu, $umlah, kualitas) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" -ampak pola istitrahat tidur terhadap akti=itas sehari > hari %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Kesulitan tidur %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Alat bantu tidur %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
/. POLA KOGNITIF PERSEPTUAL
Kemampuan pan!a indra (pendengaran, penglihatan, pen! iuman)
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Pemakaian alat bantu pendengaran, penglihatan %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" #asalah sensori perseptual %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Perubahan memori %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Presepsi Nyeri penanganan nyeri ( P, ?, R, S, ) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
0. POLA PRESEPSI - DIRI " KONSEP DIRI
Konsep diri a" 0ody &mage"""""""""""""""""""""""""""""""""""""""""""""""""""""""" """"""""""""""""""""""""""""""""""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""" b" Sel; &deal
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""" !" Sel; esteem
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" d" Role
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" e" &dentitas
"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
. POLA PERAN - HUBUNGAN
Kee;ekti;an peran %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
@ubungan dengan orang terdekat %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" E;ek perubahan peran terhadap hubungan %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
2. POLA SEKSUALITAS - REPRODUKSI
-ampak sakit terhadap seksualitas %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Riwayat haid %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" indakan pengendalian kelahiran %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Riwayat penyakit hubungan seksual %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
13. POLA KOPING - TOLERANSI STRESS
Penggunaan sistem pendukung %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Stressor sebelum sakit %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" #etode koping yg biasa digunakan %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" ;aktor yg mempengaruhi koping %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" E;ek penyakit terhadap tingkat stress %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""P enggunaan alkohol obat lain untuk mengatasi stres %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
11. POLA NILAI - KEPER4A5AAN "
Agama: Spiritualitas %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%"""""" Kegiatan keagamaan budaya %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%""""""
4. PEMERIKSAAN FISIK (He6 78 T88)
-
Ke6' U&9& """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
-
Kes6' """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
-
T'6T'6 ,%7$ (TT,):
-
o
-
: """"""""""""""
mm@g
o
Nadi
: """""""""""""""
.'mnt
o
Suhu
: """"""""""""""""
o
RR
:""""""""""""""""""
B
.'mnt
Se K;9s9s (4;e<$8 - 496) 1.
Ke<$ 6' $e;e
a" Rambut
:
b" Kulit kepala
:
!" #ata
:
d" @idung
:
e" elinga
:
;" #ulut gigi : !.
#.
Le;e
a" Asimetris'simetris
:
b" Pembesaran kelen$ar lym;e
:
!" pembesaran kelen$ar tiroid
:
Pe&e%=s' T;8=
a" Pulmonum'horak'Paru &nspeksi: Palpasi:
b" BR'9antung &nspeksi: Palpasi: Perkusi: Auskultasi +.
:
A>68&e'
&nspeksi
:
Auskultasi
:
Palpasi
:
Perkusi
:
.
I'?9%'$ - ?e'e7$% 6' '9s
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
/.
E=s7e&%7s
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
0.
I'7e?9&e'
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% .
Ne98$8?%
Re;lek
:
Re;lek Patologi
:
Pemeriksaan NCN+
:
-" PEMERIKSAAN PENUNJANG (6aborat, EK*, #edikamentosa)
E. ANALISA DATA N& Ps%e': NO
+
N8.Re?: DATA
ETIOLOGI
MASALAH
F. DAFTAR DIAGNOSA KEPERAWATAN N& Ps%e': NO
+
TANGGAL
N8.Re?: DIAGNOSA
TTD
G. REN4ANA KEPERAWATAN N& Ps%e': NO. D
N8.Re?:
TUJUAN @ KRITERIA HASIL
INTER,ENSI @ RASIONAL
PARAF
H. IMPLEMENTASI KEPERAWATAN N& Ps%e': NO D
TANGGAL JAM
N8.Re?:
TINDAKAN KEPERAWATAN
PARAF
I. E,ALUASI N& Ps%e': NO D
TANGGAL
JAM
N8.Re?: SOAP
PARAF
PANDUAN PEMFIS
PEMERIKSAAN FISIK (He6 78 T88) -
Ke6' U&9&
-
Kes6' """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
-
T'6T'6 ,%7$ (TT,): o
-
: """"""""""""""
mm@g
o
Nadi
: """""""""""""""
.'mnt
o
Suhu RR
: """"""""""""""""
o
-
:""""""""""""""""""
""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""
B
.'mnt
Se K;9s9s (4;e<$8 - 496) 2.
Ke<$ 6' $e;e
g" Rambut
: 2arna rambut, rambut rontok'tdk
h" Kulit kepala
: Kebersihan kulit kepala (ada ketombe'tdk)
i" #ata
: Re;lek pupil, kon$ungti=a, sklera, palpebra atas'bawah
(oedema'tdk), kon=ergensi dis=ergensi (normal'tdk), nistagmus =ertikal horiDontal (normal'tdk)" $" @idung
: 0ulu hidung, warna sinus, terdapat !orpus alienum'tdk,
terdapat serumen'tdk k" elinga
: Pinna, heli., lobulla, terdapat !orpus alienum'tdk, membran
tympani l" #ulut gigi : 2arna bibir, kelembapan, warna gigi, $umlah gigi, warna gusi
13. Le;e
d" Asimetris'simetris
:
e" Pembesaran kelen$ar lym;e
: ada'tdk
;"
: ada'tdk
pembesaran kelen$ar tiroid
11. Pe&e%=s' T;8=
!" Pulmonum'horak'Paru &nspeksi
: bentuk dada,
alat bantu na;as, otot bantu na;as
sternokledomastoidius, retraksi inte!oste Palpasi
: =o!al ;remitus, e.pansi paru
Perkusi
: sonor, hipersonor, redup, pekak
Auskultasi
: =esikuler'terdapat suara na;as tambahan seperti: wheeDing, ronkhi, rales, dll"
d" BR'9antung &nspeksi
: i!tus !ordis terlihat'tdk
Palpasi
: P#& teraba'tdk
Perkusi
: redup
Auskultasi
: S S+ bunyi tunggal'terdapat suara tambahan seperti: gallop, murmur
1!. A>68&e'
&nspeksi
: 0entuk abdomen, umbilikus masuk kedalam'keluar, terdapat
pembesaran =ena kolateraral'tdk" Auskultasi
: Peristaltik usus
Palpasi
: erdapat nyeri tekan'tdk, hepar gi$al teraba'tdk, lien
gin$al teraba'tdk Perkusi
: ympani'hipertympani'pekak'redup, perkusi gin$al
1#. I'?9%'$ - ?e'e7$% 6' '9s
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1+. E=s7e&%7s
Kekuatan tot: o
Nilai : otot tidak bergerak ' berkontraksi, bila lengan dan kaki diangkat dan
o
dilepas, akan $atuh pasi; Nilai : ada kontraksi dengan sedikit gerakan, sedikit tahanan sewaktu $atuh
o
Nilai +: egak, mampu menahan gra=itasi, tetapi dengan
sentuhan
akan $atuh o
Nilai /: 0ertahan tegak walau sedikit didorong, tetapi tidak tahan melawan tekanan
o
Nilai 1: Kekuatan kurang disbanding sisi yang lain
o
Nilai 3: Kekuatan utuh
1. I'7e?9&e'
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 1/. Ne98$8?%
Re;lek
: bisep, trisep, brakioradialis, patella, dst"
Re;lek Patologi
: babinsky, !haddok, openheim, s!hae;er, gordon, dst"
Pemeriksaan NCN+
:
o
o
N (l;aktorius) N+ (ptikus)
: """"""""""""""""""""" : .....................
o
N/ (kulomotorius)
: """""""""""""""""""""
o
N1 (roklearis)
: """""""""""""""""""""
o
N3 (rigeminus)
: """""""""""""""""""""
o
N4 (Abdusen)
: """""""""""""""""""""
o
N5 (
: """""""""""""""""""""
o
N7 (erstibulo!o!hlearis)
: """""""""""""""""""""
o
N8 (*loso;aringeus)
: """""""""""""""""""""
o
N (agus)
: """""""""""""""""""""
o
N (Asesoris)
: """""""""""""""""""""
o
N+ ( Hipoglosus)
: """""""""""""""""""""
