LEMBAR PENGESAHAN

JUDUL KASUS

ASUHAN KEPERAWATAN PADA AN.S DENGAN STEVEN JOHNSON SYNDROME

DIRUANG 7A RSUD DR.SAIFUL ANWAR MALANG

TANGGAL PENGAMBILAN KASUS

12 November 2018

MAHASISWA

NAIMATUZ ZUHRO
NPM : 18640803

PEMBIMBING INSTITUSI PEMBIMBING KLINIK

Endang Mei , S.Kep.Ns.M.kep Lailatul Mutmainah S.Kep.Ns

NIDN. 0708038802 NIP.19890609 2014032002

Tanggal Pengkajian : ..................................................................................

Tanggal MRS :.................................................................................

NAIMATUZ ZUHRO (18640803)

I. IDENTITAS KLIEN
Nama : …………………………………………………..
Tempat/tgl lahir : …………………………………………………..
Jenis Kelamin : …………………………………………………..
Nama ayah/Ibu : …………………………………………………..
Pekerjaan Ayah : …………………………………………………..
Pekerjaan Ibu : …………………………………………………..
Alamat : …………………………………………………..
Suku bangsa : …………………………………………………..
Agama : …………………………………………………..
Biaya ditanggung oleh : …………………………………………………..

II. KELUHAN UTAMA :

................................................................................................................................................
................................................................................................................................................

III. RIWAYAT KESEHATAN SEKARANG

a. Riwayat perjalanan penyakit:
...................................................................................................................................
...................................................................................................................................
b. Pengobatan sebelumnya:
...................................................................................................................................
...................................................................................................................................
III. RIWAYAT KEHAMILAN DAN KELAHIRAN
1. Prenatal :................................................................................................................
2. Natal :................................................................................................................
3. Postnatal :.................................................................................................................

IV. RIWAYAT MASA LAMPAU

1. Penyakit waktu kecil :.................................................................................
2. Pernah dirawat di RS :.................................................................................
3. Obat-obatan yang digunakan :..................................................................................
4. Tindakan (operasi) :.................................................................................
5. Alergi :.................................................................................
6. Kecelakaan :.................................................................................

NAIMATUZ ZUHRO (18640803)

 7. Imunisasi :................................................................................

V. RIWAYAT KESEHATAN KELUARGA

Penyakit yang pernah diderita anggota keluarga :
................................................................................................................................................
Penyakit yang sedang diderita anggota keluarga :
................................................................................................................................................

VI. GENOGRAM

VII. GENOGRAM RIWAYAT SOSIAL

1. Yang mengasuh : .......................................................................
2. Hubungan dengan anggota keluarga :........................................................................
3. Hubungan dengan teman sebaya :........................................................................
4. Pembawaan secara umum :.......................................................................
5. Lingkungan rumah :........................................................................

VIII. KEBUTUHAN DASAR

No ITEM Deskripsi

NAIMATUZ ZUHRO (18640803)

 Dirumah Dirumah Sakit
Pola nutrisi metabolik
1 Jenis diet / makanan
2 Frekuensi / pola makan
3 Porsi / jumlah
4 Pantangan
5 Nafsu makan
6 Peningkatan atau penurunan BB 6 bulan
terakhir
Pola eliminasi
1 BAB frekuensi

2 Konsistensi BAB

3 Warna / bau BAB

4 Kesulitan BAB

5 Upaya mengatasi

6 BAK frekuensi

7 Konsistensi BAK

8 Warna / bau BAK

9 Kesulitan BAK

10 Upaya menangani

IX. KEADAAN KESEHATAN SAAT INI

1. Diagnosa medis :...........................................................................................
2. Tindakan operasi :...........................................................................................
3. Status Nutrisi :...........................................................................................
4. Status Cairan :...........................................................................................
5. Obat-obatan :...........................................................................................
6. Aktifitas :...........................................................................................
7. Tindakan Keperawatan :...........................................................................................
8. Hasil laboratorium :...........................................................................................
9. X – Ray :...........................................................................................
X. PENGKAJIAN HEAD TO TOE
 Kesadaran umum
Kesadaran :................................................................................................................
GCS :...............................................................................................................
TTV : TD :........................................................

NAIMATUZ ZUHRO (18640803)

 N :........................................................
S :.........................................................
RR:.........................................................
1. Kepala
 Ukuran :........................................................................................................................
 Distribusi rambut :........................................................................................................
 Warna kulit kepala :......................................................................................................
2. Mata
 Pupil :...........................................................................................................................
 Sclera :..........................................................................................................................
 Konjunctiva :................................................................................................................
 Gangguan penglihatan :................................................................................................
3. Hidung
 Bentuk:..........................................................................................................................
 Sekresi:.........................................................................................................................
 Gangguan penciuman :................................................................................................
4. Mulut
 Warna bibir : .................................................................................................................
 Mukosa mulut : .............................................................................................................
 Mukosa bibir : ..............................................................................................................
5. Telinga
 Bentuk :.........................................................................................................................
 Sekresi :........................................................................................................................
 Gangguan pendengaran:...............................................................................................
6. LEHER
Trachea
 Palpasi:..........................................................................................................................

Glandula tyroid
 Inspeksi :.........................................................................................................
 Palpasi :.........................................................................................................
7. DADA
Paru
 Inspeksi:.....................................................................................................................

NAIMATUZ ZUHRO (18640803)

  Palpasi:.......................................................................................................................
 Perkusi:.......................................................................................................................
 Auskultasi:..................................................................................................................
Jantung
- Inspeksi :...............................................................................................
- Palpasi :...............................................................................................
- Perkusi :...............................................................................................
- Auskultasi :...............................................................................................
8. ABDOMEN
- Inspeksi :...............................................................................................
-Auskultasi :...............................................................................................
-Palpasi :...............................................................................................
-Perkusi :...............................................................................................
9. GENETALIA :...............................................................................................
10. EKSTREMITAS :...............................................................................................

XI. PEMERIKSAAN TINGKAT PERTUMBUHAN DAN PERKEMBANGAN

1. Fisik:
a. TB:.......................................................................................................................
b. BB:.......................................................................................................................
c. Gigi:.....................................................................................................................
2. Kemandirian dan Bergaul...........................................................................................
3. Motorik halus.............................................................................................................
4. Kognitif dan Bahasa...................................................................................................
5. Motorik Kasar............................................................................................................

NAIMATUZ ZUHRO (18640803)