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8/16/2019 LAPORAN CATATAN PPERKEMBANGAN
http://slidepdf.com/reader/full/laporan-catatan-pperkembangan 1/13
LAPORAN CATATAN PPERKEMBANGAN
PADA PASIEN TN. S DENGAN ANEMIA
DI RUANG UGD RUMAH SAKIT UMUM SUKADANA
LAMPUNG TIMUR 2015
Ruangan : pen a!"# $a%a& N' MR : 10())*Tangga% peng!a+"an :Pu!u% : 0*:00,IB
A. Data dasar1. Da#a $e&'g-a "
a. I$en#"#a/ pa/"en Na&a : #n. SU&u- : 5 #a un
en"/ !e%a&"n : %a!" %a!"S#a#u/ pe-!a3"nan : /u$a &en"!aPe!e-+aan : pe#an"Aga&a : "/%a&Pen$"$"!an : SMPSu!u : +a3aBa a/a ang $" guna!an : "n$'ne/"aA%a&a# -u&a :-an#au +a aSu&4e- 4"a a : BP STangga% &a/u! RS :D"agn'/a &e$"/ : ane&"a
4. Su&4e- "n '-&a/" Na&a :N . TU&u- : #a unHu4ungan $gn !e%ua-ga : "/#-"
en"/ !e%a&"n : pe-e&puanAga&a : "/%a&
Pen$"$"!an :Se!'%a $a/a- Pe!e-+aan :I4u -u&a #anggaA%a&a# -u&a : -an#au +a a
2. R"3a a# !e/e a#an !e%ua-gaa. R"3a a# !e/e #an /aa# &a/u! RS
K%"en &a/u! !e-unag pen a!"# $a%a& pa$a #angga% pu!u% 15:)0
,IB $" an#a- '%e !e%ua-ga. K%"en &enge%u pu/"ng6 pana/
&en"ng!a#6 %e&a/6 %e/u /e%a&a 1 &"nggu.
4. R"3a a# !e/e a#an /aa# peng!a+"an
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8/16/2019 LAPORAN CATATAN PPERKEMBANGAN
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La!";%a!"
K%"en
La!";%a!" Men"ngga%
Pe-e&puan Men"ngga%
T"ngga% Se-u&a
). Penge#a uan pa/"en $engan !e%ua-gaK%"en $an !e%ua-ga !%"en #"$a! &enge#a u" pen a!"# apa ang $"
$e-"#a %"en /aa# "n" an a &enge#a u" pen a!"# !e!-angan $a-a ang $"
$e-"#a !%"en /aa# "n"
. P'%a !e4"a/aan /e a-" a-"a. P'%a nu#-"/" $an 8a"-an
Nu#-"/"
Se4%u& /a!"# Saa# /a!"#K%"en &a!an )9 /e a-" $engan p'-/" ang
8u!up $an $" a4"/!an
K%"en an a &a!an 19 /e a-" $eng
ang /e$"!"#
Ca"-an
Se4e%u& /a!"# Saa# /a!"#K%"en &"nu& * ge%a/ /e a-" K%"en &"nu& 2 ge%a/ /e a-"
4. P'%a e%"&"na/"BAK
Se4e%u& /a!"# Saa# /a!"#K%"en BAK ;(9 /e a-" K%"en BAK 1;29 /e a-"
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8/16/2019 LAPORAN CATATAN PPERKEMBANGAN
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BAB
Se4e%u& /a!"# Saa# /a!"#K%"an BAB 19 /e a-" K%"en 4e%u& BAB /e%a& ) a-"
8. Pe-/'na% g"ene
Se4e%u& /a!"# Saa# /a!"#K%"en &an$" 29 /e a-" 6 !e-a&a/ 29 /e a-"
$an g'/'! g"g" 29 /e a-"
K%"en an a $" 3a/%ap a"- an
!e%ua-gan a$. P'%a "/#"-a a# $an #"$u-
Se4e%u& /a!"# Saa# /a!"#K%"en #"$u- *+a& /e a-" K%"en #"$u- 10 a& /e a-"
e. P'%a !a#"7"#a/ $an %a#" an
Se4e%u& /a!"# Saa# /a!"#K%"en $apa# &e%a!u!an a!#"7"#a/ /e a-" a-" K%"en an a 4e-4a-"ng $" #e&pa# #"$
5. Peng!a+"an "/"! a. Pe&e-"!/aan u&u&
T"ng!a# !e/a$a-an : C'&p'/&e#"/Te!anan $a-a : 0<(0 &&Hg
Na$" : =59<&en"#Su u : )(60> C
RR : 1 9<&en"#BB : 5 !gTB :1 ) 8&
4. Pe&e-"!/aan "/"! ea$ ? #'e
Ku%"# : 4e-/" 63a-na 8'!%a# !e "#a&an6 #"$a!
4e-/"/"!6 #"$a! a$a 4en+'%an
Kepa%a :4e-/" 6 #"$a! a$a e$e&&a6 #"$a! a$a
4en+'%an $an #"$a! 4e-!e#'&4e
Ra&4u# : 4e-/" 6#"$a! -'n#'!6 3a-na "#a&6 4en#u!
%u-u/6 #4a% $an !a/a-
,a+a : 4e-/" 6#"$a! !e-"pu#6 4en#u! '7a%6 #"$a! a$a
4en+'%an6 /"&e#-"/ $an #"$a! a$a e$e&a
Ma#a :peng%" a#an n'-&a%6 !'n+ung#"7a
pu8a#64en#u! 4u%a#6 -e %e! pup"% n'-&a%
Te%"nga :pen$enga-an n'-&a%6 /"&e#-"/6 #"$a! a$a
4en+'%an6 #"$a! a$a %e/"
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8/16/2019 LAPORAN CATATAN PPERKEMBANGAN
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H"$ung : pen8"u&an n'-&a%6 /"&e#-"/ 6 #"$a! a$a
4en+'%an6 pe/e!6 4e-/" 6 4u%u "$ung
n'-&a%
Mu%u# :!'#'-6 4en#u! /"&e#-"/6 3a-na 4"4- 8'!%a#6
#"$a! a$a #-'#a%"#"/ pa$a 4"4"-
G"g" : !'#'-6 8a-"e/6 #"$a! &e&a!a" !a3a# g"g"
L"$a : !'#'-6 penge8apan n'-&a%6 #"$a! a$a
+a&u-6 #"$a! a$a /#'&a#"#"/6 3a-na &e-a
&u$a
Tengg'-'!an :#"$a! a$a p&4e/a-an !e%en+a- #'n/"%6 -e %e!
&ene%an 4e-!u-ang
Le e- :/"&e#-"/6 #"$a! a$a 4en+'%an6 #"$a! a$a
pe&4e/a-an !e%en+a- ge#a 4en"ng6 #"$a!
a$a e$e&a
Da$a :/"&e#-"/6 #"$a! a$a 4en+'%an6 #"$a! a$a
e$e&a6 pe-ge-a!an $"n$"ng $a$a n'-&a%6
A4$'&en :/"&e#-"/6 #"$a! a$a n -" #e!an
Gene#a%"a :#"$a! $" !a+"E!/#-e&"#a/ :!e!ua#an '#'# n'-&a%6#e-$apa# #angan
!anan $" "n u/6 $an #angan !"-" 4"/a $"
ge-a!an
(. Pe&e-"!/aan penun+anga. Pe&e-"!/aan %a4'%a#'-"u&
He&a#'%'g"
N'
.
en"/ '4a# Ha/"% N"%a" n'-&a%
1. 1. He&'g%'4"n2. He&a#'!-"#). Leu!'/"#
. T-'&4'/"#
1. =2. 2)). ()00
. 1)06*0
1. 1)60;1*2. 0; 5). 5000;10000
. 150000; 00000
=. Pena#a%a!/anaana. P-'g-a& peng'4a#an
N'. en"/ '4a# Te-ap" D'/"/
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8/16/2019 LAPORAN CATATAN PPERKEMBANGAN
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1. 1. IU@D2. Ran"#"$"ne1. An#a/"$
1. In u// RL2. In+e!/"). O-a%
1. 20 ##/<&en"#2. 12 +a& 291). )91
4. Pena#a%a!/anaan !epe-a3a#an1. M'n"#'- TT2. An+u!-!an #e!n"! -e%a!/a/"). Mengan+u-!an &a!an /e$"!"# #e#ap" /e-"ng
. K'%a4'-aa/" $engan $'!#e- un#u! pe&4e-"an '4a#; '4a#an.
B. Data Fokus1. Da#a /u4+e!#"
a. K%"en &enga#a!an na a/ pen$e! 4. K%"en &enga#a!an %e&a/8. K%"en &enga#a!an #"$a! na /u &a!an
2. Da#a '4+e!#" a. K%"en #e-pa/ang O2
4. Te-4a-"ng %e&a/ $" #e&pa# #"$u- 8. K%"en &a!an 2 /en$'! /e#"ap &au &a!an
C. Analisa data
N'. Da#a $a/a- &a/a%a E#"'%'g"1. D/:
K%"en &enga#a!an na a/ pen$e!
D':
K%"en #e-pa/ang O2
P'%a na a/ #"a!
e e!#"
Pen e&p"#an +a%an
na a/
2. D/ :
K%"en &enga#a!an %e&a/
D' :Te-4a-"ng %e&a/ $" #e&pa# #"$u-
In#'%e-an/" a!#"7"#a/ Ke%e&a an "/"!
). D/ :
K%"en &enga#a!an #"$a! na /u
&a!an
R"/"!' nu#-"/"
!u-ang $a-"
!e4u#u an
an'-e!/"a
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D' :
K%"en &a!an 2 /en$'! /e#"ap &au
&a!an
D. Diagnosa keperawatan1. P'%a na a/ "$a! e e!#" 4.$ pen e&p"#an +a%an na a/2. In#'%e-an/" a!#"7"#a/ 4.$ !e%e&a an "/"! ). R"/"!' nu#-"/" !u-ang $a-" !e4u#u an 4.$ an'-e!/"a
E. Rencana keperawatan
N'. Ha-"
<#angga%
D9. !epe-a3a#an Tu+uan $an !-"#e-"a In#e-7en/" Ra/"'na%
1. P'%a na a/ "$a!
e e!#" 4.$ pen e&p"#an +a%an
na a/
Se#e%a $" 4e-"!an
a/u an!epe-a3a#an )92
+a&
K%"en #"$a! /e/a!
1. M'n"#'- TT2. Me&a/ang O2
). Me&4e-"!an p'/"/" n a&an
. Ka+" p'%a na a/5. K'%a4'-a/"
$engan $'!#e-
un#u!
pe&4e-"an '4a#
'4a#an
1. Menge#a u"
!'n$"/"!%"en
2. Na a/ %an8a- ). Me-a/a!an
n a&an. Pe&4e-"an
#e-ap" '4a#
2. In#'%e-an/" a!#"7"#a/
4.$ !e%e&a an "/"!
Se#e%a $" 4e-"!an
a/u an
!epe-a3a#an
K%"en #a&pa! #"$a!
%e&a/
1. M'n"#'- TT2. Ban#u %a#" an
ge-a! a!#" ). An+u-!an
"/#"-a a# ang
8u!up. K'%a4'-a/"
$engan $'!#e-
1. Menge#a u"
!'n$"/"
!%"en2. Me%en#u-!an
'#'# $an
/en$"). Pe&enu an
!e4u#u an
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un#u!
pe&4e-"an '4a#
'4a#an
p'%a
"/#"-a a#. Te-ap" '4a#
). R"/"!' nu#-"/"
!u-ang $a-"
!e4u#u an 4.$
an'-e!/"a
Se#e%a $" 4e-"!an
a/u an
!epe-a3a#an
)92 +a&Pe&enu an1. nu#-"/" #e-penu "
1. &'n"#'- TT2. an+u-!an &a!an
/e$"!"# #e#ap" /e-"ng). !a+" &a/u!an
nu#-"/" !%"en. !'%a4'-a/"
$engan a %" g" "5. !'%a4'-a/"
$engan $'!#e- un#u! pe&4e-"an
'4a# '4a#an
1. &enge#a u"
!'n$"/" !%"en2. pe&enu an
nu#-"/"). &enge#a u"
&a/u!an nu#-"/"
!%"en.pe&enu an
!e4u#u an
nu#-"/"5. Te-ap" '4a#
F. Catatan perkembangan Na&a : Tn.SD9 &e$"/ : Ane&"aRuangan : pen a!"# $a%a&
N'. MR : 10())*
N'. Ha-"<
#angga%
N'.
D9
!ep
I&p%e&en#a/" Pa-a
1. 1 1. M'n"#'- TT2. Me&a/ang O2). Me&4e-"!an p'/"/" n a&an
. Ka+" p'%a na a/5. K'%a4'-a/" $engan $'!#e-
un#u! pe&4e-"an '4a#
'4a#an
S :K%"en &enga#a!an na a/n a
&a/"! #e-a/a pen$e!
O :RR: 2(9<&en"#
A : p'%a na a/ #"$a! e e!#"
P :1. M'n"#'- TT2. Me&a/ang O2). Me&4e-"!an p'/"/"
n a&an. Ka+" p'%a na a/
5. K'%a4'-a/" $engan
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$'!#e- un#u!
pe&4e-"an '4a#
'4a#an
2. 2 1. M'n"#'- TT2. Ban#u %a#" an ge-a! a!#" ). An+u-!an "/#"-a a# ang
8u!up. K'%a4'-a/" $engan $'!#e-
un#u! pe&4e-"an '4a#
'4a#an
S :K%"en &enga#a!an 4a$ann a
&a/" #e-/a %e&a/
O :K%"en #e-4a-"ng %e&a/ $"
#e&pa# #"$u-
A :In#'%e-an/" a!#"7"#a/ 4e%u&
#e-a#a/"
P :Lan+u#!an "n#e-7en/"
1. M'n"#'- TT2. Ban#u %a#" an ge-a!
a!#" ). An+u-!an "/#"-a a#
ang 8u!up. K'%a4'-a/" $engan
$'!#e- un#u!
pe&4e-"an '4a#
'4a#an
). ) 1. &'n"#'- TT2. an+u-!an &a!an /e$"!"#
#e#ap" /e-"ng). !a+" &a/u!an nu#-"/" !%"en
. !'%a4'-a/" $engan a %" g" "5. !'%a4'-a/" $engan $'!#e-
un#u! pe&4e-"an '4a#
'4a#an
S :K%"en &enga#a!an pe-u#n a
/a!"#
O :K%"en &a!an 2 /en$'! /e#"ap
&a!an
A : Nu#-"/" 4e%u& #e-penu "
P :Lan+u#!an "n#e-7en/"
1. &'n"#'- TT
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2. an+u-!an &a!an /e$"!"#
#e#ap" /e-"ng). !a+" &a/u!an nu#-"/"
!%"en. !'%a4'-a/" $engan a %"
g" "5. !'%a4'-a/" $engan
$'!#e- un#u! pe&4e-"an
'4a# '4a#an. 1 1. M'n"#'- TT
2. Me&a/ang O2). Me&4e-"!an p'/"/" n a&an
. Ka+" p'%a na a/5. K'%a4'-a/" $engan $'!#e-
un#u! pe&4e-"an '4a#
'4a#an
S :K%"en &enga#a!an na a/n a
&a/"! #e-a/a pen$e!
O :RR: 2(9<&en"#
A : p'%a na a/ #e-a#a/"
/e4ag"an
P :1. M'n"#'- TT2. Me&a/ang O2
). Me&4e-"!an p'/"/"n a&an
. Ka+" p'%a na a/5. K'%a4'-a/" $engan
$'!#e- un#u!
pe&4e-"an '4a#
'4a#an
5. 2 1. M'n"#'- TT2. Ban#u %a#" an ge-a! a!#" ). An+u-!an "/#"-a a# ang
8u!up. K'%a4'-a/" $engan $'!#e-
un#u! pe&4e-"an '4a#
'4a#an
S :K%"en &enga#a!an 4a$ann a
&a/" #e-/a %e&a/
O :K%"en #e-4a-"ng %e&a/ $"
#e&pa# #"$u-
A :In#'%e-an/" a!#"7"#a/ 4e%u&
#e-a#a/"
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P :
Lan+u#!an "n#e-7en/"1. M'n"#'- TT2. Ban#u %a#" an ge-a!
a!#" ). An+u-!an "/#"-a a#
ang 8u!up. K'%a4'-a/" $engan
$'!#e- un#u!
pe&4e-"an '4a#'4a#an
(. ) 1. &'n"#'- TT2. an+u-!an &a!an /e$"!"#
#e#ap" /e-"ng). !a+" &a/u!an nu#-"/" !%"en
. !'%a4'-a/" $engan a %" g" "5. !'%a4'-a/" $engan $'!#e-
un#u! pe&4e-"an '4a#
'4a#an
S :K%"en &enga#a!an pe-u#n a
/a!"#O :K%"en &a!an 2 /en$'! /e#"ap
&a!an
A : Nu#-"/" #e-penu " a#au
#e-a#a/" /e4ag"an
P :Lan+u#!an "n#e-7en/"1. &'n"#'- TT2. an+u-!an &a!an /e$"!"#
#e#ap" /e-"ng). !a+" &a/u!an nu#-"/"
!%"en. !'%a4'-a/" $engan a %"
g" "5. !'%a4'-a/" $engan
$'!#e- un#u! pe&4e-"an
'4a# '4a#an=. 1 1. M'n"#'- TT
2. Me&a/ang O2). Me&4e-"!an p'/"/" n a&an
. Ka+" p'%a na a/
S :K%"en &enga#a!an na a/n a
&a/"! #e-a/a pen$e!
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5. K'%a4'-a/" $engan $'!#e-
un#u! pe&4e-"an '4a#
'4a#an
O :RR: 2(9<&en"#
A :
p'%a na a/ #e-a#a/"
P :Lan+u#!an "n#e-7en/"
1. M'n"#'- TT2. Me&a/ang O2). Me&4e-"!an p'/"/"
n a&an. Ka+" p'%a na a/
5. K'%a4'-a/" $engan
$'!#e- un#u!
pe&4e-"an '4a#
'4a#an
*. 2 1. M'n"#'- TT2. Ban#u %a#" an ge-a! a!#" ). An+u-!an "/#"-a a# ang
8u!up. K'%a4'-a/" $engan $'!#e-
un#u! pe&4e-"an '4a#
'4a#an
S :K%"en &enga#a!an 4a$ann a
&a/" #e-/a %e&a/
O :
K%"en #e-4a-"ng %e&a/ $"#e&pa# #"$u-
A :In#'%e-an/" a!#"7"#a/ #e-a#a/"
P :
Lan+u#!an "n#e-7en/"
1. M'n"#'- TT2. Ban#u %a#" an ge-a!
a!#" ). An+u-!an "/#"-a a#
ang 8u!up. K'%a4'-a/" $engan
$'!#e- un#u!
pe&4e-"an '4a#
'4a#an
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. ) 1. &'n"#'- TT2. an+u-!an &a!an /e$"!"#
#e#ap" /e-"ng). !a+" &a/u!an nu#-"/" !%"en
. !'%a4'-a/" $engan a %" g" "5. !'%a4'-a/" $engan $'!#e-
un#u! pe&4e-"an '4a#
'4a#an
S :K%"en &enga#a!an pe-u#n a
/a!"#
O :K%"en &a!an 2 /en$'! /e#"ap
&a!an
A : Nu#-"/" #e-penu " a#au
#e-a#a/"
P :
Lan+u#!an "n#e-7en/"1. &'n"#'- TT2. an+u-!an &a!an /e$"!"#
#e#ap" /e-"ng). !a+" &a/u!an nu#-"/"
!%"en. !'%a4'-a/" $engan a %"
g" "5. !'%a4'-a/" $engan $'!#e-
un#u! pe&4e-"an '4a#'4a#an
17
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