FORMAT LAPORAN ASUHAN KEPERAWATAN

ASUHAN KEPERAWATAN PADA ........................................

DENGAN ...........................................................
DI ................................................................
A. PENGKAJIAN
1.
Data Umum
Identitas Klien
Nama
Umur
Agama
Jenis Kelamin
Status Marital
Pendidikan
Pekerjaan
Suku Bangsa
Alamat
Tanggal Masuk
Tanggal Pengkajian
No. Register
Diagnosa Medis

: ...........................................................................................................
: ...........................................................................................................
: ...........................................................................................................
: ...........................................................................................................
: ...........................................................................................................
: ...........................................................................................................
: ...........................................................................................................
: ...........................................................................................................
: ...........................................................................................................
: ...........................................................................................................
: ..........................................................................................................
: ...........................................................................................................
: ...........................................................................................................

Identitas Penanggung Jawab

Nama
: ...........................................................................................................
Umur
: ...........................................................................................................
Hub. Dengan Klien
: ...........................................................................................................
Pekerjaan
: ...........................................................................................................
Alamat
: ...........................................................................................................
2.

Riwayat Kesehatan
Keluhan Utama
..............................................................................................................................................................
..................................................................................................................................................
Riwayat Penyakit Sekarang
..............................................................................................................................................................
..................................................................................................................................................
Riwayat Kesehatan Dahulu
..............................................................................................................................................................
..................................................................................................................................................
Riwayat Kesehatan Keluarga
..............................................................................................................................................................
..................................................................................................................................................
Genogram :

Riwayat Sosiokultural
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
3.
a.

Pola Fungsi Kesehatan Gordon

Pola Persepsi dan Manajemen Kesehatan

........................................................................................................................................................
........................................................................................................................................................
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

4.

Pola Nutrisi-Metabolik
........................................................................................................................................................
........................................................................................................................................................
Pola Eleminasi
........................................................................................................................................................
........................................................................................................................................................
Pola Aktivitas dan Latihan
........................................................................................................................................................
........................................................................................................................................................
Pola koqnitif dan Persepsi
........................................................................................................................................................
........................................................................................................................................................
Pola Persepsi-Konsep diri
........................................................................................................................................................
........................................................................................................................................................
Pola Tidur dan Istirahat
........................................................................................................................................................
........................................................................................................................................................
Pola Peran-Hubungan
.........................................................................................................................................................
.......................................................................................................................................................
Pola Seksual-Reproduksi
........................................................................................................................................................
........................................................................................................................................................
Pola Toleransi Stress-Koping
........................................................................................................................................................
........................................................................................................................................................
Pola Nilai-Kepercayaan
........................................................................................................................................................
........................................................................................................................................................
PEMERIKSAAN FISIK

a.
b.
c.
d.
e.
f.
g.
h.

i.

Keadaan Umum
........................................................................................................................................................
........................................................................................................................................................
Tanda Vital
........................................................................................................................................................
..................................................................................................................................
Kepala
........................................................................................................................................................
..................................................................................................................................
Mata
........................................................................................................................................................
..................................................................................................................................
Hidung
........................................................................................................................................................
..................................................................................................................................
Telinga
........................................................................................................................................................
..................................................................................................................................
Mulut
........................................................................................................................................................
..................................................................................................................................
Leher
........................................................................................................................................................
..................................................................................................................................
Dada dan Punggung

........................................................................................................................................................
.......................................................................................................................................................
j.
Abdomen
........................................................................................................................................................
........................................................................................................................................................
k.
Ekstremitas
........................................................................................................................................................
........................................................................................................................................................
l.
Genetalia
........................................................................................................................................................
.......................................................................................................................................................
m.
Anus
........................................................................................................................................................
.......................................................................................................................................................
5.

DATA PENUNJANG (Pemeriksaan Diagnostik) :

..................................................................................................................................................
....................................................................................................................................................
...........
6.
DATA TAMBAHAN
..............................................................................................................................................................
..............................................................................................................................................................
B.

ANALISA DATA
Data

Etiologi

Masalah
Kolaboratif /
Keperawatan

Tabel Daftar Masalah Kolaboratif / Diagnosa Keperawatan

NO
TANGGAL / JAM
DIAGNOSA KEPERAWATAN
DITEMUKAN

C.

TANGGAL, JAM
LENYAP / TERATASI

PERENCANAAN

D. NO.

TASI

DIAGNOSA

TUJUAN

INTERVENSI

RASIONAL

I
M
P
L
E
M
E
N

Hari/ Tgl/Jam

E.

No Dx

Tindakan Keperawatan

Evaluasi

Ttd

EVALUASI
No

Hari/Tgl

No Dx

Evaluasi

TTd

FORMAT RESUME KASUS

DI KAMAR OPERASI (Instalansi Bedah Sentral)
NAMA MAHASISWA
NIM
TANGGAL PRAKTEK
a.

b.

:
:
:

Identitas Klien
Nama
:
Jenis Kelamin
:
Umur
:
Status
:
Agama
:
Tanggal masuk
Tanggal pengkajian
:
Riwayat Kesehatan
Dx Medis
:
Rencana Operasi

Proses Keperawatan
1. Pre Operasi (Ruang Persiapan Operasi)
- Data Fokus

- Diagnosa Keperawatan/Masalah Kolaborasi

- Evaluasi

2. Intra Operasi (Ruang Operasi)

- Laporan Intra Operasi

- Diagnosa Keperawatan/Masalah Kolaborasi

- Intervensi/Implementasi

- Evaluasi

3. Post Operasi (Recovery Room)

- Data Fokus

- Diagnosa Keperawatan/Masalah Kolaborasi

- Intervensi/Implementasi

- Evaluasi

SATUAN ACARA PENYULUHAN

(SAP)
POKOK BAHASAN
SUB POKOK BAHASAN
SASARAN
TEMPAT
WAKTU

:
:
:
:
:

I.

Latar Belakang

II.

Tujuan Instruksional Umum

III.

Tujuan Instruksional Khusus

IV.

Metode

V.

Media

VI.

Rencana Pembelajaran
No
Kegiatan Penyuluhan
1
Pembukaan
2
Pelaksanaan
3
Penutup

VII.

Materi

VIII.

Evaluasi

IX.

Daftar Pustaka

Waktu

Kegiatan audiens

FORMAT STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Nama
Umur
Jenis kelamin
Ruang

:
:
:
:

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

No RM
: ............................................
Tgl MRS : ............................................
Dx Medis : ............................................

Kondisi klien :
.................................................................................................................................................
.................................................................................................................................................
Alasan masuk RS :
.................................................................................................................................................
.................................................................................................................................................
Data fokus :
.................................................................................................................................................
.................................................................................................................................................

Diagnosa keperawatan (masalah)

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

Tujuan khusus : tujuan yang akan dicapai, kriteria hasil

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

Tindakan keperawatan : tindakan apa yang akan dilakukan, SOP tindakan tersebut
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................

STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN KEPERAWATAN

ORIENTASI

Salam terapeutik
:
...................................................................................................................

Evaluasi/validasi
:
.............................................

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

Kontrak
Topik
: .................................................................................................................................
Waktu : .................................................................................................................................
Tempat : .................................................................................................................................

KERJA
(Langkah-langkah tindakan keperawatan) : komunikasi saat melakukan tindakan
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
TERMINASI
o Evaluasi respon klien terhadap tindakan keperawatan
o

Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan yang telah
dilakukan

FORMAT LAPORAN PENDAHULUAN

LAPORAN PENDAHULUAN
ASUHAN KEPERAWATAN PADA KLIEN DENGAN .......

A. KONSEP DASAR PENYAKIT

1.
Definisi/Pengertian
2.
Epidemiologi/Insidensi Kasus
3.
Penyebab/Faktor Predisposisi
4.
Patofisiologis terjadinya penyakit (dengan bagan)
5.
Klasifikasi (kalau ada)
6.
Gejala Klinis
7.
Pemeriksaan Fisik
8.
Pemeriksaan Diagnostik/Penunjang (Laboratorium, Radiologi, dll)
9.
Therapy/Tindakan Penanganan
10.
Komplikasi
B. KONSEP DASAR ASUHAN KEPERAWATAN
1.
Pengkajian (data subyektif dan obyektif)
2.
Diagnosa keperawatan yang mungkin muncul
3.
Rencana Tindakan
4.
Evaluasi
C. DAFTAR PUSTAKA

Keterangan: Format panduan ini dapat dimodifikasi disesuaikan dengan kebutuhan dan sumber yang
ada.

FORMAT RESUME KASUS POLIKLINIK

LAPORAN PRAKTIK PROFESI
DI POLIKLINIK ........ RSUP SANGLAH DENPASAR

NAMA MAHASISWA
NIM
TANGGAL PRAKTIK

:
:
:

A. IDENTITAS KLIEN
Nama
:
Umur
:
Jenis Kelamin
:
Alamat
:
No. RM
:
Dx. Medis
:
B. PENGKAJIAN
Data Fokus
:
................................................................................................................................................................
................................................................................................................................................................
C. RENCANA
No.
Dx. Keperawatan/
Masalah Kolaborasi

Tujuan

Implementasi

Evaluasi

FORMAT RESUME KASUS HEMODIALISA

LAPORAN PRAKTIK PROFESI
RUANG HEMODIALISA RSUP SANGLAH DENPASAR

NAMA MAHASISWA
NIM
TANGGAL PRAKTIK

:
:
:

A. IDENTITAS KLIEN
Nama
Umur
Jenis Kelamin
Alamat
Penanggung Jawab Biaya
Tanggal HD
No. RM
Dx. Medis

:
:
:
:
:
:
:
:

B. PENGKAJIAN
1.
Pre HD (meliputi: KU, BB, TTV, Pemeriksaan Fisik, Status cairan dan
elektrolit, Keluhan, dll.)
...........................................................................................................................................................
2.
a.

Selama Pelaksanaan HD:

Keluhan selama HD
...................................................................................................................................................

b.
-

Data Hemodialisi:
Tanggal mulai HD
: ........................................................................................
Tipe dan lokasi akses vaskuler : ........................................................................................
Frekuensi HD/minggu
: ........................................................................................
Lama HD setiap sesi
: ........................................................................................
Jenis cairan dialisat
: ........................................................................................
Dosis dan metode heparinisasi : ........................................................................................
Rata-rata Blood Flow Rate (QB)
: ........................................................................................
Berat badan kering
: ........................................................................................

C. DIAGNOSA KEPERAWATAN/MASALAH KOLABORASI (Pre, Intra dan Post HD)

................................................................................................................................................................
................................................................................................................................................................
D. RENCANA INTERVENSI DAN IMPLEMENTASI
................................................................................................................................................................
................................................................................................................................................................

E. EVALUASI
................................................................................................................................................................
................................................................................................................................................................