LAPORAN INDIVIDU
LAPORAN PENDAHULUAN DAN ASUHAN KEPERAWATAN
PASIEN DENGAN (Penyakit)
Oleh:
Nama : ………………………….
NIM : ………………………….
PK KMB 1 2018/2019 1
FORMAT LAPORAN PENDAHULUAN
B. Pengertian
E. Pemeriksaan Diagnostik
F. Penatalaksanaan Medis
G. Pengkajian Keperawatan
I. Intervensi Keperawatan
J. Referensi
PK KMB 1 2018/2019 2
FORMAT ASUHAN KEPERAWATAN
FORMAT PENGKAJIAN KEPERAWATAN
Tanggal MRS : Jam Masuk :
Tanggal Pengkajian : No. RM :
Jam Pengkajian : Diagnosa Masuk :
Hari rawat ke :
IDENTITAS KLIEN
1. Nama :
2. Jenis Kelamin :
3. Umur :
4. Status Kawin :
5. Suku/ Bangsa :
6. Agama :
7. Pendidikan :
8. Pekerjaan :
9. Alamat :
10. Sumber Biaya :
KELUHAN UTAMA
Keluhan utama:…… ………………………………………………………………………………………….
…………………………………………………………………………………………………………………
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PK KMB 1 2018/2019 3
RIWAYAT PENYAKIT DAHULU
1. Pernah dirawat : ya tidak kapan :…… diagnosa :…………
2. Riwayat penyakit kronik dan menular ya tidak jenis……………………
Riwayat kontrol : .............................
Riwayat penggunaan obat :..............
3. Riwayat alergi:
Obat ya tidak jenis……………………
Makanan ya tidak jenis……………………
Lain-lain ya tidak jenis……………………
5. Lain-lain:
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RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis
:………………….....................................................................................................................................
- Genogram :
PK KMB 1 2018/2019 4
Jenis................................................ Flow..............lpm
j. Penggunaan WSD:
- Jenis :
................................................................................................................................................................
.
- Jumlah cairan :
..................................................................................................................................................
- Undulasi
:...................................................................................................................................................
- Tekanan :
..................................................................................................................................................
k. Tracheostomy: ya tidak
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l. Lain-lain:
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PK KMB 1 2018/2019 5
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PK KMB 1 2018/2019 6
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
f. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
g. Kandung kemih : Membesar ya tidak
h. Nyeri tekan ya tidak
i. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
j. Balance cairan:
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k. Lain-lain:
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6. Sistem pencernaan (B5) Masalah Keperawatan :
a. TB :............... BB :................................
b. IMT :............... Interpretasi :................................
PK KMB 1 2018/2019 7
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Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO
8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Aurcicula
MAE
Membran
Tymphani
Rinne
Weber
PK KMB 1 2018/2019 8
Swabach
b. Tes Audiometri
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PK KMB 1 2018/2019 9
R :...................................................................
S :...................................................................
T :...................................................................
i. Sirkulasi perifer: ..............................................
j. Kompartemen syndrome ya tidak
k. Kulit: ikterik sianosis kemerahan hiperpigmentasi
l. Turgor baik kurang jelek
m. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
n. ROM : .................................................
PK KMB 1 2018/2019 10
e. Kondisi kaki DM
- Luka gangren ya tidak
Jenis ................................................................................................................
- Lama luka ...............................................................................................
- Warna ...............................................................................................
- Luas luka ...............................................................................................
- Kedalaman ...............................................................................................
- Kulit kaki ...............................................................................................
- Kuku kaki ...............................................................................................
- Telapak kaki ...............................................................................................
- Jari kaki ...............................................................................................
- Infeksi ya tidak
- Riwayat luka sebelumya ya tidak
Jika ya:
- Tahun :
- Jenis Luka :
- Lokasi :
- Riwayat amputasi sebelumya ya tidak
Jika ya:
- Tahun :
- Lokasi :
f. ABI : ....................................................
g. Lain-lain:
.......................................................................................................................................................... ............
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PK KMB 1 2018/2019 11
PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah
TERAPI MEDIS
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PK KMB 1 2018/2019 12
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Malang, 2018
(……………………………)
PK KMB 1 2018/2019 13
ANALISA DATA
Nama Pasien :
Umur :
No. Register :
Hari/
Tgl/ DATA ETIOLOGI MASALAH
Jam
PK KMB 1 2018/2019 14
DIAGNOSA KEPERAWATAN
Nama Pasien :
Umur :
No. Register :
1.
2.
3.
4. dst
PK KMB 1 2018/2019 15
PRIORITAS MASALAH KEPERAWATAN
Nama Pasien :
No. Register :
No TANGGAL TANGGAL TANDA
DIAGNOSA KEPERAWATAN
DX MUNCUL TERATASI TANGAN
PK KMB 1 2018/2019 16
RENCANA ASUHAN KEPERAWATAN
Nama Pasien :
No. Register :
Hari/ Tgl/ DIAGNOSA NOC NIC
No. RASIONAL
Jam KEPERAWATAN (Nursing Outcome Classification) (Nursing Intervention Classification)
PK KMB 1 2018/2019 17
IMPLEMENTASI DAN EVALUASI
Nama Pasien :
No. Register :
Hari/ Tgl/
No. Dx Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
Shift
PK KMB 1 2018/2019 18
FORMAT RESUME
I. BIODATA
Nama : …………………………………………………………………
Jenis kelamin ; …………………………………………………………………
Umur : …………………………………………………………………
Status Perkawinan : …………………………………………………………………
Pekerjaan : …………………………………………………………………
Agama : …………………………………………………………………
Pendidikan Terakhir : …………………………………………………………………
Alamat : …………………………………………………………………
Tanggal MRS : …………………………………………………………………
Tanggal Pengkajian : …………………………………………………………………
1. Keluhan utama
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………
2. Riwayat Kesehatan Sekarang
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………
3. Riwayat kesehatan yang lalu
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………
4. Riwayat kesehatan keluarga
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………
PK KMB 1 2018/2019 19
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V. IMPLEMENTASI
TGL PUKUL NO Dx.KEP IMPLEMENTASI TT
VI. EVALUASI
TGL
Dx.KEP DATA (soapier)
/ PUKUL
Subyektif
Obyektif
Assesment
Planning
Implementasi
Reassesment
PK KMB 1 2018/2019 20
PK KMB 1 2018/2019 21
LOG BOOK KEGIATAN PRAKTEK
KEPERAWATAN MEDIKAL BEDAH I
SEMESTER I TA. 2018/2019
PK KMB 1 2018/2019 22
KEGIATAN HARIAN
RUANG :
PERIODE PRAKTEK :
Paraf
Jam
Pembimbing
No Tanggal Dinas Kegiatan
lahan dan
/shift
institusi
PK KMB 1 2018/2019 23
Paraf
Jam
Pembimbing
No Tanggal Dinas Kegiatan
lahan dan
/shift
institusi
PK KMB 1 2018/2019 24
Paraf
Jam
Pembimbing
No Tanggal Dinas Kegiatan
lahan dan
/shift
institusi
PK KMB 1 2018/2019 25
KEGIATAN HARIAN
RUANG :
PERIODE PRAKTEK :
Paraf
Jam
Pembimbing
No Tanggal Dinas Kegiatan
lahan dan
/shift
institusi
PK KMB 1 2018/2019 26
Paraf
Jam
Pembimbing
No Tanggal Dinas Kegiatan
lahan dan
/shift
institusi
PK KMB 1 2018/2019 27
Paraf
Jam
Pembimbing
No Tanggal Dinas Kegiatan
lahan dan
/shift
institusi
PK KMB 1 2018/2019 28
DAFTAR HADIR PRAKTEK KLINIK KMB I
MINGGU I
Jam TTD Jam TTD CI dan
No Tgl TTD Mhs
Datang MHS Pulang Stempel
1
MINGGU II
Jam TTD Jam TTD CI dan
No Tgl TTD Mhs
Datang MHS Pulang Stempel
1
PK KMB 1 2018/2019 29