SUSUNAN LAPORAN PENDAHULUAN

1. Pengertian
2. Etiologi
3. Tanda dan gejala / Manifestasi Klinis
4. Patofisiologi
5. Pathways
6. Pemeriksaan penunjang
7. Penatalaksanaan
8. Komplikasi
9. Pengkajian
10. Diagnosa keperawatan yang mungkin muncul ( minimal 3 )
11. Intervensi keperawatan
12. Daftar Pustaka ( Minimal 5 referensi dan tahun buku minimal tahun 2000)

SUSUNAN LAPORAN KASUS KELOLAAN

1. Pengkajian data dasar :

- Identitas klien
- Riwayat Kesehatan
- Pengkajian sistem/ pola
- Data penunjang dan terapi
2. Analisa Data
3. Diagnosa keperawatan dan prioritas
4. Rencana Keperawatan
5. Implementasi Keperawatan
6. Evaluasi
 FORMAT ASUHAN KEPERAWATAN

Nama Mahasiswa : …………………………………………………………

Nim : …………………………………………………………

Tempat Praktik : …………………………………………………………

Tanggal / jam :....................................................

I. IDENTITAS

A. Identitas Pasien

Nama : .................................................................

Alamat : ……………………………………………………..........

Umur : ………………………………………………................

Agama : ……………………………………………………..........

Pendidikan : ……………………………………………………..........

Pekerjaan : …………………………………………………………....

Suku / bangsa : …………………………………………………………....

Jenis Kelamin : …………………………………………………………....

Tanggal Masuk : .................................................................

Diagnosa Medis : .................................................................

No. CM : .................................................................

A. Identitas Penangguang Jawab

Nama : …………………………………………………………....

Umur : …………………………………………………………....

Alamat : …………………………………………………………....

Pekerjaan : …………………………………………………………....

Agama : …………………………………………………………....

Hubungan dengan Klien : ………………………………………………………….....

II. Riwayat Kesehatan

1. Keluhan Utama
......................................................................................................................................................

2. Riwayat Kesehatan Sekarang

....................................................................................................................................................................
Riwayat Kesehatan Dahulu

......................................................................................................................................................
 3. Riwayat Kesehatan Keluarga
......................................................................................................................................................

III. Kebiasaan Sehari-hari ( Menurut Gordon )

1. Pola Persepsi Kesehatan

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

2. Pola Nutrisi
Sebelum Di RS : ...........................................................................................................................

Selama di RS :...............................................................................................................................

3. Pola Atifitas

Sebelum Di RS :.............................................................................................................................

Selama di RS :..............................................................................................................................

4. Pola Eliminasi

Sebelum Di RS :..............................................................................................................................

Selama di RS : ................................................................................................................................

5. Pola Istirahat dan Tidur

Sebelum Di RS : ..............................................................................................................................

Selama di RS : .................................................................................................................................

6. Pola Peran

Sebelum Di RS : .............................................................................................................................

Selama di RS : ................................................................................................................................

7. Pola Kognitif dan Persepsi

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

8. Pola Kebersihan Diri

Sebelum Di RS : ...........................................................................................................................

Selama di RS :
.....................................................................................................................................................

9. Pola Koping terhadap Stress

Sebelum Di RS : .........................................................................................................................

Selama di RS : .............................................................................................................................

10. Pola Seksualitas dan Reproduksi

Sebelum Di RS : ...........................................................................................................................

Selama di RS : ..............................................................................................................................
 11. Kepercayaan dan Keyakinan

Sebelum Di RS : ...........................................................................................................................

Selama di RS : ..............................................................................................................................

IV. PEMERIKSAAN FISIK

1. Keadaan Umum : ……………………………………………………………………………..

2. Kesadaran : ………………………………………………………………
3. TTV : Nadi …x/mnt, Suhu .......C Tensi ……mm RR ...............x/mnt
4. Kepala : Kontribusi rambut...............,kelaianan....................................................
5. Mata :
......................................................................................................................................................

6. Hidung
......................................................................................................................................................

7. Telinga
......................................................................................................................................................

8. Bibir dan Mulut

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

9. Leher
......................................................................................................................................................

10. Payudara
......................................................................................................................................................

11. Dada
- Jantung

I : ........................................................................................................

A : ........................................................................................................

P : ........................................................................................................

P : ........................................................................................................

- Paru
I : ........................................................................................................

A : .......................................................................................................

P : ........................................................................................................

P : ........................................................................................................

12. Abdomen
A : ........................................................................................................

I : ........................................................................................................
 P : ........................................................................................................

P : …………………………………………………………………….................................

13. Punggung
…………………………………………………………………………………………...........................

14. Genetalia dan Anus

…………………………………………………………………………………………………..................

15. Extremitas
Atas : ……………………………………………………………………....

Bawah : ……………………………………………………………………

16. Kulit
…………………………………………………………………………………………………................

V. Pemeriksaan Penunjang

1. Laboratorium……………………………………………………………………………………
2. Rontgen…………………………………………………………………………………………...
3. Therapi……………………………………………………………………………………..........
VI. ANALISA DATA

NO DATA FOKUS ETIOLOGI PROBLEM

1 DS :

DO :

2 DS :

DO :

VII. PRIORITAS DIAGNOSA

1.

2.

VIII. RENCANA KEPERAWATAN

NO DP TUJUAN INTERVENSI RASIONALISASI TTD

IX. IMPLEMENTASI / CATATAN PERKEMBANGAN

NO HARI/ IMPLEMENTASI RESPON TTD

TANGGAL
X. EVALUASI

Tgl / DP EVALUASI TTD

Jam

S:

O:

A:

P: