Jl. Medokan Semampir Indah 27 Surabaya, Tlp. 031- 5913372, Fax. 031-5939466
Email : stikesbykep@gmail.com, Website : www.stikes-sby.ac.id
IDENTITAS PASIEN
1 Nama Pasien :
2 Umur : Thn / Bulan / Hari Jenis Kelamin : L P
3 Suku/ Bangsa :
4 Agama :
5 Pendidikan :
6 Pekerjaan :
7 Alamat :
8 Sumber Biaya :
KELUHAN UTAMA
1 Keluhan utama :
GENOGRAM
Keterangan : Laki-laki
Perempuan
Meninggal Dunia
Klien / Pasien
Tinggal serumah
c Sekret :
d Konsistensi :
e Warna :
f Bau :
g Penggunaan alat bantu nafas :
h PCH ya tidak : Ya Tidak
i Irama nafas teratur tidak teratur : Teratur Tidak Teratur
j Pleural Friction Rub :
k Pola nafas : Dispnoe Kusmaul
Cheyne Stokes Biot
l Suara nafas : Cracles Ronki Wheezing
m Alat bantu napas : Ya Tidak
ü Jenis : Flow lpm
n Penggunaan WSD
ü Jenis :
ü Jumlah cairan :
ü Undulasi :
ü Tekanan :
o Tracheostomy : Ya Tidak
p Lain-lain :
MASALAH KEPERAWATAN
MASALAH KEPERAWATAN
k Balance cairan :
l Lain-lain: :
MASALAH KEPERAWATAN
MASALAH KEPERAWATAN
7 Sistem Penglihatan
a Pengkajian segmen anterior dan posterior
OD OS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO
MASALAH KEPERAWATAN
8 Sistem pendengaran
a Pengkajian segmen anterior dan posterior
OD OS
Aurcicula
MAE
Membran Tymphani
Rinne
Weber
Swabach
b Tes Audiometri :
MASALAH KEPERAWATAN
e Frankel :
f Fraktur : Ya Tidak
ü Jenis
g Traksi : Ya Tidak
ü Jenis :
ü Beban :
ü Lama pemasangan :
h Penggunaan spalk / gips : Ya Tidak
i Keluhan nyeri : Ya Tidak
ü P (Provokes / Penyebab) :
ü Q (Quality / Gambaran) :
ü R (Radiates / Penyebara) :
ü S (Severity / Skala) :
ü T (Time / Waktu) :
j Sirkulasi perifer :
k Kompartemen syndrome : Ya Tidak
l Kulit : Ikterik Sianosis Kemerahan Hiperpigmentasi
m Turgor : Baikk Kurang Jelek
n Luka operasi : Ada Tidak
ü Tanggal operasi :
ü Jenis operasi :
ü Lokasi :
ü Keadaan :
o Drain : Ada Tidak
ü Jumlah :
ü Warna :
ü Kondisi area sekitar insersi :
p ROM :
q Cardinal Sign :
r Lain-lain :
MASALAH KEPERAWATAN
10 Sistem Integumen
a Penilaian resiko decubitus
Aspek yang Kriteria Penilaian
Nilai
dinilai 1 2 3 4
Persepsi Sensori Terbatas Sepenuhnya Sangat Terbatas Keterbatasan Ringan Tidak Ada Gangguan
Kelembaban Terus Menerus Basah Sangat Lembab Kadang2 Basah Jarang Basah
Mobilisasi Immobile Sepenuhnya Sangat Terbatas Keterbatasan Ringan Tidak Ada Keterbatasan
b Warna :
c Pitting edema : Ya Tidak Grade :
d Ekskoriasis : Ya Tidak
e Psoriasis : Ya Tidak
f Pruritus : Ya Tidak
g Urtikaria : Ya Tidak
h Lain-lain :
MASALAH KEPERAWATAN
11 Sistem Endokrin
a Pembesaran tyroid : Ya Tidak
b Pembesaran kelenjar getah bening : Ya Tidak
c Hipoglikemia : Ya Tidak
d Hiperglikemia : Ya Tidak
e Kondisi kaki DM
Luka gangren : Ya Tidak
ü Jenis :
ü Lama luka :
ü Warna :
ü Luas luka : Cm
ü Kedalaman : Cm
ü Kulit kaki :
ü Kuku kaki :
ü Telapak kaki :
ü Jari kaki :
f Infeksi : Ya Tidak
g Riwayat Luka sebelumya : Ya Tidak
Jika ya
ü Tahun :
ü Jenis Luka :
ü Lokasi :
h Riwayat amputasi sebelumya : Ya Tidak
Jika ya
ü Tahun :
ü Lokasi :
i ABI :
j Lain-lain :
MASALAH KEPERAWATAN
PENGKAJIAN PSIKOSOSIAL
1 Persepsi klien terhadap penyakitnya :
5 Lain-lain :
MASALAH KEPERAWATAN
MASALAH KEPERAWATAN
PENGKAJIAN SPIRITUAL
1 Kebiasaan beribadah
a Sebelum sakit : Sering Kadang-kadang Tidak pernah
b Selama sakit : Sering Kadang-kadang Tidak pernah
2 Bantuan yang diperlukan klien untuk :
memenuhi kebutuhan beribadah
MASALAH KEPERAWATAN
ya tidak kapan :…… diagnosa :…………
PEMERIKSAAN PENUNJANG (Laboratorium, Radiologi, EKG, USG , CT-Scan)
1 Laboraorium
Hasil Pemeriksaan
No Pemeriksaan Nilai Normal
KE-1 KE-2 KE-3 KE-4
1 HAEMATOLOGI
Hemoglobin ( L 13 - 18 g/d P 11 - 16 g/d )
Lekosit ( 4,000 - 11,000/cmm )
LED ( L 0-15 P 0-20/jam )
Hitung Jenis
- Eosinofil (1-6)
- Basofil (0-1)
- Stab (3-5)
- Segmen ( 54 - 62 )
- Limfosit ( 20 - 45 )
- Monosit ( 2 - 10 )
Hematokrit ( L 40 - 54% P 35 - 47% )
Trombosit (150,000 - 450,000/cmm)
Waktu Pendarahan ( 1 - 5 Menit )
Waktu Pembekuan ( 5 - 15 Menit )
Golongan Darah
2 URINE
PH ( 4.6 - 8.0 )
Berat Jenis ( 1.01 - 1.02 )
Protein ( Negatif )
Reduksi ( Negatif )
Urobilin ( Negatif )
Bilirubin ( Negatif )
Segmen
- Lekosit ( 0 – 2 / Lpb )
- Eritrosit ( 0 – 1 / Lpb )
- Epitel ( 0 – 2 / Lpb )
- Silinder ( Negatif )
- Kristal ( Negatif )
Tes Kehamilan
3 FAECES
Macros - Warna
- Konsistensi
- Lendir
- Darah
Micros - Amuba
- Cysta
- Telur cacing
- Eritrosit
- Lekosit
- Sisa makanan
Benzidene Test
4 KIMIA KLINIK
Gula Darah Puasa ( 70–115 Mg/dl )
Gula 2 Jam PP ( <125 Mg/dl )
Gula Darah Sewaktu ( <125 Mg/dl )
Cholesterol ( <220 Mg/dl )
HDL ( >35 Mg/dl )
LDL ( <150 Mg/dl )
Trigliserida ( <200 Mg/dl )
Serum Creatinin ( L 2,4-5,7 Mg/dl P 0,4-1,2 Mg/dl )
Urea ( 10 - 50 Mg/dl )
BUN ( 5 - 23 Mg/dl )
Uric Acid ( L 3,4-7 Mg/dl P 2,4-5,7 Mg/dl )
Total Bilirubin ( <1 Mg/dl )
Direc Bilirubin ( <0.25 Mg/dl )
SGOT ( L <37 U/L P <31 U/L ) T 37°C
SGPT ( L <40 U/L P <31 U/L ) T 37°C
Alkali Phospatase ( 80 - 306 U/L ) T 37°C
Total Protein ( 6.3 - 8.8 g/dl )
Albumin ( 3.6 - 5.2 g/dl )
Globulin ( 2.6 - 3.6 g/dl )
HbA1c ( < 8% )
5 IMUNO - SEROLOGI
HBs Ab ( Negatif )
HBs Ag ( Negatif )
Widal
-O ( Negatif )
-H ( Negatif )
- PA ( Negatif )
- PB ( Negatif )
6 BTA
- Sewaktu ( Negatif )
- Pagi ( Negatif )
- Sewaktu ( Negatif )
Hasil Pemeriksaan
No Jenis Pemeriksaan
Awal Akhir
PENALAKSANAAN / TERAPI DOKTER
Advis Dokter
No Nama Dokter
Resep Signa / Anjuran / Dosis
1 Oral
R/
R/
R/
R/
R/
R/
2 Parenteral
R/
R/
R/
R/
R/
R/
3 Intravena
R/
R/
R/
R/
R/
R/
4 Lain-lain
R/
R/
R/
R/
R/
R/
DATA TANBAHAN
1 Hasil Konsultasi Dengan Dokter / Perawat / Ahli Gizi / Sanitarian / dll
1
2
3
4
5
6
RENCANA INTERVENSI
No Hari/Tgl/Jam Diagnosa Keperawatan NOC (Nursing Outcome Classification NIC (Nursing Intervention Classification
IMPLEMENTASI KEPERAWATAN
Hari/Tgl/Shift No. Dx Jam Implementasi Keperawatan Paraf
EVALUASI KEPERAWATAN
Hari/Tgl/Shift No. Dx Jam Evaluasi keperawatan (SOAP) Paraf
LAPORAN PENDAHULUAN
COVER
LEMBAR PENGESAHAN
BAB 1 PENDAHULUAN
1.1 LATAR BELAKANG
1.2 TUJUAN
1.3 MANFAAT
BAB 3 PENUTUP
3.1 KESIMPULAN
DAFTAR PUSTAKA
BAB 1
PENDAHULUAN
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1.2. TUJUAN
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1.3. MANFAAT
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BAB 2
TINJAUAN PUSTAKA
2.1. DEFINISI
2.2. ETIOLOGI
2.3. MANIFESTASI KLINIS
2.4. PATOFISIOLOGI
2.4. KOMPLIKASI
2.5. PENATALAKSANAAN
2.6. PENCEGAHAN
BAB 3
PENUTUP
3.1. KESIMPULAN
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3.2. SARAN
DAFTAR PUSTAKA