LAPORAN PENDAHULUAN DAN ASUHAN KEPERAWATAN

PADA PASIEN DENGAN PENYAKIT ……………………………….

DI RUANG …………………………… RS. ……………………………………….

OLEH:

NAMA :

NIM :

PROGRAM STUDI PROFESI NERS

SEKOLAH TINGGI ILMU KESEHATAN (STIKes) BINA SEHAT PPNI

KAB. MOJOKERTO
 LEMBAR PENGESAHAN

Pengesahan laporan Asuhan Keperawatan (ASKEP) praktik Praktik profesi Ners di Rumah Sakit
(RS), yang disusun oleh;
Nama : …………………………………………..
Nim : …………………………………………..
Telah melaksanakan praktik Profesi Ners Rumah Sakit (RS) pada:
Tanggal : ……………………………………………
Ruang : ……………………………………………
Adapun rincian asuhan keperawatan terangkum dalam laporan ini.
Mojokerto,
Mahasiswa

………………………………………
NIM

Preceptor Akademik Preceptor Klinik

……………………………………… ………………………………………
NIP/NIK NIP/NIK

Mengetahu,
Kepala Ruangan

………………………………………
NIP/NIK
 FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :
NIM :
Tempat Praktek :
Tanggal :

I. PENGKAJIAN
A. No Registrasi pasien
IDENTITAS PASIEN
Nama : ………………………….. L/P
Tanggal lahir : ……………………………….. usia: ………………….
Gol Darah : O / A / B / AB
Pendidikan Terakhir : …………………………………………………………..
Agama : …………………………………………………………..
Status perkawinan : …………………………………………………………..
Pekerjaan : …………………………………………………………..
TB/BB : ……….. cm/ …… kg
Alamat : …………………………………………………………..
Tanggal Pengkajian : …………………………………………………………..
Tanggal MRS : …………………………………………………………..
DX Medis : …………………………………………………………..

STATUS KESEHATAN
1. KELUHAN UTAMA
.............................................................................................................................................
.............................................................................................................................................
2. RIWAYAT PENYAKIT SEKARANG
...............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................

1
3. RIWAYAT PENYAKIT DAHULU
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................

4. RIWAYAT PENYAKIT KELUARGA

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

II. PENGKAJIAN SISTEM

1. B1 (BREATING)
..................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
..................................................................................................................................
....................................................................................................................................
..................................................................................................................................
....................................................................................................................................

2. B2 (BLOOD)
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................

3. B3 (BRAIN)
..................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

2
 ..................................................................................................................................
....................................................................................................................................

4. B4 (BLADDER)
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................

5. B5 (BOWEL)
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................

6. B6 (BONE)
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................
..................................................................................................................................
.............................................................................................................................................

3
III. PEMERIKSAAN PENUNJANG
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
IV. TERAPI
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................

4
V. ANALISA DATA
INTERPRETASI
NO DATA (SIGN/SYMPTOM) MASALAH (PROBLEM)
(ETIOLOGI)

5
VI. DIAGNOSIS KEPERAWATAN (PRIORITAS MASALAH)
1. ....................................................................................................................................
2. ....................................................................................................................................
3. ....................................................................................................................................
4. ....................................................................................................................................

VII. RENCANA KEPERAWATAN

NO TUJUAN /KRITERIA
INTERVENSI & RASIONAL
DX HASIL

6
VIII. IMPLEMENTASI & EVALUASI KEPERAWATAN

HARI,
NO
TANGGAL IMPLEMENTASI EVALUASI
DX
& PUKUL