LAPORAN INDIVIDU
LAPORAN PENDAHULUAN DAN ASUHAN KEPERAWATAN
PASIEN DENGAN (MASALAH)
Oleh:
Nama : ………………………….
NIM : ………………………….
B. Pengertian
E. Pemeriksaan Diagnostik
F. Penatalaksanaan Medis
G. Pengkajian Keperawatan
I. Intervensi Keperawatan
J. Referensi
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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5. Lain-lain:
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RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis
:………………….....................................................................................................................................
- Genogram :
0 1 2 3 4
Makan minum
Mandi
Berpakaian/dandan
Toileting
Mobilitas ditempat tidur
Berpindah
Berjalan
Naik tangga
Berbelanja
0 1 2 3 4
Memasak
Pemeliharaan rumah
Riwayat masalah penyembuhan kulit : Tidak ada Penyembuhan Abnormal ada ruam
Kering ada luka/lesi
Pruritus
POLA ELIMINASI
Kebiasaan defekasi (BAB) : kali/hari kali/minggu Tgl. Defekasi terakhir:
Pola BAB saat ini : dalam batas normal Konstipasi Diare Inkontinensia
Nyeri Keluar darah Warna faeces:
POLA TIDUR-ISTIRAHAT
Kebiasaan tidur : .................... jam/malam hari ................... jam/tidur siang
Nyenyak tidur : Ya tidak
Masalah tidur : Tidak ada Ya terbangun malam hari Sulit
tidur/Insomnia
Mimpi buruk Nyeri/tdk nyaman Gangg. Psikologis,
Sebutkan:
POLA KOGNITIF-PERSEPTUAL
Keadaan mental : stabil Afasia Sukar bercerita Disorientasi
Kacau mental Menyerang/agresif Tidak ada respons
Berbicara : Normal Bicara tidak jelas Berbicara inkoheren
Tidak dapat berkomunikasi verbal
Bahasa yang dikuasai : Indonesia Lain-lain:
POLA PERAN-HUBUNGAN
Peran saat ini yang dijalankan :
Penampilan peran sehubungan dengan sakit : Tidak ada masalah Ada masalah,
Sebutkan :
Sistem pendukung : Pasangan(Istri/Suami) Saudara/famili
Orang tua/wali teman dekat tetangga
Interaksi dengan orang lain : Baik Ada masalah
Menutup diri : Tidak Ya
Mengisolasi diri/diisolasi orang lain : Tidak Ya
Hasil pengkajian lain:
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POLA NILAI-KEYAKINAN
Agama yang dianut :
Pantangan agama : Tidak Ya (sebutkan)
Meminta dikunjungi Rohaniawan : Ya Tidak
Nilai/keyakinan terhadap penyakit yang
diderita:
Distres Spiritual : Tidak Ya, sebutkan
Hasil pengkajian lain:
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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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8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Aurcicula
MAE
Membran
Tymphani
Rinne
Weber
Swabach
b. Tes Audiometri
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TERAPI MEDIS
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Malang,
Tanda Tangan
(……………………………)
ANALISA DATA
Nama Pasien :
Umur :
No. Register :
Hari/
Tgl/ DATA ETIOLOGI MASALAH
Jam
DIAGNOSA KEPERAWATAN
Nama Pasien :
Umur :
No. Register :
1.
2.
3.
4. dst
PRIORITAS MASALAH KEPERAWATAN
Nama Pasien :
No. Register :
No TANGGAL TANGGAL TANDA
DIAGNOSA KEPERAWATAN
DX MUNCUL TERATASI TANGAN
RENCANA ASUHAN KEPERAWATAN
Nama Pasien :
No. Register :
Hari/ Tgl/ DIAGNOSA NOC NIC
No. RASIONAL
Jam KEPERAWATAN (Nursing Outcome Classification) (Nursing Intervention Classification)
IMPLEMENTASI DAN EVALUASI
Nama Pasien :
No. Register :
Hari/ Tgl/
No. Dx Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
Shift
EVALUASI FORMATIF
No. Diagnosa
Tgl: ......................... Tgl: ......................... Tgl: ......................... Paraf.
Keperawatan
S : ............................................................. S : ............................................................. S : .............................................................
O: O: O:
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A : .............................................................. A : .............................................................. A : ..............................................................
Tuliskan evaluasi yang dilakukan untuk menilai keberhasilan asuhan keperawatan dengan menggunakan pendekatan SOAP/SOAPIER
(Subjective, Objective, Analizing, Planning, Implementing,Evaluating, Re-Assessing)
FORMAT RESUME
I. BIODATA
Nama : …………………………………………………………………
Jenis kelamin ; …………………………………………………………………
Umur : …………………………………………………………………
Status Perkawinan : …………………………………………………………………
Pekerjaan : …………………………………………………………………
Agama : …………………………………………………………………
Pendidikan Terakhir : …………………………………………………………………
Alamat : …………………………………………………………………
Tanggal MRS : …………………………………………………………………
Tanggal Pengkajian : …………………………………………………………………
1. Keluhan utama
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2. Riwayat Kesehatan Sekarang
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3. Riwayat kesehatan yang lalu
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4. Riwayat kesehatan keluarga
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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