LAPORAN PENDAHULUAN

GANGGUAN SISTEM ___________________ : ______________________

DI RUANG ______________________ RSUD AL IHSAN BALEENDAH BANDUNG

1. DEFINISI

2. ETIOLOGI

3. PATOFISIOLOGI (PATHWAYS) (mencakup pre dan post operatif)

4. MANIFESTASI KLINIS

5. KLASIFIKASI

6. PENGKAJIAN
(Keluhan utama, Riwayat kesehatan sekarang, riwayat kesehatan dahulu,
riwayat kesehatan keluarga, riwayat pengobatan, riwayat alergi, riwayat
pembedahan)

7. PEMERIKSAAN FISIK
(Persistem ; Fokus pada system yang terkait dengan diagnosa medis)

8. PEMERIKSAAN DIAGNOSTIK

9. PENATALAKSANAAN KLINIS
A. MEDIS
Nama Obat INDIKASI Efek Samping
Nama Generik:
___________________ _______________________________
___________________ _______________________________
Nama Dagang : ___________________ _______________________________
___________________ _______________________________
___________________ _______________________________

Dosis Sediaan: ___________________ _______________________________

___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
Rute :
___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
Dosis Aman
___________________ _______________________________
___________________ _______________________________
 ___________________ _______________________________
___________________ _______________________________
Nama Obat INDIKASI Efek Samping
Nama Generik:
___________________ _______________________________
___________________ _______________________________
Nama Dagang : ___________________ _______________________________
___________________ _______________________________
___________________ _______________________________

Dosis Sediaan: ___________________ _______________________________

___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
Rute :
___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
Dosis Aman
___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
___________________ _______________________________

Nama Obat INDIKASI Efek Samping

Nama Generik:
___________________ _______________________________
___________________ _______________________________
Nama Dagang : ___________________ _______________________________
___________________ _______________________________
___________________ _______________________________

Dosis Sediaan: ___________________ _______________________________

___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
Rute :
___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
Dosis Aman
___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
 ___________________ _______________________________
Nama Obat INDIKASI Efek Samping
Nama Generik:
___________________ _______________________________
___________________ _______________________________
Nama Dagang : ___________________ _______________________________
___________________ _______________________________
___________________ _______________________________

Dosis Sediaan: ___________________ _______________________________

___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
Rute :
___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
Dosis Aman
___________________ _______________________________
___________________ _______________________________
___________________ _______________________________
___________________ _______________________________

B. KEPERAWATAN
________________________________________________________________________________________
________________________________________________________________________________________

10. ANALISA DATA

PRE OPERATIF
Masalah
NO Data Etiologi
Keperawatan
 POST OPERATIF
Masalah
NO Data Etiologi
Keperawatan

11. DIAGNOSA KEPERAWATAN PRIORITAS

PRE OPERATIF
___________________________________________________________________________________________
___________________________________________________________________________________________

POST OPERATIF
___________________________________________________________________________________________
___________________________________________________________________________________________
 12. RENCANA ASUHAN KEPERAWATAN
PRE OPERATIF
DIAGNOSA TUJUAN DAN KRITERIA
NO INTERVENSI RASIONAL
KEPERAWATAN HASIL
 POST OPERATIF
DIAGNOSA TUJUAN DAN KRITERIA
NO INTERVENSI RASIONAL
KEPERAWATAN HASIL

13. DAFTAR PUSTAKA