COVER LAPORAN PENDAHULUAN

LAPORAN INDIVIDU
LAPORAN PENDAHULUAN DAN ASUHAN KEPERAWATAN
PASIEN DENGAN (Penyakit)

Disusun Untuk Memenuhi Tugas Laporan Individu Praktek Profesi

Keperawatan Gawat Darurat dan Kritis
Di Ruang ………..
RS ……….

Oleh:
Nama : ………………………….
NIM : ………………………….

PRODI PENDIDIKAN PROFESI NERS MALANG

JURUSAN KEPERAWATAN
POLITEKNIK KESEHATAN KEMENKES MALANG
TAHUN AJARAN 2019/2020
 LEMBAR PENGESAHAN

Laporan Pendahuluan dan Asuhan Keperawatan Pada pasien dengan diagnosa medis

……………………………….......………………… di ruang………….………………………

Rumah Sakit …………………………………………………….. Periode ………………. s/d

…………….. ………Tahun Akademik …………………………

Telah disetujui dan disahkan pada tanggal………Bulan………..……… Tahun 20.........

Mengetahui,

Preceptor Akademik Preceptor Klinik Ruang ……………

RS……………………..

_____________________________ _____________________________
NIK/NIP. NIK/NIP.

Kepala Ruang ……….……

RS…………………….…..

_____________________________
NIK/NIP.

FORMAT LAPORAN PENDAHULUAN

Laporan pendahuluan memuat point-point sebagai berikut:

A. Masalah Kesehatan : (Diagnosa pasien)

B. Pengertian

C. Gejala dan Tanda

D. Pohon Masalah (Dibuat dalam bentuk bagan berdasarkan patofisiologi, prosedur

tindakan, evidence based). Nb: Khusus Pohon Masalah Wajib ditulis tangan.

E. Pemeriksaan Diagnostik

F. Penatalaksanaan Medis

G. Pengkajian Keperawatan

H. Daftar Diagnosa Keperawatan

(Berdasarkan pohon masalah)

I. Intervensi Keperawatan (NOC dan NIC)

J. Referensi

- Minimal 3 buku keperawatan, buku diagnose keperawatan

- Tidak boleh mengambil sumber dari internet yang tidak bisa
dipertanggungjawabkan,.

FORMAT LAPORAN SEMINAR AKHIR GERBONG

Laporan seminar akhir gerbong memuat point-point sebagai berikut:

1. Cover luar
2. Cover dalam
3. Lembar pengesahan
4. Kata pengantar
5. Daftar isi
6. Daftar gambar/tabel/lampiran
7. BAB 1 Latar Belakang
8. BAB 2 Tinjauan Pustaka
9. BAB 3 Kasus Asuhan Keperawatan
10. BAB 4 Review Jurnal Dan Pembahasan
11. Penutup
12. Daftar Pustaka
13. Lampiran-Lampiran

Referensi:
- Minimal 3-5 buku keperawatan yang terbit maksimal 10 tahun terakhir
- Tidak boleh mengambil sumber dari internet yang tidak bisa
dipertanggungjawabkan.
 FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT
IDENTITAS PASIEN Tanggal :
No.reg :
Nama : Tgl lahir Usia: Jenis Kelamin:
/ /  pria  wanita
Alamat : Agama: Jenis pembayaran:

Waktu kedatangan : Waktu Dead On Arrival (DOA):

diperiksa  Denyut nadi (-)
:  Refleks cahaya (-/-)
 EKG Asistole
Jam Penentuan Kematian:

Jenis Kasus : Tanggal dan jam Kejadian: Kondisi Diantar oleh:

 Trauma Tempat Kejadian: kedatangan:  Ambulance
Mekanisme Cedera:  sadar  keluarga
 Non Trauma  tidak sadar  datang sendiri
 rangsang verbal  polisi
 rangsang nyeri  lain2 :_________
Informasi diperoleh dari :  pasien  keluarga, nama :_________________  orang lain , nama : ________________

FALSE
TRIASE / NON
RESUSITASI EMERGENCY URGENT EMERGENC
KATEGORI URGENT
Y
JALAN NAPAS  Sumbatan  Stridor/disstres  Bebas  Bebas  Bebas
 Henti Napas  Napas >32x/menit  Napas 24-32  Napas  Napas
 Napas  Wheezing x/menit Normal 16- Normal 16-20
PERNAPASAN
<10x/menit  Wheezing 20 x//menit x//menit
 Sianosis
 Henti  Nadi tidak  Nadi 100-150  Nadi  Nadi
Jantung teraba/lemah x/menit Normal Normal
 Nadi tidak  Bradikardia  TD Sistole   Luka
teraba/lemah (<50x/mnt) >160 mmHg Perdarahan Ringan
 Pucat  Takikardia  TD Diastole Ringan
 Akral Dingin (>150x/mnt) >100 mmHg  Cedera
 GDA < 80  Pucat  Perdarahan Kepala
mg/dl  Akral Dingin sedang ringan
SIRKULASI  GDA >200  CRT >2 setik  Muntah  Muntah /
mg/dl  TD Sistole <100  dehidrasi diare tanpa
 Kejang mmHg  Kejang tapi dehidrasi
 TD Diastole <60 sadar  Nyeri
mmHg  Nyeri Sedang ringan
 Nyeri akut (>8)
 Perdarahan akut
 multiple Fraktur
 Suhu >39 C
DISABILITY  GCS <9  GCS 9-12  GCS >12  GCS 15  GCS 15
AREA P1 P2 P3
RESPON TIME 1 MENIT 10 MENIT 60 MENIT
Pengkajian Perawat, jam: Riwayat Penyakit Dahulu:
Keluhan utama (SAMPLE):  TB  Kanker  Infark Miokard
 PPOK  Hepatitis  Peny.Jantung
 DM  Hipertensi  Stroke
 Kejang  Asma 
Lain2:___________
Riwayat Pemakaian Alkohol:
 YA  TIDAK Jml/hri:
Riwayat Merokok:
 YA  TIDAK Jml/hri:
Riwayat Alergi:
 YA  TIDAK Jenis Alergi:
TD: mmHg Nadi: x/menit SUHU: C TB: cm / BB: Kg
GDA: mg/dl SaO2: % Skala Nyeri (0-10): Status Gizi:
Skala Nyeri Untuk Umur > 9 Tahun: Skala Nyeri Untuk Umur < 9 Tahun: NILAI SKALA
NYERI:
0 (Tidak
Nyeri)
 1-3
(Ringan)
 4-6
(Sedang)
 7-10 (Berat)

Diagram kode diagram

A : Abrasi
B: Bruise
Bu : Burn
E : eritema
L : laserasi
P : Ptekie
Pu : Pressure ulcer
R : Rash
S : Scar
ST: stoma
U : Ulcer
O : other (tato,
amputasi, perubahan
warna)
Ket: ____

Penilaian Resiko Jatuh

MORSE FALL SCALE (MFS)/ SKALA JATUH DARI MORSE
NO PENGKAJIAN SKALA NILAI KET.
1. Riwayat jatuh: apakah lansia pernah jatuh dalam 3 Tidak 0
bulan terakhir? Ya 25
2. Diagnosa sekunder: apakah lansia memiliki lebih Tidak 0
dari satu penyakit? Ya 15
3. Alat Bantu jalan:

- Bed rest/ dibantu perawat 0

- Kruk/ tongkat/ walker 15
- Berpegangan pada benda-benda di sekitar 30

(kursi, lemari, meja)

4. Terapi Intravena: apakah saat ini lansia terpasang Tidak 0
infus? Ya 20
5. Gaya berjalan/ cara berpindah:

- Normal/ bed rest/ immobile (tidak dapat bergerak 0

sendiri)
- Lemah (tidak bertenaga) 10
- Gangguan/ tidak normal (pincang/ diseret) 20
 6. Status Mental

- Lansia menyadari kondisi dirinya 0

- Lansia mengalami keterbatasan daya ingat 15
Total Nilai
Keterangan:
Tingkatan Risiko Nilai MFS Tindakan
Tidak berisiko 0 - 24 Perawatan dasar
Risiko rendah 25 - 50 Pelaksanaan intervensi pencegahan jatuh standar
Risiko tinggi ≥ 51 Pelaksanaan intervensi pencegahan jatuh risiko tinggi
Pemeriksaan diagnostic jam : Hasil Pemeriksaan Diagnostik:
 tidak ada  USG
 darah lengkap  X Ray
 BUN  MRI
 enzim jantung  CT scan
 glukosa  lain-lain
 tes fungsi hati  urinalisis
 gas darah arteri  tes kehamilan
 alcohol dalam darah  oksmetri nadi
 HIV serologi  EKG
MEDIKASI: PROSEDUR
 orofaringeal airway  terapi nasogastrik
 nasofaringeal airway  kateter urin
 intubasi ETT  kateter vena sentral (CVP)
 terapi oksigen  perawatn Ob/Gyn
 terapi nebulizer  perawatan orthopedic
 CPR  terapi trombolitik
 IV fluid  perawatan luka
 DC shock lain-lain :

DIAGNOSIS MEDIS:

MASALAH
KEPERAWATAN:
JAM IMPLEMENTASI TTD
 EVALUASI
(SOAP)

PERAWATAN  Rawat  Rawat Inap Pulang Paksa  dirujuk  Meninggal

LANJUTAN Jalan
Bila Rawat Jalan/pulang paksa, Tanggal: Jam: Vital Sign Sebelum
transfer/rujuk/pulang:
Bila Rawat Inap, Transfer ke Ruang: TD:

Bila Meninggal, Tanggal: Jam: Nadi:

Penyebab:
RR:

Suhu:
Bila dirujuk/alih rawat, Tanggal: Jam:
SpO2:

GCS:

Malang, 20__

Ttd Perawat

(……………………………)
 FORMAT ASUHAN KEPERAWATAN ICU
FORMAT PENGKAJIAN KEPERAWATAN
Tanggal MRS : Jam Masuk :
Tanggal Pengkajian : No. RM :
Jam Pengkajian : Diagnosa Masuk :
Hari rawat ke :

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 :

IDENTITAS KELUARGA PASIEN (Yang dapat Dihubungi)

1. Nama :
2. Jenis Kelamin :
3. Umur :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :
8. Hubungan dengan klien:

KELUHAN UTAMA
Keluhan utama:…… ………………………………………………………………………………………….
…………………………………………………………………………………………………………………
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................

RIWAYAT PENYAKIT SEKARANG

1. Riwayat Penyakit Sekarang:
……………………………………………………………………………….......................................................
……………………………………………………………………………………………………………...........
...............................................................................................................................................................................
……………………………………………………………………………………………………………...........
...............................................................................................................................................................................
……………………………………………………………………………………………………………...........
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
RIWAYAT PENYAKIT DAHULU
1. Pernah dirawat : ya tidak kapan :…… diagnosa :…………
2. Riwayat penyakit kronik dan menular ya tidak jenis……………………
Riwayat kontrol : .............................
Riwayat penggunaan obat :..............
3. Riwayat alergi:
Obat ya tidak jenis……………………
Makanan ya tidak jenis……………………
Lain-lain ya tidak jenis……………………

4. Riwayat operasi: ya tidak

- Kapan : ……………………
- Jenis operasi : ……………………

5. Lain-lain:
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis
:………………….....................................................................................................................................
- Genogram :

PERILAKU YANG MEMPENGARUHI KESEHATAN

Perilaku sebelum sakit yang mempengaruhi kesehatan:
Alkohol ya tidak keterangan……….....................
Merokok ya tidak
keterangan…………………….........................................................
Obat ya tidak
keterangan…..............................................................………………
Olah raga ya tidak
keterangan…..........................................................…………………

OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda tanda vital
S: N: T: RR :
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma

2. Sistem Pernafasan (B1)

a. RR:................................
b. Keluhan: sesak nyeri waktu nafas orthopnea
Batuk produktif tidak produktif
Sekret:…….. Konsistensi :......................
Warna:.......... Bau :.................................. Masalah Keperawatan :
c. Penggunaan otot bantu nafas:
......................................................................................................................................................................
......................................................................................................................................................................
........................
d. PCH ya tidak
e. Irama nafas teratur tidak teratur
f. Pleural Friction rub:.....................................................................................................................
g. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot
h. Suara nafas Cracles Ronki Wheezing
i. Alat bantu napas ya tidak

Jenis................................................ Flow..............lpm
 j. Penggunaan WSD:
- Jenis
: .....................................................................................................................................................
............
- Jumlah cairan
: ..................................................................................................................................................
- Undulasi
:...................................................................................................................................................
- Tekanan
: ..................................................................................................................................................

k. Tracheostomy: ya tidak
......................................................................................................................................................................
......................................................................................................................................................................
l. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................

3. Sistem Kardio vaskuler (B2)

a. TD : Masalah Keperawatan :
b. N :
c. Keluhan nyeri dada: ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
d. Irama jantung: reguler ireguler
e. Suara jantung: normal (S1/S2 tunggal) murmur
gallop lain-lain.....
f. Ictus
Cordis: .........................................................................................................................................................
....
g. CRT :.............detik
h. Akral: hangat kering merah basah pucat
panas dingin
i. Sikulasi perifer: normal menurun
j. JVP :.................................
k. CVP :.................................
l. CTR :.................................
m. ECG & Interpretasinya:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
n. Lain-lain :
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
.............................................................................................................. ............................ .........................
4. Sistem Persyarafan (B3)
a. GCS : .................................................. Masalah Keperawatan :
b. Refleks fisiologis patella triceps biceps
c. Refleks patologis babinsky brudzinsky kernig
Lain-lain
d. Keluhan pusing ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................

e. Pemeriksaan saraf kranial:

N1 : normal tidak Ket.: ……..............................................................
N2 : normal tidak Ket.: ……..............................................................
N3 : normal tidak Ket.: ……..............................................................
N4 : normal tidak Ket.: ……..............................................................
N5 : normal tidak Ket.: ……..............................................................
N6 : normal tidak Ket.: ……..............................................................
N7 : normal tidak Ket.: ……..............................................................
N8 : normal tidak Ket.: ……..............................................................
N9 : normal tidak Ket.: ……..............................................................
N10 : normal tidak Ket.: ……..............................................................
N11 : normal tidak Ket.: ……..............................................................
N12 : normal tidak Ket.: ……..............................................................

f. Pupil anisokor isokor Diameter: ……/......

g. Sclera anikterus ikterus
h. Konjunctiva ananemis anemis
i. Isitrahat/Tidur :................. Jam/Hari Gangguan
tidur : ..............................................................
j. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
............................................................

5. Sistem perkemihan (B4)

Masalah Keperawatan
a. Kebersihan genetalia: Bersih Kotor
b. Sekret: Ada Tidak
c. Ulkus: Ada Tidak
d. Kebersihan meatus uretra: Bersih Kotor
e. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
Kemampuan berkemih:
Spontan Alat bantu,
sebutkan: .................................................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
 f. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
g. Kandung kemih : Membesar ya tidak
h. Nyeri tekan ya tidak
i. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
j. Balance cairan:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................
k. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................
6. Sistem pencernaan (B5) Masalah Keperawatan :
a. TB :............... BB :................................
b. IMT :............... Interpretasi :................................

c. Mulut: bersih kotor berbau

d. Membran mukosa: lembab kering stomatitis
e. Tenggorokan:
sakit menelan kesulitan menelan
pembesaran tonsil nyeri tekan
f. Abdomen: tegang kembung ascites
g. Nyeri tekan: ya tidak
h. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
i. Peristaltik:.............. x/menit
j. BAB: ......................x/hari Terakhir tanggal : ............................................................................
k. Konsistensi: keras lunak cair lendir/darah
l. Diet: padat lunak cair
m. Diet Khusus:
......................................................................................................................................................................
......................................................................................................................................................................
n. Nafsu makan: baik menurun Frekuensi:.......x/hari
o. Porsi makan: habis tidak Keterangan:.......................
p. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
 Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO

b. Keluhan nyeri ya tidak

P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................

c. Luka operasi: ada tidak

Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
d. Pemeriksaan penunjang lain : .........................
e. Lain-lain :
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................

8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Aurcicula
MAE
Membran
Tymphani
Rinne
Weber
Swabach
 b. Tes Audiometri
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................

c. Keluhan nyeri ya tidak

P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
d. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
e. Alat bantu dengar: .........................
f. Lain-lain :
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................
7. Sistem muskuloskeletal (B6)
a. Pergerakan sendi: bebas terbatas
b. Kekuatan otot: Masalah Keperawatan :

c. Kelainan ekstremitas: ya tidak

d. Kelainan tulang belakang: ya tidak
Frankel: ................................................................................
e. Fraktur: ya tidak
- Jenis :...................
f. Traksi: ya tidak
- Jenis :...................
- Beban :...................
- Lama pemasangan :...................
g. Penggunaan spalk/gips: ya tidak
h. Pengkajian Nyeri
Keluhan nyeri: ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
i. Sirkulasi perifer: ..............................................
 j. Kompartemen syndrome ya tidak
k. Kulit: ikterik sianosis kemerahan hiperpigmentasi
l. Turgor baik kurang jelek
m. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
n. ROM : .................................................

o. Cardinal Sign : ................................................

p. Resiko Jatuh:
MORSE FALL SCALE (MFS)/ SKALA JATUH DARI MORSE
NO PENGKAJIAN SKALA NILAI KET.
1. Riwayat jatuh: apakah lansia pernah jatuh dalam 3 bulan Tidak 0
terakhir? Ya 25
2. Diagnosa sekunder: apakah lansia memiliki lebih dari Tidak 0
satu penyakit? Ya 15
3. Alat Bantu jalan:

- Bed rest/ dibantu perawat 0

- Kruk/ tongkat/ walker 15
- Berpegangan pada benda-benda di sekitar 30

(kursi, lemari, meja)

4. Terapi Intravena: apakah saat ini lansia terpasang infus? Tidak 0
Ya 20
5. Gaya berjalan/ cara berpindah:

- Normal/ bed rest/ immobile (tidak dapat bergerak 0

sendiri)
- Lemah (tidak bertenaga) 10
- Gangguan/ tidak normal (pincang/ diseret) 20
6. Status Mental

- Lansia menyadari kondisi dirinya 0

- Lansia mengalami keterbatasan daya ingat 15
Total Nilai
Keterangan:
Tingkatan Risiko Nilai MFS Tindakan
Tidak berisiko 0 - 24 Perawatan dasar
Risiko rendah 25 - 50 Pelaksanaan intervensi pencegahan jatuh standar
Risiko tinggi ≥ 51 Pelaksanaan intervensi pencegahan jatuh risiko tinggi

q. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................

10. Sistem Integumen

a. Penilaian resiko decubitus
Kriteria Penilaian Nilai
 Aspek Yang 1 2 3 4
Dinilai
Persepsi Terbatas Sangat Keterbatasan Tidak Ada
Sensori Sepenuhnya Terbatas Ringan Gangguan
Kelembaban Terus Sangat Kadang2 Basah Jarang
Menerus Lembab Basah
Basah
Aktifitas Bedfast Chairfast Kadang2 Jalan Lebih Sering
jalan
Mobilisasi Immobile Sangat Keterbatasan Tidak Ada
Sepenuhnya Terbatas Ringan Keterbatasan
Nutrisi Sangat Kemungkinan Adekuat Sangat Baik
Buruk Tidak
Adekuat
Gesekan & Bermasalah Potensial
Tidak
Pergeseran Bermasalah
Menimbulkan
Masalah
NOTE: Pasien dengan nilai total < 16 maka dapat dikatakan Total Nilai
bahwa pasien beresiko mengalami dekubisus (pressure ulcers)
(15 or 16 = low risk, 13 or 14 = moderate risk, 12 or less = high
risk)

b. Warna Masalah Keperawatan :

c. Pitting edema: +/- grade:................
d. Ekskoriasis: ya tidak
e. Psoriasis: ya tidak
f. Pruritus: ya tidak
g. Urtikaria: ya tidak
h. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................

11. Sistem Endokrin

a. Pembesaran tyroid: ya tidak Masalah Keperawatan :
b. Pembesaran kelenjar getah bening: ya tidak
c. Hipoglikemia: ya tidak
d. Hiperglikemia: ya tidak
e. Kondisi kaki DM
- Luka gangren ya tidak
Jenis ................................................................................................................
- Lama luka ...............................................................................................
- Warna ...............................................................................................
- Luas luka ...............................................................................................
- Kedalaman ...............................................................................................
- Kulit kaki ...............................................................................................
- Kuku kaki ...............................................................................................
- Telapak kaki ...............................................................................................
- Jari kaki ...............................................................................................
- Infeksi ya tidak
- Riwayat luka sebelumya ya tidak
Jika ya:
- Tahun :
- Jenis Luka :
- Lokasi :
- Riwayat amputasi sebelumya ya tidak
Jika ya:
- Tahun :
- Lokasi :
f. ABI : ....................................................
 g. Lain-lain:
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PENGKAJIAN PSIKOSOSIAL Masalah keperawatan :

a. Persepsi klien terhadap penyakitnya:
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Ekspresi klien terhadap penyakitnya
Murung/diam gelisah tegang marah/menangis
b. Reaksi saat interaksi kooperatif tidak kooperatif curiga

c. Gangguan konsep diri:

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d. Lain-lain:
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PERSONAL HYGIENE & KEBIASAAN Masalah Keperawatan :
Jelaskan :
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PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah

b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:

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PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)

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TERAPI MEDIS
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DATA TAMBAHAN LAIN :

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PERENCANAAN PULANG
- Tujuan Pulang:

- Transportasi Pulang:

- Dukungan Keluarga:

- Antisipasi bantuan biaya setelah pulang:

- Antisipasi masalah perawatan diri setelah pulang:

- Pengobatan:

- Rawat jalan ke:

- Hal-hal yang perlu diperhatikan di rumah:

Malang, 2019

(……………………………)
 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/ NOC NIC
No. DIAGNOSA KEPERAWATAN
Jam (Nursing Outcome Classification) (Nursing Intervention Classification)
 IMPLEMENTASI
Nama Pasien :
No. Register :
HARI/ TGL/
NO. DX JAM IMPLEMENTASI PARAF JAM RESPON PARAF
SHIFT
 EVALUASI
Nama Pasien :
No. Register :
Hari/ Tgl/
Diagnosa Kep Jam evaluasi Paraf
Shift
 FORMAT RESUME RUANGAN
Nama : Tanggal MRS :
No. RM : Tanggal Pengkajian :
Diagnosa Medis : Ruang :

Subjektif Objektif Analisa Planning Implementation Evaluation

Isi data subyektif Isi data obyektif Isi Diagnosa keperawatan Isi rencana tindakan Isi pelaksanaan tindakan Isi evaluasi berupa
yang bermasalah yang bermasalah keperawatan yang (1x8 jam) yang perawatan disertai jam S:
(data fokus) dari (data fokus), seperti muncul disertai pathway terdiri dari: Tujuan, pelaksanaannya.
pemeriksaan yang hasil pemeriksan etiologi Kriteria Hasil, dan
didapatkan, seperti pola aktifitas, intervensi
keluhan utama, pemeriksaan fisik,
riwayat penyakit pemeriksaan O:
sekarang, riwayat psikososial,
penyakit dahulu, pemeriksaan
riwayat akergi, dll spiritual,
pemeriksaan
penunjang
A:

P: