KUMPULAN LAPORAN
STASE KEPERAWATAN DASAR PROFESI
DI RUANG ......
RSU SARI MULIA BANJARMASIN
Disusun Oleh:
NIM:
Disusun Oleh:
Disusun Oleh:
LEMBAR PENGESAHAN
JUDUL KASUS :
KELOMPOK :
NAMA ANGGOTA KELOMPOK : 1. ..………………………………..
2. ..………………………………..
3. ..………………………………..
4. …… dst
Banjarmasin,……………….2020
Menyetujui,
…………………………………. ………………………………….
NIK. ..................... NIK. ......................
Mengetahui,
Ketua Jurusan Profesi Ners
Fakultas Kesehatan
Universitas Sari Mulia Banjarmasin
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NIK. ..............................
Lampiran 5. Format Lembar Persetujuan (untuk tugas individu dan kelompok)
LEMBAR PERSETUJUAN
Tanggal ..................................
Disusun oleh :
NIM
Banjarmasin, …………………….
Mengetahui,
Preseptor Akademik, Preseptor Klinik,
(……………………………..) (……………………………..)
NIK. NIK.
Lampiran 6. Format Penulisan Laporan Pendahuluan Individu
Halaman Judul
Lembar Persetujuan
1. Konsep Anatomi dan Fisiologi Sistem
a. Anatomi Sistem
b. Fisiologis Sistem
c. Kebutuhan Dasar Manusia (Sesuai Sistem)
2. Konsep dasar penyakit
a. Definisi
b. Etiologi
c. Klasifikasi dan penyebab hepatitis
d. Patofisiologi (Pathway)
e. Manifestasi klinis
f. Pemeriksaan penunjang
g. Penatalaksanaan
h. Pegkajian fokus keperawatan
i. Diagnosa Keperawatan
j. Tujuan Keperawatan (NOC)
k. Rencana Tindakan Keperawatan (NIC)
Daftar Pustaka (minimal literatur 5 buah dalam 10 tahun terakhir)
Catatan:
1. Diagnosa keperawatan (minimal 5 diagnosa, wajib terdapat diagnosa aktual, resiko, dan
peningkatan derajat kesehatan klien & keluarga)
2. NOC (Minimal 1 label dengan minimal 3 kriteria hasil per label) dan NOC (Minimal 1 label
dan 5 intervensi per label)
Lampiran 7. Format Penulisan Laporan Asuhan Keperawatan Dasar Profesi Individu
Halaman Judul
Lembar Persetujuan
A. Pengkajian Keperawatan
1. Identitas Klien
2. Identitas Penanggungjawab
3. Pengkajian:
a. Keluhan Utama
b. Riwayat Penyakit Dahulu
c. Riwayat Penyakit Sekarang
d. Riwayat Keluarga dan Genogram
e. Keadaan Umum
f. Tingkat Kesadaran
g. Antropometrik
h. Tanda-tanda Vital
i. Kebutuhan Oksigen
j. Pemeriksaan Fisik
k. Kebutuhan Cairan
l. Intake Cairan & Output cairan
m. Balance Cairan
n. Nutrisi
o. Pola Tidur
p. Kebersihan Diri
q. Eliminasi
r. Spiritualitas
s. ADL
t. Nyeri
u. Resiko Jatuh
v. Skala Cemas
w. Hasil Laboratorium
x. Foto Thoraks (dll)
y. Terapi Farmakologi
4. Data Fokus
B. Analisa Data
C. Diagnosa Keperawatan
D. Perencanaan Keperawatan
E. Implementasi dan evaluasi
F. Catatan Perkembangan Pasien
Lampiran 8. Format Penulisan Resume Keperawatan
Halaman Judul
Lembar Persetujuan
1. Identitas Klien dan Penanggungjawab
2. Riwayat Kesehatan
a. Keluhan Utama
b. Riwayat Penyakit Dahulu
c. Riwayat Penyakit Sekarang
d. Riwayat Keluarga dan Genogram
3. Analisa Data
4. Diagnosa Keperawatan
5. Rencana Keperawatan
6. Implementasi dan Evaluasi Keperawatan
FORMAT PENGKAJIAN
STASE KEPERAWATAN DASAR PROFESI
I. IDENTITAS KLIEN
Nama : …………………… Suku : …………………………
Tanggal lahir/Umur : …………………… Tgl masuk : …………………………
Jenis kelamin : …………………… Tgl dikaji : …………………………
Alamat : …………………… Ruang perawatan: …………………...
Pendidikan : …………………… Diagnosa medis : ……………………
Agama : …………………… No. Rekam Medis : ………………….
PENGKAJIAN
a. Keluhan Utama:
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b. Riwayat Penyakit Dahulu:
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c. Riwayat Penyakit Sekarang:
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e. Keadaan umum :
f. Tingkat
kesadaran:
g. Antropometrik : TB : .................................. cm BMI: ..................................
BB : ..................T................
cm
h. TTV : RR ............ x/m SpO2 .................. %
HR ............ x/m Suhu .................. 0C
TD ............ mmHg MAP .................. mmHg
i. Kebutuhan O2 : Via:
j. Pemeriksaan fisik :
1. Kulit, ......................................................................................................................
Kuku ......................................................................................................................
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2. Rambut ......................................................................................................................
, Kepala, Mata, ......................................................................................................................
Telinga ......................................................................................................................
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3. Hidung, ......................................................................................................................
Mulut/ ......................................................................................................................
Tenggorokan ......................................................................................................................
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4. Leher, ......................................................................................................................
Thorax/dada, ......................................................................................................................
Abdomen ......................................................................................................................
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5. Ekstre ......................................................................................................................
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6. Genitali ......................................................................................................................
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7. Refleks ......................................................................................................................
neurologis ......................................................................................................................
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8. Nervus ......................................................................................................................
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k. Kebutuhan Cairan :
m. Balance Cairan :
Pengkajian Skala Nyeri dengan Wong-Baker FACES Pain Rating Scale (3-7 tahun)
Wajah 0 : sangat senang karena tidak ada rasa sakit sama sekali.
Wajah 1 : rasa sakit hanya sedikit.
Wajah 2 : rasa sakit sedikit lebih (agak sakit).
Wajah 3 : rasa sakit agak lebih (sakit sekali).
Wajah 4 : rasa sakit yang dalam (sangat sakit sekali).
Wajah 5 : rasa sakit yang hebat (sangat kesakitan/ nyeri hebat) meskipun anak tidak harus
menangis karena merasa ini buruk.
Pengkajian Skala Nyeri dengan Visual Analog Scale (VAS) (> usia 7 tahun/ dewasa)
u. Resiko Jatuh :
MORSE FALL SCALE (MFS)/ SKALA JATUH DARI MORSE
Perempuan 1
Kelainan neurologi 4
Perubahan dalam oksigenasi (masalah sal. Nafas, 3
anemia, dehidrasi, anoreksia, sakit kepala,
Diagnosis
sinkop/pusing, dll)
Kelainan psikis/ perilaku 2
Diagnosis lain 1
Tidak menyadari keterbatasan 3
Gangguan
Lupa akan keterbatasan diri 2
Kognitif
Sadar akan kemampuan sendiri 1
Riwayat jatuh dari tempat tidur saat bayi – anak 4
Pasien menggunakan alat bantu atau tempat tidur 3
Faktor
bayi/ pencahayaan
Lingkungan
Pasien berada di tempat tidur 2
Rawat Jalan 1
Respon Dalam 24 jam 3
terhadap Dalam 48 jam 2
operasi/ obat >48 jam/ tidak ada 1
penenang/ efek
anastesi
Bermacam-macam obat digunakan: obat sedative 3
(diluar pasien ICU yang sedang mengalami sedasi
Penggunaan dan paralisis), hipnotik, barbiturate, fenotiazin,
obat antidepresan, laksatif, diuretic, narkotik
Salah satu dari pengobatan diatas 2
Pengobatan lain/tidak ada 1
Skor 7 – 11 : Risiko rendah untuk jatuh Skor Minimal : 7
Skor ≥ 12 : Risiko tinggi untuk jatuh Skor Maksimal : 23 TOTAL
v. Skala Cemas (Hamilton Rating Scale for Anxiety/ HARS) :
Skor
No Pertanyaan
0 1 2 3 4
1 Perasaan Ansietas
- Cemas
- Firasat Buruk
- Takut Akan Pikiran Sendiri
- Mudah Tersinggung
2 Ketegangan
- Merasa Tegang
- Lesu
- Tak Bisa Istirahat Tenang
- Mudah Terkejut
- Mudah Menangis
- Gemetar
- Gelisah
3 Ketakutan
- Pada Gelap
- Pada Orang Asing
- Ditinggal Sendiri
- Pada Binatang Besar
- Pada Keramaian Lalu Lintas
- Pada Kerumunan Orang Banyak
4 Gangguan Tidur
- Sukar Masuk Tidur
- Terbangun Malam Hari
- Tidak Nyenyak
- Bangun dengan Lesu
- Banyak Mimpi-Mimpi
- Mimpi Buruk
- Mimpi Menakutkan
5 Gangguan Kecerdasan
- Sukar Konsentrasi
- Daya Ingat Buruk
6 Perasaan Depresi
- Hilangnya Minat
- Berkurangnya Kesenangan Pada Hobi
- Sedih
- Bangun Dini Hari
- Perasaan Berubah-Ubah Sepanjang Hari
7 Gejala Somatik (Otot)
- Sakit dan Nyeri di Otot-Otot
- Kaku
- Kedutan Otot
- Gigi Gemerutuk
- Suara Tidak Stabil
8 Gejala Somatik (Sensorik)
- Tinitus
- Penglihatan Kabur
- Muka Merah atau Pucat
- Merasa Lemah
- Perasaan ditusuk-Tusuk
9 Gejala Kardiovaskuler
- Takhikardia
- Berdebar
- Nyeri di Dada
- Denyut Nadi Mengeras
- Perasaan Lesu/Lemas Seperti Mau Pingsan
- Detak Jantung Menghilang (Berhenti
Sekejap)
10 Gejala Respiratori
- Rasa Tertekan atau Sempit Di Dada
- Perasaan Tercekik
- Sering Menarik Napas
- Napas Pendek/Sesak
11 Gejala Gastrointestinal
- Sulit Menelan
- Perut Melilit
- Gangguan Pencernaan
- Nyeri Sebelum dan Sesudah Makan
- Perasaan Terbakar di Perut
- Rasa Penuh atau Kembung
- Mual
- Muntah
- Buang Air Besar Lembek
- Kehilangan Berat Badan
- Sukar Buang Air Besar (Konstipasi)
12 Gejala Urogenital
- Sering Buang Air Kecil
- Tidak Dapat Menahan Air Seni
- Amenorrhoe
- Menorrhagia
- Menjadi Dingin (Frigid)
- Ejakulasi Praecocks
- Ereksi Hilang
- Impotensi
13 Gejala Otonom
- Mulut Kering
- Muka Merah
- Mudah Berkeringat
- Pusing, Sakit Kepala
- Bulu-Bulu Berdiri
14 Tingkah Laku Pada Wawancara
- Gelisah
- Tidak Tenang
- Jari Gemetar
- Kerut Kening
- Muka Tegang
- Tonus Otot Meningkat
- Napas Pendek dan Cepat
- Muka Merah
Total Skor
Keterangan:
Skor: 0 = tidak ada Total Skor:
1 = ringan kurang dari 14 = tidak ada kecemasan
2 = sedang 14 – 20 = kecemasan ringan
3 = berat 21 – 27 = kecemasan sedang
4 = berat sekali 28 – 41 = kecemasan berat
42 – 56 = kecemasan berat sekali
w. Hasil laboratorium
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y. Terapi Farmakologi
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Analisis Data
DATA KLIEN MASALAH
No ETIOLOGI
(Data Subjektif & Data Objektif) KEPERAWATAN
Diagnosa Keperawatan
1. ..............................................................................................................................
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2. ..............................................................................................................................
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5. ..............................................................................................................................
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Rencana Keperawatan
Diagnosa Perencanaan
No
Keperawatan Tujuan Keperawatan & NOC Intervensi Keperawatan (NIC)
Implementasi dan Evaluasi
S:
O:
A:
P:
Catatan Perkembangan
S:
O:
A:
P:
FORMAT RESUME
STASE KEPERAWATAN DASAR PROFESI
I. IDENTITAS KLIEN
Nama : …………………… Suku : …………………………
Tanggal lahir/Umur : …………………… Tgl masuk : …………………………
Jenis kelamin : …………………… Tgl dikaji : …………………………
Alamat : …………………… Ruang perawatan: …………………...
Pendidikan : …………………… Diagnosa medis : ……………………
Agama : …………………… No. Rekam Medis : ………………….
II. PENGKAJIAN
A. Keluhan Utama:
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B. Riwayat Penyakit Dahulu:
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C. Riwayat Penyakit Sekarang:
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A. Data Subjektif
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B. Data Objektif
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Diagnosa Perencanaan
No
Keperawatan Tujuan Keperawatan ( SLKI ) Intervensi Keperawatan ( SIKI)
VII. Implementasi dan Evaluasi
Hari/ Nomor Dx Jam Implementasi Keperawatan Evaluasi Keperawatan TTD
Tgl Keperawatan
S:
O:
A:
P:
S:
O:
A:
P: