LAPORAN INDIVIDU
LAPORAN PENDAHULUAN DAN ASUHAN KEPERAWATAN
PASIEN DENGAN (Penyakit)
Oleh:
Nama : ………………………….
NIM : ………………………….
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LEMBAR PENGESAHAN
Medis………………………………………….………. Di…………………………………
…………………………………….
Malang,
___________________________ _________________________
NIP. NIP.
Atasan Langsung
___________________________
NIP.
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FORMAT LAPORAN PENDAHULUAN
B. Pengertian
E. Pemeriksaan Diagnostik
F. Penatalaksanaan Medis
G. Pengkajian Keperawatan
J. Referensi
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FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT
IDENTITAS PASIEN Tanggal :
No.reg :
Nama : Tgl lahir Usia: Jenis Kelamin:
/ / pria wanita
Alamat : Agama: Jenis pembayaran:
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-
PERNAPASAN
<10x/menit Wheezing 20 x//menit 20 x//menit
Sianosis
Henti Jantung Nadi tidak Nadi 100-150 Nadi Nadi
Nadi tidak teraba/lemah x/menit Normal Normal
teraba/lemah Bradikardia TD Sistole Luka
Pucat (<50x/mnt) >160 mmHg Perdarahan Ringan
Akral Dingin Takikardia TD Diastole Ringan
GDA < 80 (>150x/mnt) >100 mmHg Cedera
mg/dl Pucat Perdarahan Kepala
GDA >200 Akral Dingin sedang ringan
SIRKULASI mg/dl CRT >2 setik Muntah Muntah /
Kejang TD Sistole <100 dehidrasi diare tanpa
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:
4
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: ____
Pemeriksaan fisik head to toe) (DCAPBTLS): (D=Deformitas, C=Contution, A=Abration, P=Penetration, B=Burns,
T=Tenderness, L=Laceration, S=Swelling)
A. Kepala:
B. Leher:
C. Bahu :
D. Dada:
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E. Perut :
F. Genitalia:
G. Punggung:
H. Panggul:
I. Tangan:
J. Kaki:
Keterangan:
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Nilai MFS Tindakan
Tingkatan Risiko
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 : RENCANA PROSEDUR
tidak ada USG orofaringeal airway terapi nasogastrik
darah lengkap X Ray nasofaringeal airway kateter urin
BUN MRI intubasi ETT kateter vena sentral (CVP)
enzim jantung CT scan terapi oksigen perawatn Ob/Gyn
glukosa lain-lain terapi nebulizer perawatan orthopedic
tes fungsi hati urinalisis CPR terapi trombolitik
gas darah arteri tes kehamilan IV fluid perawatan luka
alcohol dalam darah oksmetri nadi DC shock lain-lain :
HIV serologi EKG
DIAGNOSIS MEDIS:
DIAGNOSIS
KEPERAWATAN:
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PERENCANAAN DAN IMPLEMENTASI
JAM TINDAKAN
8
Airway:
Breathing:
Circulation:
EVALUASI
Disability:
Eksposure:
Suhu:
Bila dirujuk/alih rawat, Tanggal: Jam:
SpO2:
GCS:
Malang,
Ttd Perawat
(……………………………)
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FORMAT ASUHAN KEPERAWATAN KRITIS
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 :
KELUHAN UTAMA
Keluhan utama:…… ………………………………………………………………………………………….
…………………………………………………………………………………………………………………
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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……………………
5. Lain-lain:
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RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis :
………………….....................................................................................................................................
- Genogram :
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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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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:
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k. Lain-lain:
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6. Sistem pencernaan (B5) Masalah Keperawatan :
a. TB :............... BB :................................
b. IMT :............... Interpretasi :................................
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Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO
8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Aurcicula
MAE
Membran
Tymphani
Rinne
Weber
Swabach
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b. Tes Audiometri
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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 : .................................................
q. Lain-lain:
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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 SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah
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TERAPI MEDIS
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PERENCANAAN PULANG
- Tujuan Pulang:
- Transportasi Pulang:
- Dukungan Keluarga:
- Pengobatan:
Malang, 2019
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(……………………………)
ANALISA DATA
Nama Pasien :
Umur :
No. Register :
Hari/
Tgl/ DATA ETIOLOGI MASALAH
Jam
22
DIAGNOSA KEPERAWATAN
Nama Pasien :
Umur :
No. Register :
1.
2.
3.
4. dst
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PRIORITAS MASALAH KEPERAWATAN
Nama Pasien :
No. Register :
No TANGGAL TANGGAL TANDA
DIAGNOSA KEPERAWATAN
DX MUNCUL TERATASI TANGAN
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RENCANA ASUHAN KEPERAWATAN
Nama Pasien :
No. Register :
Hari/ Tgl/
No. DIAGNOSA KEPERAWATAN LUARAN KEPERAWATAN INTERVENSI
Jam
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IMPLEMENTASI
Nama Pasien :
No. Register :
HARI/ TGL/ PARA
NO. DX JAM IMPLEMENTASI JAM RESPON PARAF
SHIFT F
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EVALUASI KEPERAWATAN
Nama Pasien :
No. Register :
Hari/ Tgl/
Diagnosa Kep Jam Evaluasi Paraf
Shift
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FORMAT RESUME RUANGAN
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:
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