Oleh:
Nama : ………………………….
NIM : ………………………….
Laporan Pendahuluan dan Asuhan Keperawatan Pada pasien dengan diagnosa medis
……………………………….......………………… di ruang………….………………………
Mengetahui,
Preceptor Akademik Preceptor Klinik Ruang ……………
RS……………………..
NIK/NIP. NIK/NIP.
NIK/NIP.
B. Pengertian
E. Pemeriksaan Diagnostik
F. Penatalaksanaan Medis
G. Pengkajian Keperawatan
J. Referensi
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:
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 20 x//menit x//menit
<10x/menit Wheezing
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)
DIAGNOSIS MEDIS:
MASALAH
KEPERAWATAN:
JAM IMPLEMENTASI TTD
EVALUASI
(SOAP)
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 :
KELUHAN UTAMA
Keluhan utama:…… ………………………………………………………………………………………….
…………………………………………………………………………………………………………………
............................................................................................................................. ...............................................
...
............................................................................................................................................... .............................
...
............................................................................................................................................................................
...
5. Lain-lain:
............................................................................................................................. ................................................
..
.............................................................................................................................................................................
..
............................................................................................................................. ................................................
..
RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis
:………………….....................................................................................................................................
- Genogram :
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 e. Pemeriksaan saraf
c. Refleks patologis babinsky brudzinsky kernig kranial:
Lain-lain N1 :
d. Keluhan pusing ya tidak normal
P :.................................................................. tidak
. Ket.:
Q :................................................................... …….....
R :.................................................................. .............
. .............
.............
S :.................................................................. .............
. T .....
:................................................................... 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 : Kemampuan
.............................................
berkemih:
.................
j. Lain-lain: Spontan
........................................................................................................... Alat bantu,
.................. ......................................... sebutkan: .............
........................................................................................................... .............................
........................................................... .............................
........................................................................................................... ..........................
.................. ......................................... Jenis :..............
........................................................................................................... ........................
.. ......................................................... ......
........................................................................................................... Ukuran
........................................................... :......................
... ......................
... Hari ke
... :......................
... ......................
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
............................................................................................................................. .....................................
....
...................................................................................................................................................................
...
......................................................................................................................... .........................................
Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Visus b
.
Palpebra
Conjunctiva K
e
Kornea l
BMD u
h
Pupil a
Iris n
Lensa n
TIO y
e
r
i
y
a
t
i
d
a
k
P
:
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.........
.........
......... Masalah
...... Keperawatan :
Q :....
.........
.........
.........
.........
.........
.........
.........
R :...
.........
.........
.........
.........
.........
.........
.........
. S
:........
.........
.........
.........
.........
.........
.........
.....
T :...
.........
.........
.........
.........
.........
.........
.........
.
OD
OS
A
u
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
Masalah Keperawatan :
b. Kekuatan otot:
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
S :..................................................................
.
T :..................................................................
. i. Sirkulasi
h. Pengkajian Nyeri
Keluhan nyeri: ya tidak
P :..................................................................
.
Q :...................................................................
R :..................................................................
.
S :..................................................................
.
T :..................................................................
. i. Sirkulasi
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 Tidak 0
bulan terakhir? Ya 25
2. Diagnosa sekunder: apakah lansia memiliki lebih dari Tidak 0
satu penyakit? Ya 15
3. Alat Bantu jalan:
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 Masalah Keperawatan :
tidak
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:
............................................................................................................................. .......................................
..
.....................................................................................................................................................................
.
......................................................................................................................... ...........................................
..
PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak
pernah
TERAPI MEDIS
............................................................................................................................. ....................................................
...
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...
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..
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...
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...
............................................................................................................................. ....................................................
...
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..
............................................................................................................................. ....................................................
...
............................................................................................................................. ....................................................
...
............................................................................................................................. ...................................................
....
.................................................................................................................................................................................
...
....................................................................................................................... .........................................................
....
............................................................................................................................ ....................................................
....
............................................................................................................................... .................................................
....
............................................................................................................................ .....................................................
...
..................................................................................................................................................................................
..
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...
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...
..................................................................................................................................................................................
..
....................................................................................................................... ..........................................................
...
............................................................................................................................. ....................................................
...
..................................................................................................................................................................................
..
..................................................................................................................................................................................
..
PERENCANAAN PULANG
- Tujuan Pulang:
- Transportasi Pulang:
- Dukungan Keluarga:
- Pengobatan:
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
DX MUNCUL DIAGNOSA KEPERAWATAN 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 :
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: