POLITEKNIK KESEHATAN RS dr.

SOEPRAOEN
PROGRAM STUDI KEPERAWATAN

FORMAT LAPORAN PENDAHULUAN

NAMA MAHASISWA :

NIM :

RUANG :

PEMENUHAN KEBUTUHAN DASAR ……..…

I. KONSEP DASAR KEBUTUHAN

1. Definisi
2. Anatomi Fisiologi
3. Patofisiologi
4. Jenis Gangguan Kebutuhan Dasar...........................................................................
5. Tanda dan Gejala Gangguan Kebutuhan Dasar ........ ............................................
6. Etiologi Gangguan Kebutuhan Dasar ....... ..............................................................
7. Komplikasi Kebutuhan Dasar ..... ............................................................................
8. Penatalaksanaan Kebutuhan Dasar ....... ................................................................
(NB: menyesuaikan jenis kebutuhan dasar yang menjadi pokok pembahasan)
II. KONSEP ASUHAN KEPERAWATAN

A. PENGKAJIAN
1. Riwayat Keperawatan
…………………………………………………………………..................……………..........

2. Pemeriksaan Fisik
…………………………………………………...................…………………………………..

3. Pemeriksaan Diagnostik
…………………………………………………….................…………………………………

B. DIAGNOSA KEPERAWATAN
C. PERENCANAAN
D. PELAKSANAAN
E. EVALUASI
SUMBER/REFERENSI:

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POLITEKNIK KESEHATAN RS dr. SOEPRAOEN
PROGRAM STUDI KEPERAWATAN

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Nata Dirgantara PW Tempat Praktik :

NIM : 201080 Tgl Praktik :

A. Identitas Klien
Nama : Tn.D No. RM : 026052

Usia : 70 th Tanggal Masuk : 30-03-2020

Jenis kelamin : Laki-laki Tanggal Pengkajian : 01-04-2020

Alamat : Tangkirsari Sumber Informasi : Tn. D

No. Telepon : 083848251656 Nama klg. dekat yang bisa dihubungi: Tn. S

Status pernikahan : Menikah

Agama : Islam Status : Menikah

Suku : Jawa Alamat : Tangkirsari

Pendidikan : SLTA No. telepon : 081567897665

Pekerjaan : Sudah pensiun Pendidikan : S1

Lama bekerja : 15 Tahun Pekerjaan : Wiraswasta

B. Status Kesehatan Saat Ini

1. Keluhan utama : Sesak
2. Lama keluhan : 3 hari
3. Kualitas keluhan: Sesak pada dada seperti tertekan benda berat
4. Faktor pencetus: Sesak yang disebabkan oleh penyakit COPD
5. Faktor pemberat: aktivitas fisik berat
6. Upaya yang telah dilakukan: pemberian oksigen
7. Keluhan saat pengkajian: Sesak dan batuk

Diagnosa Medis: COPD

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C. Riwayat Kesehatan Saat Ini
Pasien datang dengan keluhan sesak dan batuk selama 3 hari seperti ditekan oleh benda berat,
sebelumnya pasien pernah masuk rumah sakit dengan gejala yang sama

D. Riwayat Kesehatan Dahulu

1. Penyakit Yang Pernah Dialami
a. Kecelakaan (Jenis &waktu) : tidak pernah
b. Operasi (Jenis &waktu) : tidak pernah
c. Penyakit :
 Kronis : Hipertensi (5th),diabetes (3th)
 Akut : tidak ada
d. Terakhir masuk RS: 8 bulan yang lalu
2. Alergi (obat, makanan, plester, dll) :
3. Imunisasi
( √ )BCG ( √ )Hepatitis
( √ )Polio ( √ )Campak
( √ )DPT ( )……………
4. Kebiasaan
Jenis Frekuensi Jumlah Lamanya
Kopi. 1x. 1 gelas. 30th

5. Obat-obatan yang digunakan

Captopril sudah 3th dengan dosis 25mg 2x1

E. Riwayat Kesehatan Keluarga

Di keluarga pasien tidak terdapat penyakit menurun ataupun penyakit yang sama dengan klien

F. Genogram

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G. Riwayat Lingkungan
Jenis Rumah Pekerjaan
 Kebersihan
 Bahaya Kecelakaan
 Polusi
 Ventilasi
 Pencahayaan

H. Pola Aktivitas – Latihan

Jenis Rumah Rumah sakit
Sebelum sakit Sesudah sakit
 Makan minum
 Mandi
 Berpakaian/berdandan
 Toileting
 Mobilitas di tempat tidur
 Berpindah
 Berjalan
 Naik tangga
Pemberian skor : 0 = mandiri, 1 = alat bantu, 2 = dibantu 1 orang, 3 = dibantu>1 orang, 4 =
tidak mampu
I. Pola Nutrisi Metabolik
Jenis Rumah Rumah sakit
 Jenis diet
 Frekuensi/pola
 Porsi yng dihabiskan
 Komposisi menu
 Pantangan
 Nafsu makan
 Fluktuasi BB 6 bulan terakhir
 Jenis minuman
 Frekuensi/pola
J. Pola Eliminasi
Rumah Rumah sakit
BAB
 Frekuensi/pola
 Konsistensi
 Warna & bau
 Kesulitan
 Upaya mengatasi
BAK
 Frekuensi/pola
 Konsistensi
 Warna & bau
 Kesulitan
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 Upaya mengatasi
K. Pola Tidur – Istirahat
Rumah Rumah sakit
Tidur siang : lamanya
 Jam….s/d…..
 Kenyamanan stlh tidur
Tidur malam : lamanya
 Jam….s/d…..
 Kenyamanan stlh tidur
 Kebiasaan sblm tidur
 Kesulitan
 Upaya mengatasi

L. Pola Kebersihan Diri

Rumah Rumah sakit
 Mandi : frekuensi
Penggunaan sabun
 Keramas : frekuensi
Penggunaan sampo
 Gosok gigi : frekuensi
Penggunaan odol
 Ganti baju : frekuensi
 Potong kuku : frekuensi
 Kesulitan
 Upaya yg dilakukan

M. Pola Toleransi Koping-Stress

1. Pengambilan keputusan: ( ) sendiri ( ) dibantu orang lain, sebutkan
2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri, dll)
3. Yang biasa dilakukan apabila stress/mengalami masalah
4. Harapan setelah menjalani perawatan:
5. Perubahan yang dirasa setelah sakit:
N. Konsep Diri
1. Gambaran
2. Ideal diri
3. Harga diri
4. Peran
5. Identitas diri
O. Pola Peran dan Hubungan
1. Peran dalam keluarga: kepala keluarga
2. Sistem pendukung: suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain, sebutkan:

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 3. Kesulitan dalam keluarga: -
( ) hubungan dengan orang tua ( ) hubungan dengan pasangan
( ) hubungan dengan sanak saudara ( ) hubungan dengan anak
( ) lain-lain sebutkan,
4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS:
5. Upaya yang dilakukan untuk mengatasi
P. Pola Komunikasi
1. Bicara ( ) Normal ( ) bahasa utama
( ) Tidak jelas ( ) bahasa daerah
( ) bicara berputar putar ( ) rentang perhatian
( ) Mampu mengerti pembicaraan orang lain ( ) afek
Q. Pola Seksualitas
1. Masalah dalam hubungan seksual selama sakit: ( ) tidak ada ( ) ada
2. Upaya yang dilakukan pasangan:
( ) perhatian ( ) sentuhan ( ) lain-lain, seperti
R. Pola Nilai dan Kepercayaan
1. Apakah Tuhan, agama, dan kepercayaan penting untuk Anda, Ya/Tidak
2. Kegiatan agama/kepercayaan yang dilakukan di rumah (jenis dan frekuensi)
3. Kegiatan agama/kepercayaan tidak dapat dilakukan di RS
4. Harapan klien terhadap perawat untuk melakukan ibadahnya
S. Pemeriksaan Fisik
1. Keadaan umum :
 Kesadaran :
 Tanda tanda vital :
Tekanan Darah : Suhu :
Nadi : RR :
 Tinggi Badan : cm Berat Badan : kg

2. Kepala & Leher

a. Kepala
 Bentuk:
 Massa:
 Distribusi rambut:
 Warna kulit kepala:
 Keluhan: pusing/sakit kepala/migraine, lainnya:
b. Mata
 Bentuk:
 Konjungtiva:
 Pupil: ( ) reaksi terhadap cahaya ( ) isokor ( ) miosis ( ) pin point ( ) midriasis
 Tanda radang:
 Fungsi penglihatan:
 Penggunaan alat bantu:
c. Hidung
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  Bentuk :
 Warna :
 Pembengkakan :
 Nyeri tekan :
 Perdarahan :
 Sinus :
d. Mulut & Tenggorokan
 Warna bibir :
 Mukosa :
 Ulkus :
 Lesi :
 Massa :
 Warna lidah :
 Perdarahan gusi :
 Karies :
 Gangguan bicara :
e. Telinga
 Bentuk :
 Warna :
 Lesi :
 Massa :
 Nyeri :
 Nyeri tekan :
f. Leher
 Kekakuan :
 Benjolan/massa :
 Vena jugularis :
 Nyeri :
 Nyeri tekan :
 Keterbatasan gerak :
 Keluhan lain :
3. Thorak & Dada
 Jantung
- Inspeksi :

-
Palpasi :..................................................................................................................................
................................................................................................................................................
- Perkusi :...................................................................................................................................
................................................................................................................................................
- Auskultasi : .............................................................................................................................
................................................................................................................................................
 Paru
- Inspeksi ..................................................................................................................................
................................................................................................................................................
- Palpasi : ..................................................................................................................................
................................................................................................................................................
- Perkusi : ..................................................................................................................................
................................................................................................................................................
- Auskultasi : .............................................................................................................................
................................................................................................................................................
4. Payudara & Ketiak
 Benjolan/massa : ..........................................................................................................................

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  Bengkak : ......................................................................................................................................
 Nyeri : ...........................................................................................................................................
 Nyeri tekan : ................................................................................................................................
 Kesimetrisan : ...............................................................................................................................
5. Punggung & Tulang Belakang
.............................................................................................................................................................
.............................................................................................................................................................
6. Abdomen
 Inspeksi ............................................................................................................................................
..........................................................................................................................................................
 Palpasi...............................................................................................................................................
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 Perkusi..............................................................................................................................................
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 Auskultasi..........................................................................................................................................
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7. Genitalia & Anus

 Inspeksi : ..........................................................................................................................................
..........................................................................................................................................................
 Palpasi...............................................................................................................................................
..........................................................................................................................................................
8. Ekstremitas (kekuatan otot, kontraktur, deformitas, edema, luka, nyeri/nyeri tekan, pergerakan)
 Atas : ................................................................................................................................................
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 Bawah ..............................................................................................................................................
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9. Sistem Neurologi 9SSP : I-XII, reflek, motorik, sensorik)
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10. Kulit & Kuku
 Kulit : (warna, lesi, turgor, jaringan parut, suhu, tekstur, diaphoresis)
.......................................................................................................................................................
.......................................................................................................................................................
 Kuku : (warna, lesi, bentuk, CRT)
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.

T. Hasil Pemeriksaan Penunjang (Laboratorium, USG, Rontgen, MRI)

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U. Terapi (Medis, RehabMedik, Nutrisi)
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V. Persepsi Klien Terhadap Penyakitnya
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W. Kesimpulan
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X. 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............................................................................................
 Keterangan lain....................................................................................................................................

Malang,
Pengkaji

__________________
ANALISA DATA

NO DATA ETIOLOGI MASALAH

. KEPERAWATAN

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 DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

NAMA KLIEN :

NO.REG :

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 NO TANGGAL DIAGNOSA TANGGAL TANDA
MUNCUL KEPERAWATAN TERATASI TANGAN

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 RENCANA ASUHAN KEPERAWATAN

Nama / Usia : Dx / No.Reg :

NO TGL DX KEPERAWATAN TUJUAN & KRITERIA HASIL INTERVENSI RASIONAL

IMPLEMENTASI DAN EVALUASI

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 Nama : __________________ Ruangan : ______________________ RM No. : _____________________Dx medis : _____________________

No. Tanggal/
IMPLEMENTASI KEPERAWATAN EVALUASI
Dx Jam

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