Lampiran 1.

Cover Kumpulan Laporan Stase Keperawatan Dasar Profesi

KUMPULAN LAPORAN
STASE KEPERAWATAN DASAR PROFESI
DI RUANG ......
RSU SARI MULIA BANJARMASIN

Untuk Menyelesaikan Tugas Profesi Keperawatan Dasar Profesi

Program Profesi Ners

Disusun Oleh:

NIM:

PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS SARI MULIA
BANJARMASIN
2021
Lampiran 2. Cover Laporan Pendahuluan

LAPORAN PENDAHULUAN …………………

DI RUANG ......
RSU SARI MULIA BANJARMASIN

Untuk Menyelesaikan Tugas Profesi Keperawatan Dasar Profesi

Program Profesi Ners

Disusun Oleh:

NIM:

PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS SARI MULIA
BANJARMASIN
2021
Lampiran 3. Cover Laporan Resume

ASUHAN KEPERAWATAN DASAR PROFESI

PADA TN/ NY….. DENGAN ……………………
DI RUANG ......
RSU SARI MULIA BANJARMASIN

Untuk Menyelesaikan Tugas Profesi Keperawatan Dasar Profesi

Program Profesi Ners

Disusun Oleh:

NIM:

PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS SARI MULIA
BANJARMASIN
2021
Lampiran 4. Format Lembar Persetujuan

LEMBAR PERSETUJUAN

ASUHAN KEPERAWATAN PADA NY. Y DENGAN HIPERTENSI

DI RUANG ...................... RUMAH SAKIT UMUM SARI MULIA BANJARMASIN

Tanggal ..................................

Disusun oleh :

NIM

Banjarmasin, …………………….
Mengetahui,
Preseptor Akademik, Preseptor Klinik,

(……………………………..) (……………………………..)
NIK. NIK.
Lampiran 5. 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. Patofisiologi (Pathway)
d. Manifestasi klinis
e. Pemeriksaan penunjang
f. Penatalaksanaan
g. Pegkajian fokus keperawatan
h. Diagnosa Keperawatan
i. Tujuan Keperawatan (NOC/ SLKI)
j. Rencana Tindakan Keperawatan (NIC/SIKI)
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/ SLKI (Minimal 1 label dengan minimal 3 kriteria hasil per label) dan NOC/ SLKI
(Minimal 1 label dan 5 intervensi per label)
Lampiran 6. 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 : ………………….

Identitas Penanggung jawab

Nama : …………………… Alamat : …………………………
Umur : …………………… Pendidikan : …………………………
Jenis kelamin : …………………… Pekerjaan : …………………………
Suku/bangsa : …………………… Hubungan : …………………………

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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d. Riwayat Keluarga: Genogram:

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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 ......................................................................................................................
mitas, ......................................................................................................................
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6. Genitali ......................................................................................................................
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7. Refleks ......................................................................................................................
neurologis ......................................................................................................................
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8. Nervus ......................................................................................................................
 Cranial ......................................................................................................................
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k. Kebutuhan Cairan :

l. Intake cairan : Output Cairan :

m. Balance Cairan :

n. Nutrisi : Sebelum di RS Sesudah di RS

Frekuensi : .............................. ................................................................
Porsi makan/minum: ................ ................................................................
Keterangan: .............................. ................................................................

o. Pola tidur : Sebelum di RS Sesudah di RS

Siang/ malam : .....jam/ ... jam Siang/ malam : .....jam/ .......jam
Kebiasaan tidur: ....................... Kebiasaan tidur: ........................

p. Kebersihan diri : Sebelum di RS Sesudah di RS

Mandi : ................ x/hari Mandi : ................ x/hari
Sikat gigi : ................ x/hari Sikat gigi : ................ x/hari
Potong kuku: ................ x/hari Potong kuku: ................ x/hari

q. Eliminasi : Sebelum di RS Sesudah di RS

BAB: ........ x/hari BAB: ........ x/hari
 BAK: ........ x/hari BAK: ........ x/hari

r. Spiritualitas : Apa aktivitas spiritualitas Anda sebelum masuk RS?

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Selama di RS, apakah Anda masih bisa melakukan aktivitas spiritualitas?
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Jika, tidak. Apakah hal tersebut menjadi kekhawatiran Anda?
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s. ADL (Indeks Barthel)

Item penilaian Skor Hasil

Makan (Feeding) 0 = tidak mampu
1 = butuh bantuan
2 = mandiri
Mandi (Bathing) 0 = butuh bantuan
1 = mandiri
Perawatan diri 0 = butuh bantuan
(Grooming) 1 = mandiri
Berpakaian (Dressing) 0 = butuh bantuan total
1 = sebagian dibantu
2 = mandiri
Buang air kecil (Bowel) 0 = inkontinensia/ pakai kateter
1 = kadang inkontinensia (1x/ minggu)
2 = kontinensia
Buang air besar (Bladder) 0 = inkontinensia/ perlu enema
1 = kadang inkontinensia (1x/ minggu)
2 = kontinensia
Penggunaan toilet 0 = butuh bantuan total
1 = sebagian dibantu
2 = mandiri
Transfer 0 = tidak mampu
1 = butuh bantuan (2 orang)
2 = butuh bantuan (1 orang)
3 = mandiri
Mobilitas 0 = immobile
1 = menggunakan kursi roda
 2 = berjalan dengan bantuan 1 orang
3 = mandiri
Naik turun tangga 0 = tidak mampu
1 = butuh bantuan
2 = mandiri
Total Skor

Keterangan: Skor 20 : mandiri

Skor 12-19 : ketergantungan ringan
Skor 9-11 : ketergantungan sedang
Skor 5-8 : ketergantungan berat
Skor 0-4 : ketergantungan total

t. Nyeri :
Pengkajian nyeri pada anak (QUESTT) Pengkajian nyeri pada dewasa (PQRST)
Q  question the child (tanyakan pada anak) P  Provokatif / Paliatif
U  Use a pain rating scale (tanyakan pada anak) Q  Qualitas / Quantitas
E  Evaluate behavioral and physiologic changes (evaluasi R  Region / Radiasi
perubahan sikap dan fisiologis) S  Skala Nyeri
S  Secure parent’s involvement (pastikan keterlibatan T  Timing
orangtua)
T  Take the cause of pain into account (pertimbangkan
penyebab nyeri)
T  Take action and evaluate results (lakukan tindakan dan
evaluasi hasilnya)

Pengkajian Skala Nyeri dengan FLACC (usia < 3 tahun)

SKOR
NO KATEGORI TOTAL
0 1 2
Face (Wajah) Tidak ada Menyeringai, Dagu gemetar,
ekspresi mengerutkan gigi gemeretak
khusus, dahi, tampak (sering)
senyum tidak tertarik
(kadang-
kadang)
2 Leg (Kaki) Normal, rileks Gelisah, Menendang,
tegang kaki tertekuk
3 Activity (Aktivitas) Berbaring Menggeliat, Kaku atau
tenang, posisi tidak bisa kejang
normal, diam, tegang
gerakan mudah
4 Cry (Menangis) Tidak menangis Merintih, Terus
merengek, menangis,
kadang- berteriak,
kadang sering
mengeluh mengeluh
5 Consability Rileks Dapat Sulit dibujuk
(Konsabilitas) ditenangkan
dengan
sentuhan,
 pelukan,
bujukan, dapat
dialihkan
SKOR TOTAL
Keterangan:
Skor 1 – 3 = nyeri ringan Skor 4 – 6 = nyeri sedang Skor 7 – 10 = nyeri berat

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

No. PENGKAJIAN SKALA NILAI KET.

Riwayat jatuh: Tidak 0
1. Apakah pasien pernah jatuh dalam 3 bulan
Ya 25
terakhir?
Diagnosa sekunder: Tidak 0
2. Apakah pasien memiliki lebih dari satu
Ya 25
penyakit?
3. Alat bantu jalan:
0
 Bed rest/dibantu perawat?
 Kruk/tongkat/walker 15
 Berpegangan pada benda-benda
30
disekitar (kursi, lemari, meja)
4. Terapi Intravena: Tidak 0
 Apakah pasien saat ini terpasang infus? Ya 20
Gaya berjalan/cara berpindah:
5.  Normal/bed rest/ immobile (tidak dapat 0
bergerak sendiri)
 Lemah (tidak bertenaga) 10
 Gangguan/ tidak normal
20
(pincang/diseret)
Status Mental:
6. 0
 Pasien menyadari kondisi dirinya
 Pasien mengalami keterbatasan daya
15
ingat
TOTAL
Nilai 0-24 : tidak beresiko
Nilai 25-50 : risiko rendah
Nilai > 51 : risiko tinggi

SKALA RESIKO JATUH ONTARIO MODIFIED STRTIFY – SYDNEY SCORING UNTUK

GERIATRI
Keterangan
No. Parameter Skrining Jawaban Skor
Nilai
1. Riwayat Jatuh Apakah pasien datang kerumah sakit Salah satu
Ya/Tidak
karena jatuh? jawaban
Jika tidak, apakah pasien mengalami Ya=6
Ya/Tidak
jatuh dalam 2 bulan terakhir ini?
2. Status Mental Apakah pasien delirium? (tidak dapat Salah satu
membuat keputusan, pola pikir tidak Ya/Tidak jawaban
terorganisir, gangguan daya ingat) Ya=14
Apakah pasien disorientasi? (salah
Ya/Tidak
menyebutkan waktu, tempat atau orang)
Apakah pasien mengalami agitasi?
Ya/Tidak
(ketakutan, gelisah, dan cemas)
3. Penglihatan Apakah pasien memakai kacamata? Ya/Tidak Salah satu
Apakah pasien mengeluh adanya jawaban
Ya/Tidak
penglihatan buram? Ya=1
Apakah pasien mempunyai
Ya/Tidak
Glaukoma/Katarak/ Degenerasi Makula?
Kebiasaan Apakah terdapat perubahan perilaku
4. berkemih berkemih? (frekuensi, urgensi, Ya/Tidak Ya=2
inkontinensia, nokturia)
5. Transfer (dari Mandiri (boleh memakai alat bantu jalan) 0 Jumlah nilai
 Memerlukan sedikit bantuan (1 orang)
1
/dalam pegawasan
Memerlukan bantuan yang nyata (2
2
orang)
Tidak dapat duduk dengan seimbang,
3
perlu bantuan total
Mandiri (boleh menggunakan alat bantu
0
jalan)
Berjalan dengan bantuan 1 orang
1
(verbal/fisik)
Menggunakan kursi roda 2
Immobilisasi 3
TOTAL
Keterangan skor:
0 – 5: resiko rendah 6 – 16 : resiko sedang 17 – 30 : resiko tinggi

SKALA RESIKO JATUH UNTUK ANAK

Parameter Kriteria Nilai Skor
< 3 tahun 4
3 – 7 tahun 3
7 – 13 tahun 2
≥ 13 tahun 1
Laki-laki 2
Perempuan 1
Kelainan neurologi 4
Perubahan dalam oksigenasi (masalah sal. Nafas, 3
anemia, dehidrasi, anoreksia, sakit kepala,
sinkop/pusing, dll)
Kelainan psikis/ perilaku 2
Diagnosis lain 1
Tidak menyadari keterbatasan 3
Lupa akan keterbatasan diri 2
Sadar akan kemampuan sendiri 1
Riwayat jatuh dari tempat tidur saat bayi – anak 4
Pasien menggunakan alat bantu atau tempat tidur 3
bayi/ pencahayaan
Pasien berada di tempat tidur 2
Rawat Jalan 1
Dalam 24 jam 3
Dalam 48 jam 2
>48 jam/ tidak ada 1
Bermacam-macam obat digunakan: obat sedative 3
(diluar pasien ICU yang sedang mengalami sedasi
dan paralisis), hipnotik, barbiturate, fenotiazin,
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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x. Foto thoraks, dll (Hasil pembacaan)

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y. Terapi Farmakologi
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III. Data Fokus

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IV. Analisis Data

DATA KLIEN MASALAH
No ETIOLOGI
(Data Subjektif & Data Objektif) KEPERAWATAN
V. Diagnosa Keperawatan
1. ....................................................................................................................................
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2. ....................................................................................................................................
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3. ....................................................................................................................................
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4. ....................................................................................................................................
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5. ....................................................................................................................................
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VI. Rencana Keperawatan

Diagnosa Perencanaan
No
Keperawatan Tujuan Keperawatan & NOC Intervensi Keperawatan (NIC)
VII. Implementasi dan Evaluasi

Hari/ Nomor Dx Implementasi Evaluasi

Jam TTD
Tgl Keperawatan Keperawatan Keperawatan

S:

O:

A:

P:
I:

E: