KUMPULAN LAPORAN

STASE KEPERAWATAN DASAR PROFESI

DI RUANG NURI
RSU SARI MULIA BANJARMASIN

Untuk Menyelesaikan Tugas Profesi Keperawatan Dasar Profesi

Program Profesi Ners

Disusun Oleh:
Rohandi Yusuf
NIM:111946921010120

PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS SARI MULIA
BANJARMASIN
2021
 LAPORAN PENDAHULUAN APPENDISITIS AKUT
DI RUANG NURI
RSU SARI MULIA BANJARMASIN

Untuk Menyelesaikan Tugas Profesi Keperawatan Dasar Profesi

Program Profesi Ners

Disusun Oleh:
Rohandi Yusuf
NIM: 111946921010120

PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS SARI MULIA
BANJARMASIN
2021
 RESUME KEPERAWATAN DASAR PROFESI
PADA TN. F DENGAN APPENDISITIS AKUT
DI RUANG NURI
RSD IDAMAN BANJARBARU

Untuk Menyelesaikan Tugas Profesi Keperawatan Dasar Profesi

Program Profesi Ners

Disusun Oleh:
Rohandi Yusuf
NIM: 111946921010120

PROGRAM STUDI PROFESI NERS

FAKULTAS KESEHATAN
UNIVERSITAS SARI MULIA
BANJARMASIN
2021
 LEMBAR PERSETUJUAN

RESUME PADA TN.F DENGAN APPENDISITIS AKUT

DI RUANG NURI RUMAH SAKIT DAERAH IDAMAN BANJARBARU

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

Disusun oleh :
Rohandi Yusuf
NIM 11194692110120

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

(M. Arief Wijaksono, Ns., MAN) (Reza Fathan, S.Kep., Ns)

NIK. NIK.
 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 ......................................................................................................................
a, anus, ......................................................................................................................
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7. Refleks ......................................................................................................................
neurologis ......................................................................................................................
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8. Nervus
Cranial
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 dewasa (PQRST)

P :

Q :

R :

S :

T :
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)
Terapi Intravena: Tidak 0
4.
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

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
 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)
 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: