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.
 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
tempat tidur Memerlukan sedikit bantuan (1 orang) transfer dan
1
ke kursi dan /dalam pegawasan mobilitas.
kembali lagi Memerlukan bantuan yang nyata (2 Jika nilai total
2
ke tempat orang) 0 – 3 maka
tidur) Tidak dapat duduk dengan seimbang, skor = 0
3
perlu bantuan total Jika nilai total
6 Mobilitas Mandiri (boleh menggunakan alat bantu 4 – 6, maka
0
jalan) skor = 7
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
Umur
7 – 13 tahun 2
≥ 13 tahun 1
Laki-laki 2
Jenis Kelamin
SKRINING RISIKO JATUH (Humpthy Dumpty)

Perempuan 1
Kelainan neurologi 4
Perubahan dalam oksigenasi (masalah sal. Nafas, 3
anemia, dehidrasi, anoreksia, sakit kepala,
Diagnosis
sinkop/pusing, dll)
Kelainan psikis/ perilaku 2
Diagnosis lain 1
Tidak menyadari keterbatasan 3
Gangguan
Lupa akan keterbatasan diri 2
Kognitif
Sadar akan kemampuan sendiri 1
Riwayat jatuh dari tempat tidur saat bayi – anak 4
Pasien menggunakan alat bantu atau tempat tidur 3
Faktor
bayi/ pencahayaan
Lingkungan
Pasien berada di tempat tidur 2
Rawat Jalan 1
Respon Dalam 24 jam 3
terhadap Dalam 48 jam 2
operasi/ obat >48 jam/ tidak ada 1
penenang/ efek
anastesi
Bermacam-macam obat digunakan: obat sedative 3
(diluar pasien ICU yang sedang mengalami sedasi
Penggunaan dan paralisis), hipnotik, barbiturate, fenotiazin,
obat 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. Rencana Keperawatan
No Diagnosa Perencanaan
Keperawatan Tujuan Keperawatan & NOC Intervensi Keperawatan (NIC)
VI. Implementasi dan Evaluasi

Hari/ Nomor Dx Implementasi Evaluasi

Jam TTD
Tgl Keperawatan Keperawatan Keperawatan

S:

O:

A:

P:

I:

E: