FORMAT LAPORAN PENDAHULUAN

1. DIAGNOSA (MEDIK)
DAN PATOFISIOLOGI
2. DIAGNOSA
KEPERAWATAN PADA KASUS PEMENUHAN KEBUTUHAN DASAR
MANUSIA
3. FOKUS PENGKAJIAN
(RIWAYAT KEPERAWATAN, PEMERIKSAAN FISIK DAN TEST
DIAGNOSTIC) DAN ANALISA DATA.

4. DIAGNOSA
KEPERAWATAN
5. INTERVENSI
KEPERAWATAN DAN RASIONAL
6. DAFTAR PUSTAKA

FORMAT LAPORAN KASUS (PROSES KEPERAWATAN)

I. PENGKAJIAN
1. IDENTITAS PASIEN
2. RIWAYAT KEPERAWATAN
3. OBSERVASI DAN PEMERIKSAAN FISIK (BODY SYSTEM/HEAD TO
TOE)
4. DIAGNOSTIC TEST
5. ANALISA DAN SINTESA DATA

II. DIAGNOS
A KEPERAWATAN
III. PERENCA
NAAN
1. PRIORITAS MASALAH
2. TUJUAN DAN HASIL YANG
DIHARAPKAN
3. RENCANA TINDAKAN

IV. IMPLEME
NTASI
V. EVALUAS
I
 FORMAT PENGKAJIAN KEPERAWATAN

Data diambil tanggal : 30 september 2021

Ruangrawat/kelas : pav ar raudho / kelas 2
No. RekamMedik : 590645

I. IDENTITAS
Nama : Ny. Z
Umur : 56 th
Jenis kelamin : perempuan
Pekerjaan : IRT
Tanggal MRS : 28 sept 2021 jam 18.30
Alamat : petiken driyorejo
Diagnosa medis : CF Femur dextra
Sumber informasi : pasien
Tanggal Pengkajian : 30 september 2021 jam 14.30

II. RIWAYAT KEPERAWATAN

1. Riwayat keperawatan sekarang
a. Keluhan utama
pasien kesulitan untuk bergerak ............................................................................
.................................................................................................................................

b. Riwayat penyakit saat ini

pasien post jatuh dari kamar mandi, terpeleset 2 minggu yang lalu, nyeri,
bengkak di bagian paha kanan, tidak bisa berjalan. tidak mau di bawa ke RS
karena takut.
hari selasa sore di bawa anaknya ke IGD untuk mendapatkan perawatan
lanjutan.....................................................................................................................
..................................................................................................................................
 ..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
2. Riwayat keperawatan/Penyakit sebelumnya
a. Riwayat kesehatan yang lalu :
tidak ada...................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................

MasalahKeperawatan:
1.Nyeri
2.Hambatan mobilisasi fisik
……………………………………………………………………………………
……………………………………………………………………………………
3. Riwayat kesehatan keluarga
a. Penyakit yang pernah diderita oleh anggota keluarga :
tidak ada...................................................................................................................
..................................................................................................................................
Lingkungan rumah dan komunitas ..........................................................................
covid 19....................................................................................................................
..................................................................................................................................
b. Perilaku yang mempengaruhi kesehatan
kuatir dan takut saat akan di bawa ke RS,................................................................
..................................................................................................................................
..................................................................................................................................
c. Persepsi terhadap penyakit
pasien kuatir sebelum nya, tetapi setelah operasi pasien optimis sembuh dan bisa
berjalan kembali walaupun dengan walker..............................................................
..................................................................................................................................
..................................................................................................................................

MasalahKeperawatan:
…1. Ansietas
……………………………………………………………………………………
……………………………………………………………………………………
…………………………………………………………………
4. Kesadaran :
compos mentis..........................................................................................................
..................................................................................................................................
..................................................................................................................................
5. Tanda- Tanda Vital :
 Suhu : 36,3 ’ c : ...........................................................................
TD : 124/60mmHg...............................................................................
RR : 20x/mnt .
Nadi : 78x/mnt ................................................................................

6. Genogram (3 generasi)

III. POLA FUNGSI KESEHATAN

1. Pola penatalaksanaan kesehatan / persepsi sehat
......................................................................................................................................
pasien yakin setelah operasi, bisa kembali berjalan.....................................................
......................................................................................................................................
......................................................................................................................................
MasalahKeperawatan :
......................................................................................................................................
tidak ada........................................................................................................................
......................................................................................................................................

2. PolaNutrisi– Metabolik
......................................................................................................................................
pasien makan sehari 3x, diet selalu habis, ....................................................................
......................................................................................................................................
......................................................................................................................................
MasalahKeperawatan :
......................................................................................................................................
tidak ada........................................................................................................................
......................................................................................................................................

3. PolaEliminasi
Eliminasi Alvi
pasien belum BAB setelah tindakan operasi (H+1)......................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

Eliminasi Uri
BAK lancar dengan menggunakan pampers................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
 ......................................................................................................................................
Masalah Keperawatan :
tidak ada........................................................................................................................
......................................................................................................................................
......................................................................................................................................

4. Pola Istirahat dan tidur

pasien sering tidur, sehari 7-8 jam, terbangun ketika nyeri timbul atau saat ingin ganti
pampers.........................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
MasalahKeperawatan :
tidak ada........................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

5. Pola Aktifitas - Latihan

saat di rumah : pasien hanya bedrest di TT, aktivitas di bantu oleh anak2 nya., di RS pun
demikian, ADL dibantu dengan perawat.
post op ; pasien mobilisasi duduk 45’ bersandar. aktivitas dengan bantuan.................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
MasalahKeperawatan :
gangguan hambatan mobilisasi.....................................................................................
......................................................................................................................................
......................................................................................................................................

6. Polakognitif – perseptual – keadekuatan alat sensori

......................................................................................................................................
pasien mengatakan nyeri post op dan kaki susah untuk di gerakkan...........................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
MasalahKeperawatan :
1. nyeri
2. gangguan mobilisasi fisik............................................................................
......................................................................................................................................
......................................................................................................................................

7. Pola persepsi dan konsep diri

Pola persepsi
 saat ini pasien hanya ingin bisa berjalan agar tidak merepoti keluarganya..................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

Konsepdiri
a. Gambaran diri
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
b. Harga diri
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
c. Ideal diri
pasien dulunya adalah seorang guru, tapi pensiun dini karena merawat anak2 nya....
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
d. Peran diri
pasien berperan sebagai ibu dan istri di rumah. ..........................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
e. Identitas diri
pasien adalah seorang ibu dari 3 anaknya, ..................................................................
......................................................................................................................................
......................................................................................................................................
MasalahKeperawatan :
......................................................................................................................................
......................................................................................................................................
8. Pola Reproduksi Seksual
......................................................................................................................................
pasien berjenis kelamin perempuan dan sudah menikah...............................................
......................................................................................................................................
......................................................................................................................................
MasalahKeperawatan :
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

9. Pola hubungan peran

Persepsi klien tantang pola hubungan

......................................................................................................................................
pasien sebelum masuk RS aktif di banyak kegiatan di kampungnya ( PKK, ) ,
mengajar ngaji di masjid, tapi semnjak sakit, pasien tidak bisa aktif kembali...........
 ......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

Persepsi klien tentang peran dan tanggung jawab

......................................................................................................................................
pasien adalah ibu dari 3 anak, dan seorang istri. sebelum sakit pasien mengurusi rumah
tangga, dan jika sudah selesai sore nya pasien biasa mengajar ngaji di masjid. semenjak
sakit pasien tidak bisa berbuat apa2, hanya tiduran saja...............................................
......................................................................................................................................
Masalah Keperawatan :
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

10. Mekanisme Koping

Kemampuan mengendalian stress

......................................................................................................................................
...................................................................pasien mengetahui dia sakit, sebelum ke RS pasien memang ta
covid, tapi karena bujukan dari anaknya pasien mau , pasien selalu berdzikir di sela2
waktu jika tidak sedang tidur........................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
Sumber pendukung
suami dan anak anaknya...............................................................................................
......................................................................................................................................
......................................................................................................................................

Masalah Keperawatan :
......................................................................................................................................
tidak ada........................................................................................................................
......................................................................................................................................

11. Pola tata nilai dan kepercayaan

......................................................................................................................................
pasien beragama islam, pasien selalu menjalankan kewajibannya sebagai seorng muslim,
jika tidak tidur pasien biasa dzikir atau mengaji..........................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
MasalahKeperawatan :
......................................................................................................................................
tidak ada........................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

12. PemeriksaanRefleks
 Refleks : Fisilogis

DextraSinistra DextraSinistra

Biceps Triceps
\ \

DextraSinistra DextraSinistra

Knee Achiles
\

RefleksPatologis DextraSinistra DextraSinistra

Babinski Oppenheim
\ \

DextraSinistra

Chadok

MasalahKeperawatan :
……………………………………………………………………………………………
……gangguan mobilitas fisik
……………………………………………………………………………………………
………………………………………………………………

13. AspekSosial

a. Ekspresi efek dan emosi : Senang Sedih

Menangis
Cemas Marah Diam
Takut Lain ...................................
b. Hubungan dengan keluarga :
Akrab Kurang akrab
 MasalahKeperawatan :
……………………………………………………………………………………
……tidak ada
……………………………………………………………………………………
………………………………………………………………………………

14. Pemeriksaan Penunjang

1. Pemeriksaan Laboratorium
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
2. Pemeriksaan Radiologi
.................................................................................................................................
thorak ; normal
foto pelvis : tampak fraktur 1/3 distal os femur kanan, terpasang internal fiksasi,
aligament cukup baik

3. Pemeriksaan Lain – lain

.................................................................................................................................
swab antigen ; negatif..............................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

4. Terapi dan Diet.

.................................................................................................................................
diet nasi TKTP
terapi ; inj santagesik 3x1 amp, inj ceftriaxone 2x1 gr, inj ranitidin 2x1 amp........

DAFTAR MASALAH KEPERAWATAN

1 Gangguan Mobilisasi Fisik………………………………………

2 Nyeri…………………………………
3 Ansietas…………………………………………………………………………………
4……………………………………………………………………………………
5……………………………………………………………………………………
6……………………………………………………………………………………
7……………………………………………………………………………………
8……………………………………………………………………………………
9……………………………………………………………………………………
10……………………………………………………………………………………

Surabaya,
Preceptee

(……………………….)
 ANALISA DATA

NamaPasien : ny Z No. Register : 590645

Umur : 56 th DiagnosaMedis : CF Femur D

DATA ETIOLOGI PROBLEM

DS : pasien mengatakan sulit Gangguan Mobilitas Fisik
bergerak karena kakinya Gangguan muskulosekletal
yang fraktur dan kesulitan
jika ingin berpindah posisi

DO :
-pasien menderita patah di
bagian paha kanan
-pasien masih takut jika akan
berpindah posisi
-Segala aktivitas di bantu oleh
keluarga dan perawat
-pasien kesulitan jika ingin
mobilisasi mika/miki
-tonus otot pada kaki kanan 3
-terpasang bebat pada luka
bekas operasi dipaha kanan
sampai betis

DS ; Pasien mengatakan nyeri Agen Pencedera Fisik Nyeri Akut

pada kaki kanan bagian paha
seperti di tusuk2

DO;
-wajah pasien terlihat
meringis
-pasien lebih suka terlentang
daripada mobilisasi

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

NamaPasien : ny Z No. Register : 590645
Umur : 56 th DiagnosaMedis : CF Femur D

NO DIAGNOSA KEPERAWATAN TTD

1. Gangguan Mobilitas Fisik berhubungan dengan gangguan
muskulosekeletal di tandai dengan pasien mengeluh kesulitan jika
akan menggerakkan extremitas , kekuatan otot menurun, dan
Rentang gerak (ROM) menurun

2. Nyeri Akut berhubungan dengan agen pencedera fisik ditandai

dengan wajah pasien terlihat meringis, pasien mengeluh nyeri pada
kaki paha kanan, skala nyeri 7-8
 INTERVENSI KEPERAWATAN

NamaPasien : Ny Z No. Register : 560944

Umur : 56 th DiagnosaMedis : CF Femur Dextra

NO DIAGNOSA TUJUAN KRITERIA HASIL INTERVENSI RASIONAL

KEPERAWATAN
1. Gangguan Mobilitas Setelah dilakukan 1.Pergerakan extremitas Dukungan Ambulasi
Fisik b/d gangguan tindakan keperawatan meningkat Observasi
muskuloskletal di 3 x 8 jam mobilitas 2.Kekuatan tonus otot 1.identifikasi adanya nyeri /
buktikan dengan ; fisik meningkat meningkat keluhan fisik yang lain
3.Rentang gerak (ROM) 2.Identifikasi toleransi fisik
-pasien mengatakan meningkat melakukan ambulasi
sulit bergerak karena 4.Kelemahan fisik 3. Monitor kondisi umum selama
keadaaan kakinya yang menurun melakukan ambulasi
fraktur Teraupetik
-segala aktivitas pasien 1.Fasilitasi aktivitas mobilisasi dg
dibantu oleh keluarga alat bantu (tongkat/kruk)
dan perawat 2.Fasilitasi melakukan mobilisasi
-Pasein mengatakan jika perlu
tidak bisa beraktivitas 3.Libatkan keluarga untuk
normal seperti biasanya membantu pasien dalam
meningkatkan ambulasi
Edukasi ;
1.Jelaskan tujuan dan prosedur
ambulasi
2.Anjurkan melakukan ambulasi
dini
3. Ajarkan ambulasi sederhana
yang harus dilakukan
 IMPLEMENTASI

NamaPasien : Ny Z No. Register : 560094

Umur : 56 th DiagnosaMedis :CF Femur Dextra

TANGGAL / JAM IMPLEMENTASI TTD

1 okt 2021 , jumat

07.30 1.melihat kondisi umum pasien selama melakukan
mobilisasi
- posisi pasien hanya terlihat terbaring di tempat
tidur dengan ttv TD ; 120/80mmHg, N; 86x/mnt, T;
36,4’c

08.30 Meminta keluarga membantu dalam merencanakan

program latihan ambulasi
-keluarga berperan aktif dalam membantu pasien
melakukan gerakan dini seperti mengangkat kaki
perlahan

08.50 Mengajarkan mobilisasi sederhana yang harus

dilakukan
-Membantu pasien untuk latihan duduk secara
perlahan

09.10 Mengecek dan melihat apakah ada edema pada kaki

kanan
Menganjurkan pasien mengkonsumsi makanan
tinggi kalori dan protein
-Edema pada tungkai kanan terlihat menurun
-Pasien mengkonsumsi diet dari RS
 EVALUASI

NamaPasien : ny Z No. Register : 590044

Umur :56 th DiagnosaMedis : CF Femur dextra

TGL / DIAGNOSE EVALUASI

JAM KEPERAWATAN
Gangguan Mobilitas Fisik S; pasien mengatakan sudah belajar duduk
berhubungan dengan sendiri dengan bantuan pagar TT
gangguan muskuloskletal
O;
-pasien post op H+1 fraktur pada kaki kanan
-pasien mulai beraktivitas lebih baik

A; masalah gangguang mobilitas fisik teratasi

sebagian

P; lanjutkan intervensi
-Identifikasi kemampuan pasien beraktivitas
-Monitor kondisi umum selama melakukan
mobilisasi
-Anjurkan mobilisasi dini