FORMAT
PENUGASAN
(CONTOH COVER/HALAMAN DEPAN LAPORAN PENDAHULUAN)
Font yang
digunakan arial
14 dengan spasi
1,5
Ukuran
gambar
T = 4,55 cm
L = 5 cm
DI SUSUN OLEH :
Nama Mahasiswa (NIM)
Sertakan nama
mahasiswa beserta
NIM
Untuk penugasan
kelompok, sertakan
nomer urut kelompok
beserta nama seluruh
anggota dan NIM
2
(CONTOH COVER/HALAMAN DEPAN LAPORAN ASUHAN KEPERAWATAN)
Font yang
digunakan arial
14 dengan spasi
1,5
Ukuran
gambar
T = 4,55 cm
L = 5 cm
DI SUSUN OLEH :
Nama Mahasiswa (NIM)
Sertakan nama
mahasiswa beserta
NIM
Untuk penugasan
kelompok, sertakan
nomer urut kelompok
beserta nama seluruh
anggota dan NIM
3
(FORMAT LEMBAR PERSETUJUAN UNTUK PENUGASAN KELOMPOK)
LEMBAR PERSETUJUAN
JUDUL KASUS :
KELOMPOK :
2. ……………………………..
3. ……………………………..
Banjarmasin,……………….20
Menyetujui,
…………………………… ………………………………….
NIK NIK.
Page Layout :
Top = 3 cm
Right = 4 cm
Left = 3 cm
Left = 3 cm
4
(FORMAT LEMBAR PENGESAHAN UNTUK PENUGASAN KELOMPOK)
LEMBAR PENGESAHAN
JUDUL KASUS :
TEMPAT PENGAMBILAN KASUS :
KELOMPOK :
NAMA ANGGOTA KELOMPOK : 1 ..……………………………
2. ……………………………..
3. ……………………………..
Banjarmasin,……………….20
Menyetujui,
…………………………… ………………………………….
NIK. NIK.
Page Layout :
Top = 3 cm
Right = 4 cm
Left = 3 cm
Left = 3 cm
5
(FORMAT LEMBAR PERSETUJUAN UNTUK PENUGASAN INDIVIDU)
LEMBAR PERSETUJUAN
JUDUL KASUS :
TEMPAT PENGAMBILAN KASUS :
NAMA :
Banjarmasin,……………….20
Menyetujui,
…………………………… ………………………………….
NIK NIK.
Page Layout :
Top = 3 cm
Right = 4 cm
Left = 3 cm
Left = 3 cm
6
(FORMAT LEMBAR PENGESAHAN UNTUK PENUGASAN INDIVIDU)
LEMBAR PENGESAHAN
JUDUL KASUS :
TEMPAT PENGAMBILAN KASUS :
NAMA :
Banjarmasin,……………….20
Menyetujui,
…………………………… ………………………………….
NIK. NIK.
Page Layout :
Top = 3 cm
Right = 4 cm
Left = 3 cm
Left = 3 cm
7
(FORMAT KERANGKA PENULISAN LAPORAN PENDAHULUAN INDIVIDU)
COVER
LEMBAR PERSETUJUAN (PARAF DARI CI DAN CT)
LEMBAR PENGESAHAN (PARAF DARI CI DAN CT, SETELAH DIREVISI)
TINJAUAN PUSTAKA
A. Pengertian
B. Etiologi/Penyebab
C. Patofisiologi
D. Manifestasi Klinik/Tanda dan Gejala
E. Komplikasi
F.Penatalaksanaan Medis
G.Penatalaksanaan Keperawatan
DAFTAR PUSTAKA (minimal 5 referensi sumber pustaka)
Page Layout :
Top = 3 cm
Right = 4 cm
Left = 3 cm
Left = 3 cm
8
FORMAT PENULISAN ASUHAN KEPERAWATAN
KEPERAWATAN MEDIKAL BEDAH
I. Pengkajian
Font arial 11 dengan spasi 1,5
Hari/Tanggal pengkajian :
A. IDENTITAS Page Layout :
1. IDENTITAS KLIEN Top = 3 cm
Right = 4 cm
Nama :
Left = 3 cm
Jenis Kelamin : Left = 3 cm
Umur :
Pendidikan :
Pekerjaan :
Alamat :
Status Perkawinan :
Agama :
Suku/bangsa :
Tanggal masuk RS :
Diagnosa Medis :
Nomer Rekam Medik :
A. B. Riwayat Kesehatan
1. Keluhan Utama
……………………………………………………………………………………………………
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9
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2. Riwayat Kesehatan/ Penyakit Sekarang
……………………………………………………………………………………………………
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Penanganan yang telah dilakukan:
…………………………………………………………..
……………………………………………………………………………………………………...
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3. Riwayat Kesehatan/ Penyakit Dahulu
……………………………………………………………………………………………………
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4. Riwayat Kesehatan/ Penyakit Keluarga (SERTAKAN GENOGRAM)
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5. Nilai Budaya atau Kepercayaan (terkait Penyakit yang diderita saat ini)
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6. Riwayat Tumbuh Kembang (khusus pada klien: anak yang berusia 0-18 tahun)
(OPTIONAL, JIKA ADA PASIEN)
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10
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7. Full Set Vital Sign
TD : mmHg
x
Nadi : /mnt (Irama : ………………… ; Pulse : ……………..…….)
x
Respirasi : /mnt (Irama : ………………… ; Kedalaman : …………….)
0
T : C
Tingkat Kesadaran : ……………………………………………
GCS : E: ……..; V: ……..; M: ……..
11
B. Pemeriksaan Fisik
1. Keadaan Umum
……………………………………………………………………………………………………
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2. Kulit
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3. Kepala dan Leher
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4. Penglihatan dan Mata
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5. Penciuman dan Hidung
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12
6. Pendengaran dan Telinga
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7. Mulut dan Gigi
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8. Dada, Pernafasan dan Sirkulasi
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Sirkulasi:
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9. Abdomen
Diisi hasil pengkajian yang meliputi:
Inspeksi : ……………………………………………………………………..
…………………………………………………………………….
……………………………………………………………………..
Auskultasi : ……………………………………………………………………..
……………………………………………………………………..
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Palpasi : ……………………………………………………………………..
13
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Perkusi : ……………………………………………………………………..
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10. Genetalia dan Reproduksi
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14
4. Eliminasi (BAB dan BAK)
Di Rumah : ………………………………………………………………………….
………………………………………………………………………….
Di RS : …………………………………………………………………………..
………………………………………………………………………….
5. Seksualitas
……………………………………………………………………………………………………
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6. Psikososial
……………………………………………………………………………………………………
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Peran Keluarga:
…………………………………………………………………………………............................
..........................................................................................................................................
Peran Orang Terdekat:
………………………………………………………………………….......................................
...........................................................................................................................................
.
7. Respon Kognitif
Pasien/ Keluarga menginginkan informasi tentang:
Penyakit yang diderita
Tindakan Pemeriksaan Lanjut
Tindakan/ pengobatan dan perawatan yang diberikan
Perubahan aktifitas sehari-hari
Perencanaan Diet dan menu
Perawatan setelah di rumah
8. Spiritual
Agama: Perlu Pemuka Agama: Ya Tidak
15
……………………………………………………………………………………………………
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7. Harapan dan Rencana Pasien terhadap Penyakitnya
……………………………………………………………………………………………………
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D. Data Fokus
Data Subjektif:
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Data Objective:
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Inspeksi : ……………………………………………………………………..
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Perkusi : ……………………………………………………………………..
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Palpasi : ……………………………………………………………………..
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Auskultasi : ……………………………………………………………………..
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16
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E. Pemeriksaan Penunjang
Pemeriksaan Laboratorium
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Pemeriksaan Diagnostik
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F. Terapi Farmakologi (Obat-Obatan)
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17
No Nama Dosis Cara Komposisi Golongan Indikasi/ Efek
Obat Pemberian Obat Kontaindikasi Samping
(Isi)
18
II. Analisa Data
No. DATA ETIOLOGI MASALAH
19
III. Prioritas masalah
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20
II. Intervensi Keperawatan
No Diagnosa Keperawatan NOC NIC Rasional
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22
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23
IV. Evaluasi
Instruksi PPA
Profesional
Diagnosa Evaluasi Termasuk pasca Paraf (nama,
No Hari / Tanggal Pukul Pemberi
Keperawatan (SOAPIE) bedah (di tulis paraf, tgl, jam)
Asuhan
jelas dan rinci)
………
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………
… …………………… …………………………………………
………
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… …………………… ……..
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… …………………… …………………………………………
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… ……………………. ……..
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24
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… ............. .............................. …………………………………………
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… ............. .............................. …………………………………………
………………… ............. .............................. …………………………………………
… ............. .............................. ……..
………………… ............. .............................. …………………………………………
… ............. .............................. …………………………………………
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… ............. .............................. …………………………………………
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… ............. .............................. ……..
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… ............. .............................. …………………………………………
………………… ............. .............................. ……..
… ............. .............................. …………………………………………
………………… ............. .............................. …………………………………………
…......................... ............. .............................. ……..
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25
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26
V. ANALISIS PELAKSANAAN INTERPROFESSIONAL COLLABORATION PADA
ASUHAN KEPERAWATAN DENGAN DIAGNOSIS ………
A. Analisis Interprofessional Collaboration masing-masing diagnosa keperawatan.
(sebutkan diagnosa keperawatan). Contoh:
1. Nyeri berhubungan dengan agen injury biologis
(Jabarkan diagnosa yang diangkat, profesi keilmuan yang dapat terlibat menangani
masalah keperawatan tersebut, mengapa profesi tersebut diperlukan hingga evaluasi
dari intervensi yang dilakukan). Contoh:
a. Profesi yang terlibat :
1) Perawat
Bertindak dalam memenuhi kebutuhan dasar pasien secara holistik, memberikan
rasa nyaman dan mengurangi nyeri dengan teknik farmakologis. Perawat turut
pula berperan aktif mengkonsultasikan kondisi pasien kepada dokter terkait
terapi farmakologis pasien dst…dst…dst…
2) Dokter
Bertindak dalam mengidentifikasi proses penyakit, berkoordinasi dengan
perawat dalam menentukan terapi medis, yaitu….. untuk menghilangkan
penyebab utama dari masalah nyeri pasien.
3) Apoteker
Bertindak dalam pemenuhan kebutuhan terapi medis melalui pemberian obat-
obatan, edukasi penggunaan obat, dst…dst…
Hasil evaluasi ditemukan, nyeri berkurang dalam… x jam perawatan. Ditandai dengan
…………
2. Lakukan penjabaran yang sama dengan nomer sebelumnya
3. dst..
27
VI. Discharge Planning
DISCHARGE PLANNING
Nama Pasien: Umur: Tanggal Masuk: No. RMK
d. Pencegahan
factor resiko
e. Lingkungan yang
perlu dipersiapkan
Pasien Masuk
f. Rencana tindak
lanjut
g. Support system
4 Pemahaman pasien/
keluarga terhadap
penjelasan dari:
a. Fisioterapi
b. Ahli gizi
c. Dokter
d. Bidan
e. Farmasi
f. Perawat
lainnya
Tahap II
5 Penkes tentang
proses penyakit:
a. Pengertian,
28
penyebab, tanda
dan gejala
b. Faktor resiko
c. Komplikasi
6 Penkes tentang obat-
obatan
7 Penkes tentang
Penatalaksanaan
8 Penkes tentang
Fase Diagnostik
Pemeriksaan
diagnostik
9 Penkes tentang
rehabilitasi
10 Penkes tentang
perawatan dalam
hygiene personal,
perubahan posisi,
pencegahan jatuh,
pencegahan aspirasi,
laihan ROM dan
teknik relaksasi
11 Penkes tentang
modifikasi gaya hidup:
a. Pengaturam diet
(sesuai factor
resiko)
b. Aktifitas fisik
Tahap III
c. Merokok
d. Penggunaan
alcohol dan obat-
Fase Stabilisasi
obatan
12 Diskusi tentang
modifikasi lingkungan
pasien setelah pulang
dari RS
13 Diskusikan tentang
rencana perawatan
lanjutan pasien
a. Bantuan ADL
b. Jadwal kontrol
29
14 Diskusi tentang
pengawasan
15 Diskusi tentang
support system
keluarga, financial,
dan alat/transportasi
yang akan digunakan
pasien
30
(FORMAT RESUME IGD MEDIK)
I. Identitas Klien
1. Nama :
2. Jenis Kelamin :
3. Umur :
4. Pendidikan :
5. Pekerjaan :
6. Alamat :
7. Status Perkawinan :
8. Agama :
9. Suku / Bangsa :
10. Tgl Masuk RS :
11. Diagnosa Medis :
12. No. Rekam Medik :
13. Tanggal Pengkajian :
32
IV. Pemeriksaan Status Nyeri
Nyeri: Jantung:
□ Ada □ Tidak Skala Nyeri: Nyeri dada sekarang: □ Ya
Penyebab: □ Tidak
Menyebar ke: □ Menyebar □ Tidak Menyebar
V. Data Fokus
1. Inspeksi
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
2. Palpasi
……………………………………………………………………………………………
……………………………………………………………………………………………
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3. Perkusi
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33
4. Auskultasi
……………………………………………………………………………………………
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……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
5. Tanda-Tanda Vital
Tekanan Darah : ………mmHg
Nadi : ………x/mnt (Kualitas:……………..; Ritme:………………)
Respirasi : ………x/mnt (Effort:…………….…..; Ritme:………………)
Suhu : ………0C
Tingkat Kesadaran : ………………………
34
VI. Intervensi, Implementasi, Dan Evaluasi
(TABEL)
Tujuan/Kriteria Profesional
Data Dx. Kep Intervensi (NIC) Rasional Implementasi Evaluasi
Hasil (NOC) Pemberi Asuhan
35
VII. ANALISIS PELAKSANAAN INTERPROFESSIONAL COLLABORATION PADA ASUHAN
KEPERAWATAN DENGAN DIAGNOSIS ………
A. Analisis Interprofessional Collaboration masing-masing diagnosa keperawatan.
(sebutkan diagnosa keperawatan). Contoh:
1. Nyeri berhubungan dengan agen injury biologis
(Jabarkan diagnosa yang diangkat, profesi keilmuan yang dapat terlibat menangani
masalah keperawatan tersebut, mengapa profesi tersebut diperlukan hingga evaluasi dari
intervensi yang dilakukan). Contoh:
b. Profesi yang terlibat :
1) Perawat
Bertindak dalam memenuhi kebutuhan dasar pasien secara holistik, memberikan
rasa nyaman dan mengurangi nyeri dengan teknik farmakologis. Perawat turut pula
berperan aktif mengkonsultasikan kondisi pasien kepada dokter terkait terapi
farmakologis pasien dst…dst…dst…
2) Dokter
Bertindak dalam mengidentifikasi proses penyakit, berkoordinasi dengan perawat
dalam menentukan terapi medis, yaitu….. untuk menghilangkan penyebab utama
dari masalah nyeri pasien.
3) Apoteker
Bertindak dalam pemenuhan kebutuhan terapi medis melalui pemberian obat-
obatan, edukasi penggunaan obat, dst…dst…
Hasil evaluasi ditemukan, nyeri berkurang dalam… x jam perawatan. Ditandai dengan
…………
2. Lakukan penjabaran yang sama dengan nomer sebelumnya
3. dst..
36
(FORMAT RESUME IGD TRAUMA)
RESUME KEPERAWATAN PASIEN TRAUMA
RUANG INSTALASI GAWAT DARURAT
UNIVERSITAS SARI MULIA BANJARMASIN
I. Identitas Klien
1. Nama :
2. Jenis Kelamin :
3. Umur :
4. Pendidikan :
5. Pekerjaan :
6. Alamat :
7. Status Perkawinan :
8. Agama :
9. Suku / Bangsa :
10. Tgl Masuk RS :
11. Diagnosa Medis :
12. No. Rekam Medik :
13. Tanggal Pengkajian :
V. Data Fokus
1. Inspeksi
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2. Palpasi
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3. Perkusi
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4. Auskultasi
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5. Tanda-Tanda Vital
Tekanan Darah : ………mmHg
Nadi : ………x/mnt (Kualitas:……………..; Ritme:………………)
Respirasi : ………x/mnt (Effort:…………….…..; Ritme:………………)
Suhu : ………0C
GCS : ………………………
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VI. Intervensi, Implementasi, Dan Evaluasi
(TABEL)
Tujuan/Kriteria Profesional
Data Dx. Kep Intervensi (NIC) Rasional Implementasi Evaluasi
Hasil (NOC) Pemberi Asuhan
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VII. ANALISIS PELAKSANAAN INTERPROFESSIONAL
COLLABORATION PADA ASUHAN KEPERAWATAN DENGAN
DIAGNOSIS ………
A. Analisis Interprofessional Collaboration masing-masing diagnosa
keperawatan.
(sebutkan diagnosa keperawatan). Contoh:
1. Nyeri berhubungan dengan agen injury biologis
(Jabarkan diagnosa yang diangkat, profesi keilmuan yang dapat terlibat
menangani masalah keperawatan tersebut, mengapa profesi tersebut
diperlukan hingga evaluasi dari intervensi yang dilakukan). Contoh:
a. Profesi yang terlibat :
1) Perawat
Bertindak dalam memenuhi kebutuhan dasar pasien secara
holistik, memberikan rasa nyaman dan mengurangi nyeri
dengan teknik farmakologis. Perawat turut pula berperan aktif
mengkonsultasikan kondisi pasien kepada dokter terkait terapi
farmakologis pasien dst…dst…dst…
2) Dokter
Bertindak dalam mengidentifikasi proses penyakit,
berkoordinasi dengan perawat dalam menentukan terapi medis,
yaitu….. untuk menghilangkan penyebab utama dari masalah
nyeri pasien.
3) Apoteker
Bertindak dalam pemenuhan kebutuhan terapi medis melalui
pemberian obat-obatan, edukasi penggunaan obat, dst…dst…
Hasil evaluasi ditemukan, nyeri berkurang dalam… x jam perawatan.
Ditandai dengan …………
2. Lakukan penjabaran yang sama dengan nomer sebelumnya
dst..
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ASUHAN KEPERAWATAN KRITIS
Nama :
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NIM :
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TempatPraktek :
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Mingguke-/Tanggal :
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Nama :
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Usia :
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Alamat :
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No. Register :
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Kriteria Klien : ……………………………………………………………....
Tanggal MRS : …………………………………………………………........
Tanggal Pengkajian : ……………………………………………………………...
I. PENGKAJIAN
1. Riwayat Penyakit
a. Riwayat Penyakit Sekarang
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d. Diagnosa Medis
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2. Secondary Survey
a. B1 (Breath)
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b. B2 (Blood)
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c. B3 (Brain)
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d. B4 (Bowel)
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e. B5 (Bladder)
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f. B6 (Bone)
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3. Pemeriksaan Penunjang
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4. Terapi Farmakologi
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Banjarmasin, 2019
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II. ANALISA DATA
No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)
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No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)
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III. PRIORITAS DIAGNOSA KEPERAWATAN
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IV. RENCANA KEPERAWATAN
No. Diagnosa Keperawatan Tujuan dan Kriteria Hasil Intervensi
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V. IMPLEMENTASI
Profesional
No
Tanggal/Jam Tindakan Keperawatan Pemberi Paraf
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Asuhan
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VI. EVALUASI
No Diagnosa Keperawatan Tanggal/Jam Evaluasi (SOAP)
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