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 PENGAKJIAN KEPERAWATAN

Data diambil tanggal : ……………………………………………

Ruang rawat/kelas : ……………………………………………
No. Rekam Medik : ……………………………………………

I. IDENTITAS
Nama : ..............................................................................................

Umur : ..............................................................................................

Jenis kelamin : ..............................................................................................

Pekerjaan : ..............................................................................................
Tanggal MRS : ..............................................................................................

Alamat : ..............................................................................................

Diagnosa medis : ..............................................................................................

Sumber informasi : .............................................................................................

Tanggal Pengkajian : ..............................................................................................

II. RIWAYAT KEPERAWATAN

1. Riwayat keperawatan sekarang
a. Keluhan utama
.................................................................................................................................
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b. Riwayat penyakit saat ini

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2. Riwayat keperawatan/Penyakit sebelumnya
a. Riwayat kesehatan yang lalu :
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Masalah Keperawatan:
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3. Riwayat kesehatan keluarga

a. Penyakit yang pernah diderita oleh anggota keluarga :
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Lingkungan rumah dan komunitas ..........................................................................
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b. Perilaku yang mempngaruhi kesehatan
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c. Persepsi terhadap penyakit
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Masalah Keperawatan:
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4. Kesadaran :
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5. Tanda- Tanda Vital :
 Suhu : ...............................................................................
TD : ...............................................................................
RR : ...............................................................................
Nadi : ................................................................................

6. Genogram (3 generasi)

III. POLA FUNGSI KESEHATAN

1. Pola penatalaksanaan kesehatan / persepsi sehat
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Masalah Keperawatan :
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2. Pola Nutrisi– Metabolik

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Masalah Keperawatan :
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3. Pola Eliminasi
Eliminasi Alvi
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Eliminasi Uri
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Masalah Keperawatan :
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4. Pola Istirahat dan tidur

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Masalah Keperawatan :
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5. Pola Aktifitas - Latihan

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Masalah Keperawatan :
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6. Pola kognitif – perseptual – keadekuatan alat sensori

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Masalah Keperawatan :
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7. Pola persepsi dan konsep diri

Pola persepsi
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Konsep diri
a. Gambaran diri
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b. Harga diri
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c. Ideal diri
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d. Peran diri
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e. Identitas diri
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Masalah Keperawatan :
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8. Pola Reproduksi Seksual
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Masalah Keperawatan :
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9. Pola hubungan peran

Persepsi klien tantang pola hubungan

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Persepsi klien tentang peran dan tanggung jawab

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Masalah Keperawatan :
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10. Mekanisme Koping

Kemampuan mengendalian stress

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Sumber pendukung
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Masalah Keperawatan :
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11. Pola tata nilai dan kepercayaan

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Masalah Keperawatan :
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12. Pemeriksaan Refleks

Refleks : Fisilogis

Dextra Sinistra Dextra Sinistra

Biceps Triceps
\ \

Dextra Sinistra Dextra Sinistra

Knee Achiles
\

Refleks Patologis Dextra Sinistra Dextra Sinistra

Babinski Oppenheim
\ \

Dextra Sinistra

Chadok

Masalah Keperawatan :
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13. Aspek Sosial

a. Ekspresi efek dan emosi : Senang Sedih

Menangis
Cemas Marah Diam
Takut Lain ...................................
b. Hubungan dengan keluarga :
Akrab Kurang akrab

Masalah Keperawatan :
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14. Pemeriksaan Penunjang

1. Pemeriksaan Laboratorium
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2. Pemeriksaan Radiologi
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3. Pemeriksaan Lain – lain

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4. Terapi dan Diet.

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DAFTAR MASALAH KEPERAWATAN

1……………………………………………………………………………………
2……………………………………………………………………………………
3……………………………………………………………………………………
4……………………………………………………………………………………
5……………………………………………………………………………………
6……………………………………………………………………………………
7……………………………………………………………………………………
8……………………………………………………………………………………
9……………………………………………………………………………………
10……………………………………………………………………………………

Surabaya,
Preceptee

(……………………….)
 ANALISA DATA

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

DATA ETIOLOGI PROBLEM

 DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

Nama Pasien : No. Register :

Umur : Diagnosa Medis :
NO DIAGNOSA KEPERAWATAN TTD
 INTERVENSI KEPERAWATAN

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

NO DIAGNOSA TUJUAN KRITERIA HASIL INTERVENSI RASIONAL

KEPERAWATAN
 IMPLEMENTASI

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

TANGGAL / JAM IMPLEMENTASI TTD

 EVALUASI

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

TGL / DIAGNOSE EVALUASI

JAM KEPERAWATAN