Pedoman Preklinik

Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

LAPORAN KASUS

PADA Tn. E DENGAN CHRONIC KIDNEY DISEASE (CKD)

DI RUANG MARWAH RSUD HARAPAN
DAN DOA KOTA BENGKULU

DISUSUN OLEH:

WANTO SYAPUTRA
NPM: 1826010004

Perceptor Akademik Perceptor Klinik

(Ns. Fernalia, S.Kep., M.Kep) (Ns. Irhan, S.Kep)

PROGRAM STUDI ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN
TRI MANDIRI SAKTI
BENGKULU
2022
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

LAPORAN KASUS

KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI NERS TA S1 KEPERAWATAN
STIKES TRI MANDIRI SAKTI BENGKULU

FORMAT PENGKAJIAN

Nama Mahasiswa : Tanggal praktek :

Nomor NPM : Tempat praktek :

1. Data Biografi
Identitas Klien:
Nama : ………………….. No Register : ……………….
Umur : …………………..
Suku/ bangsa : …………………..
Status perkawinan : …………………..
Agama : …………………..
Pendidikan : ..............................
Pekerjaan : ..............................
Alamat : ..............................
Tanggal masuk RS : ..............................
Tanggal pengkajian : ..............................
Catatan kedatangan : Kursi roda ( ), Ambulans ( ), Brankar ( )

Keluarga Terdekat yang dapat dihubungi :

Nama/ Umur : ........................... No Telepon : .........................
Pendidikan : .............................
Pekerjaan : .............................
Alamat : .............................
Sumber informasi : .............................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

2. Riwayat Kesehatan/ Keperawatan

1) Keluhan utama/ alasan masuk RS :
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
2) Riwayat kesehatan sekarang :
Faktor
pencetus : ........................................................................................................
.........................................................................................................................
.........................................................................................................................
.................
Sifat keluhan (mendadak/perlahan- lahan/ terus menerus/ hilang timbul
atau berhubungan dengan
waktu) : ..........................................................................................................
........................................................................................................................
........................................................................................................................
..............
Lokalisasi dan sifatnya (menjalar/ menyebar/ berpindah- pindah/
menetap):
........................................................................................................................
........................................................................................................................
........................................................................................................................
Berat ringannya keluhan (menetap/ cenderung bertambah atau berkurang) :
........................................................................................................................
........................................................................................................................
........................................................................................................................
Lamanya
keluhan : ........................................................................................................
................
........................................................................................................................
........................................................................................................................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Upaya yang telah dilakukan untuk

mengatasi : ....................................................................................................
....................
........................................................................................................................
........................................................................................................................
Keluhan saat pengkajian :
……………………………………………………………............................
..............……………………………………………………………………..
………………......…………………………………………………………..
…………………………….………………………………………………...
………………………………………..……………………………………..
Diagnosa medik :
......................................... Tanggal .......................................
..........................................Tanggal ........................................

3) Riwayat Kesehatan Dahulu

Penyakit yang pernah dialami (jenis penyakit, lama dan upaya untuk
mengatasi, riwayat masuk
RS) : ..............................................................................................................
.......... .............................................................................................................
........................................................................................................................
........................................................................................................................
...........
Alergi:
........................................................................................................................
........................................................................................................................
Obat- obatan Dosis Dosis terakhir Frekuensi
(Resep/ obat
bebas)
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

4) Riwayat Kesehatan Keluarga :

Penyakit menular atau keturunan dalam
keluarga : .......................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
.................

3. Pola Fungsi Kesehatan (Gordon) :

1) Pola persepsi dan pemeliharaan kesehatan
Persepsi terhadap
penyakit :........................................................................................................
........................................................................................................................
........................................................................................................................
............... ........................................................................................................
................
Penggunaan :
Tembakau (bungkus/ hari, pipa, cerutu, berapa lama, kapan
berhenti) :.......................................................................................................
................
Alkohol (jenis,
jumlah/hari/minggu/bulan) : ..........................................................................
..............................................
Alergi (obat-obatan, makanan, plester,
dll) : ...............................................................................................................
.........
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Reaksi
alergi ..............................................................................................................
..........
2) Pola nutrisi dan metabolisme
Diet/ suplemen
khusus : ..........................................................................................................
..............
Instruksi diet
sebelumnya : ..................................................................................................
......................
Nafsu makan (normal, meningkat,
menurun) : .....................................................................................................
...................
Penurunan sensasi kecap, mual-muntah, stomatitis :
................................................................................................................... cc
Fluktuasi BB 6 bulan terakhir (naik/
turun) : ...........................................................................................................
.............
........................................................................................................................
........................................................................................................................
Kesulitan menelan
(disfagia) : .....................................................................................................
...................
Gigi (lengkap/ tidak, gigi
palsu) : ...........................................................................................................
.............
Riwayat masalah kulit/ penyembuhan (ruam, kering, keringat berlebihan,
penyembuhan
abnormal : ......................................................................................................
..................
........................................................................................................................
........................................................................................................................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Jumlah minum/ 24 jam dan jenis (kehausan yang

sangat) ...........................................................................................................
.............
........................................................................................................................
........................................................................................................................
Frekuensi
makan : ..........................................................................................................
..............
Jenis
makanan : ......................................................................................................
..................
Pantangan/
alergi : ............................................................................................................
............
Lain-
lain : ...............................................................................................................
.........
3) Pola Eliminasi
Buang air besar (BAB) :
Frekuensi : ................... Waktu :............................
Warna : ................... Konsistensi : ............................
Kesulitan (diare, konstipasi, inkontinensia) : ............................

Buang air kecil (BAK) :

Frekuensi : ....................... Warna : .......................
Kesulitan (disuria, nokturia, hematuria, retensi,
inkontinensia) : ..................................................................................
..........................
Alat bantu (kateter intermitten, indweling, kateter
eksternal) : .........................................................................................
...................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Lain-
lain : ...............................................................................................................
.........
........................................................................................................................
........................................................................................................................
4) Pola aktivitas dan latihan
Kemampuan perawatan diri :
0 = Mandiri 3 = Dibantu orang lain dan peralatan
1 = Dengan alat bantu 4 = Ketergantungan/ tidak mampu
2 = Dibantu orang lain
Kegiatan/ aktivitas 0 1 2 3 4
Makan/ minum
Mandi
Berpakaian/ berdandan
Toileting
Mobilisasi ditempat tidur
Berpindah
Berjalan
Menaiki tangga
Berbelanja
Memasak
Pemeliharaan rumah

Alat bantu (kruk, pispot, tongkat, kursi roda) : .............................................

Kekuatan otot : ..............................................................................................
Kemampuan ROM:
........................................................................................................................
Keluhan saat
beraktivitas : ..................................................................................................
......................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Lain-
lain : ...............................................................................................................
.........

5) Pola istirahat dan tidur

Lama tidur : .................. jam/ malam ................. tidur siang ...................
tidur sore : ..................
Waktu : ..........................................................................................................
..............
Kebiasaan menjelang
tidur : .............................................................................................................
...........
Masalah tidur (insomnia, terbangun dini, mimpi
buruk) : ..........................................................................................................
..............
Lain- lain (merasa segar/ tidak setelah
bangun) : ........................................................................................................
................

6) Pola kognitif dan persepsi

Status mental (sadar/ tidak, orientasi baik/
tidak) : ...........................................................................................................
.............
Bicara : Normal ( ), tak jelas ( ), gagap ( ), aphasia ekspresif ( )
Kemampuan berkomunikasi : Ya ( ), Tidak ( )
Kemampuan memahami : Ya ( ), Tidak ( )
Tingkat ansietas : Ringan ( ), Sedang ( ), berat ( ), panik ( )
Pendengaran : DBN ( ), tuli ( ) kanan/ kiri, tinitus ( ), alat bantu
dengar ( )
Penglihatan (DBN, buta, katarak, kacamata, lensa kontak, dll)
:.......................................................................................................................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Vertigo : ........................................................................................................
................
Ketidaknyamanan/ nyeri (akut/
kronik) : .........................................................................................................
...............
........................................................................................................................
........................................................................................................................
Penatalaksanaan
nyeri : ............................................................................................................
............
Lain-
lain : ...............................................................................................................
.........

7) Persepsi diri dan konsep diri

Perasaan klien tentang masalah kesehatan
ini : ................................................................................................................
........
Lain-
lain : ...............................................................................................................
.........

8) Pola peran hubungan

Pekerjaan : .....................................................................................................
...................
Sistem pendukung : pasangan ( ), tetangga/ teman ( ), tidak ada ( ),
keluarga serumah ( ), keluarga tinggal berjauhan ( )
Masalah keluarga berkenaan dengan perawatan di
RS : ................................................................................................................
........................................................................................................................
........
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Kegiatan
sosial : ............................................................................................................
............
Lain-
lain : ...............................................................................................................
.........

9) Pola seksual dan reproduksi

Tanggal menstruasi akhir
(TMA) : .........................................................................................................
...............
Masalah
menstruasi : ...................................................................................................
.....................
Pap Smear
terakhir : ........................................................................................................
................
Masalah seksual b.d
penyakit : .......................................................................................................
.................
Lain-
lain : ...............................................................................................................
.........

10) Pola koping dan toleransi stress

Perhatian utama tentang perawatan di RS atau penyakit (finansial,
perawatan
diri) : ..............................................................................................................
........................................................................................................................
..........
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Kehilangan/ perubahan besar dimasa

lalu : ...............................................................................................................
.........
Hal yang dilakukan saat ada masalah (sumber
koping) : ........................................................................................................
................
Penggunaan obat untuk menghilangkan
stress : ............................................................................................................
............
Keadaan emosi dalam sehari- hari (santai/
tegang) : .........................................................................................................
...............
Lain-
lain : ...............................................................................................................
.........

11) Keyakinan dan kepercayaan

Agama : .........................................................................................................
...............
Pengaruh agama dalam
kehidupan : ....................................................................................................
....................
........................................................................................................................
........................................................................................................................

4. Pemeriksaan Fisik :
1) Keadaan umum :
........................................................................................................................
........................................................................................................................
Kesadaran : ....................................... GCS .............................................
BB : ................... Kg
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

TB : ................... cm
2) Tanda- tanda vital :
TD : ..................... mmHg
ND : ..................... x/menit
RR : ..................... x/menit
S : ..................... oC
3) Kulit
Warna kulit (sianosis, ikterus, pucat, eritema, dll) :
........................................................................................................................
Kelembapan : ................................................................................................
........................
Turgor kulit :
........................................................................................................................
Ada/tidaknya oedema :
........................................................................................................................
4) Kepala/ rambut
Inspeksi
: ..........................................................................................................
..............
........................................................................................................................
Palpasi
: ..........................................................................................................
.............. .........................................................................................................
...............
5) Mata
Sklera : ..............................................
Konjungtiva : ..............................................
Palbebra : ..............................................
Pupil : ..............................................
Pergerakan otot mata : ..............................................
6) Telinga
Fungsi pendengaran : .................................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Fungsi keseimbangan : .................................

Kebersihan : ................................. Sekret ....................................
Daun telinga : ................................. Mastoid..................................
7) Hidung dan sinus
Inspeksi :
........................................................................................................................
Fungsi penciuman :
........................................................................................................................
Pembengkakan : ..............................................
perdarahan : ..............................................
Kebersihan : ......................................sekret :................................
8) Mulut dan tenggorok
Membran mukosa : ..............................................
kebersihan mulut : ..............................................
Keadaan gigi
: ..........................................................................................................
..............
Tanda radang (bibir, gusi,
lidah) : ...........................................................................................................
.............
Trismus : ........................................................................................................
................
Kesulitan
menelan : .......................................................................................................
.................
9) Leher
Trakea (simetris/ tidak) :
........................................................................................................................
Kelenjar limfe :
........................................................................................................................
Kelenjar tiroid :
........................................................................................................................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Fungsi Menelan :
........................................................................................................................

10) Thorak / paru

Inspeksi :
........................................................................................................................
Palpasi : ..............................................................................................
..........................
Perkusi : ..............................................................................................
..........................Auskultasi : ......................................................................
..................................................
11) Jantung
Inspeksi :
........................................................................................................................
Palpasi : ..............................................................................................
..........................
Perkusi : ..............................................................................................
..........................
Auskultasi : ..............................................................................................
..........................
12) Paru-paru
Inspeksi :
........................................................................................................................
Palpasi : ..............................................................................................
..........................
Perkusi : ..............................................................................................
..........................
Auskultasi : ..............................................................................................
..........................
13) Abdomen
Inspeksi :
........................................................................................................................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Auskultasi : ..............................................................................................
..........................
Perkusi : ..............................................................................................
..........................
Palpasi : ..............................................................................................
..........................
14) Genetalia :
........................................................................................................................
15) Rektal :
........................................................................................................................
16) Ekstremitas
Ekstremitas atas :
........................................................................................................................
Ekstremitas bawah :
........................................................................................................................
ROM : ............................................................................................................
............
Kekuatan otot :
........................................................................................................................
17) Neurologis
Olfaktorius (Indra penciuman) :
........................................................................................................................
Optikus (Indra Penglihatan) :
........................................................................................................................
Oculomotorius (Penggerak bola mata) :
........................................................................................................................
Troclecris (Penggerak kelopak mata) :
........................................................................................................................
Trigeminus (Kornea, Otot mengunyah) :
........................................................................................................................
Abdusen (Menoleh, Gerakan mata) :
........................................................................................................................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Facialis (Wajah, 2/3 Lidah depan) :

........................................................................................................................
Auditorius (Indera pendengaran) :
........................................................................................................................
Glusofaringeus (Refleks menelan) :
........................................................................................................................
Vagus (Mengontrol lidah) :
........................................................................................................................
Assesorius (Gerak leher, Bahu) :
........................................................................................................................
Hipoglosus (Bagian bawah lidah) :
........................................................................................................................

5. Pemeriksaan Penunjang
Pemeriksaan diagnostik
…………………………………………………………………………………..
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 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Pemeriksaan laboratorium
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6. Penatalaksanaan Pengobatan
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 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

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FORMAT
ANALISA DATA

Nama klien :
Ruang rawat :
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Diagnosa medik :

No Data Etiologi Masalah

 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

NURSING CARE PLANING

Nama klien :
Ruang rawat :
Diagnosa medik :

No Diagnosa Keperawatan Kode SLKI Kode SIKI

 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

CATATAN PERKEMBANGAN

Nama klien :
Ruang rawat :
Diagnosa medik :

No Diagnosa Keperawatan Hari/tanggal Jam Implementasi Evaluasi Paraf

 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

PENILAIAN LAPORAN

NAMA MAHASISWA
KOMPONEN YANG DINILAI
A. LAPORAN PENDAHULUAN (10)
1. Definisi dan Etiologi (0-2)
2. Kelengkapan patofisiologi dan pemeriksaan
penunjang (0-2)
3. Kelengkapan diagnosa awal (0-3)
4. Kelengkapan tindakan keperawatan (0-3)

B. RENCANA KEPERAWATAN
I. Pengkajian (10)
1. Mengumpulkan riwayat keperawatan (0-3)
2. Mengumpulkan data hasil pemeriksaan fisik
(0-4)
3. Mengumpulkan data hasil pemeriksaan
penunjang (0-3)

II. Diagnosa Keperawatan (10)

1. Mengidentifikasi masalah yang potensial dan
actual (0-4)
2. Menetapkan prioritas (0-3)
3. Menetapkan tujuan dan kriteria yang SMART
(0-3)

III. Tindakan Keperawatan (10)

1. Rencana tindakan sesuai dengan diagnosa
keperawatan (0-5)
2. Membuat pencatatan tindakan keperawatan
secara benar (0-5)

IV. Evaluasi (10)

1. Melakukan evaluasi SOAP setiap hari sesuai
diagnosa (0-5)
2. Memodifikasi rencana sesuai evaluasi (0-5)

NILAI TOTAL
NILAI AKHIR = NILAI TOTAL X 2
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

EVALUASI KINERJA KLINIK

NAMA MAHASISWA
KOMPONEN YANG DINILAI
A. KOMUNIKASI (10)
Mahasiswa menunjukkan kemampuan :
1. Menciptakan interaksi dengan klien dengan
penuh percaya diri (0-4)
2. Menggunakan komunikasi verbal yang
efektif (0-3)
3. Melakukan dokumentasi secara benar (0-3)

B. KETERAMPILAN DASAR (25)

Mahasiswa menunjukkan kemampuan :
1. Melakukan pengkajian awal (wawancara dan
pemeriksaan fisik) (0-5)
2. Melakukan tindakan yang sudah
direncanakan (0-5)
3. Melakukan tindakan pencegahan terhadap
infeksi (0-5)
4. Menciptakan keamanan dan kenyamanan (0-
5)
5. Memberikan pendidikan kesehatan (0-5)

C. PERILAKU PROFESIONAL (15)

Mahasiswa menunjukkan kemampuan :
1. Menampilkan sikap baik dan sopan (0-3)
2. Melaksanakan kontrak dengan pasien (0-3)
3. Mengambil inisiatif dalam situasi belajar
4. Memperlihatkan sikap selalu tepat waktu (0-
3)
5. Bekerjasama dan berpartisipasi dalam
kegiatan ruangan (0-3)

NILAI TOTAL

NILAI AKHIR = NILAI TOTAL X 2

PENILAI :