FORMAT LAPORAN PENDAHULUAN

ASUHAN KEPERAWATAN PADA

Tn/ Ny DI RUANG RS

1. KONSEP DASAR :

A. DEFENISI :

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B. ETIOLOGI :

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C. KLASSIFIKASI :

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D. PATOFISIOLOGI :

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SKEMA PATOFISIOLOGI

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E. MANIFESTASI KLINIK :

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F. PEMERIKSAAN

1. PEMERIKSAAN LABORATORIUM :

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2. PEMERIKSAAN DIAGNOSTIK :

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3. PEMERIKSAAN FISIK :

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G. PENATALAKSANAAN

1. Keperawatan :

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2. Medis :

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N Nama Obat Dos Ef
o is ek

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H. KOMPLIKASI :

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II. RENCANA KEPERAWATAN

1. DASAR PENGKAJIAN :

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2. SDKI, SLKI, SIKI

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 FORMAT PENGKAJIAN
KEPERAWATANMEDIKAL
BEDAH

I. BIODATA
A. IDENTITAS
PASIEN Nama (Inisial)
:
Jenis Kelamin :
Status Perkawinan :
Agama :
Pendidikan :
Pekerjaan :
Alamat :
Tanggal Masuk R. S :
No. Register :
Ruangan/Kamar :
Golongan Darah :
TanggalPengkajian :
TanggalOperasi

:
Diagnosa Medis :

B. PENANGGUNG
JAWAB Nama (Inisial) :
Pekerjaan :
Alamat :

II. KELUHAN UTAMA

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 III. RIWAYAT KESEHATAN SEKARANG
1. Provocative/Palliative
a. Apa penyebabnya :

b. Hal – hal yang memperbaiki keadaan :

2. Quantity/Quality
a. Bagaimana dirasakan :

b. Bagaimana dilihat :

3. Region (daerah)
a. Dimana lokasinya :

b. Apakah menyebar :

4. Severity (mengganggu aktivitas)

5. Time (kapan mulai timbul dan

bagaimana terjadinya)

IV. RIWAYAT KESEHATAN MASA LALU

a. Penyakit yang pernah dialami

b. Pengobatan/tindakan yang dilakukan

c. Pernah dirawat/dioperasi

d. Lamanya dirawat

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e. Alergi

f. Imunisasi

V. RIWAYAT KESEHATAN KELUARGA

a. Orang tua

b. Saudara kandung

c. Penyakit keturunan yang ada

d. Anggota keluarga yang meninggal

e. Penyebab meninggal

f. Genogram

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VI. RIWAYAT ATAU KEADAAN PSIKOSOSIAL
a. Bahasa yang digunakan

b. Bahasa yang digunakan

c. Persepsi pasien tentang penyakitnya

d. Konsep diri

e. Keadaan emosi

f. Perhatian terhadap orang lain/lawan bicara

g. Hubungan dengan keluarga

h. Hubungan dengan saudara

i. Hubungan dengan orang lain

j. Kegemaran

k. Daya adaptasi

l. Mekanisme pertahanan diri

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VII. PEMERIKSAAN FISIK

a. Kesan umum/keadaan umum

:
b. Tanda-tanda vital :
TD : Temp :
HR : TB :
RR : BB :

c. Pemeriksaan kepala dan leher :

1. Kepala dan rambut

a. Bentuk Kepala :

b. ubun-ubun :

c. kulit kepala :

d. Rambut
- penyebaran dan keadaan rambut :

- bau :

- warna kulit :

e. Wajah
- warna kulit

- Struktur wajah :

2. Mata
a. kelengkapan dan kesimetrisan

b. kelopak mata (palpebra)

c. konjunctiva dan sklera

d. pupil

e. kornea dan iris

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f. ketajaman penglihatan/visus

g. ketekanan bola mata

3. Hidung
a. tulang hidung dan posisi saptum nasi

b. lubang hidung

c. cuping hidung

4. Telinga
a. bentuk telinga

b. lubang telinga

c. ketajaman pendengaran

5. Mulut dan Faring

a. keadaan bibir

b. keadaan gusi dan gigi

c. keadaan lidah

d. orofaring

6. Leher
a. posisi trakhea

b. tiroid

c. suara

d.kelenjar lymphe

e. vena jugularis

f. denyut nadi carotis

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d. Pemeriksaan payudara pada ketiak
a. ukuran dan bentuk payudara

b. warna payudara dan areola

c. kelainan-kelainan payudara dan puting

d. axilla dan clavicula

e. Pemeriksaan thorak/dada
1. Inspeksi thorak
a. bentuk thorak

b. pernapasan
- jumlah

- irama

c. tanda-tanda kesulitan bernafas

2. pemeriksaan paru
a. palpasi getaran suara (vocal fremitus)

b. perkusi

c. auskultasi
- suara nafas

- suara ucupan

- suara tambahan

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2. pemeriksaan jantung
a. Inspeksi dan palpasi :
- Pulsasi :

- Ictus cordis :

b. Perkusi
- Batas-batas jantung :

c. Auskultasi
- Bunyi jantung I :

- Bunyi jantung II :

- Bunyi Jantung Tambahan :

- Bising/makmur :

- Frekuensi denyut jantung :

f. Pemeriksaan abdomen
a. Inspeksi :
- Bentuk abdomen

- Benjolan / massa

- Bayangan pembuluh darah pada abdomen

b. Auskultasi
- Peristaltik usus

- Bunyi jantung anak (BJA)

c. Palpasi
- Tanda-tanda nyeri tekan

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 - Benjolan/massa

- Tanda-tanda ascites

- Hepar

- Lien

- Titik Mc. Burney

d. Perkusi
- Suara abdomen

- Pemeriksaan ascites

g. Pemeriksaan kelamin dan daerah sekitarnya

1. Genetalia
a. Rambut pubis

b. Lubang urethra

c. Kelainan-kelainan pada genetalia

eksterna dan daerah inguinal

2. Anus dan perineum

a. Lubang anus

b. Kelainan-kelainan pada anus

c. Perineum

h. Pemeriksaan muskuloskletal (ekstrimitas)

a. Kesimetrisan otot

b. Pemeriksaan oedem

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 c. Kekuatan otot

d. Kelainan-kelainan pada ekstremitas dan kuku

h.Pemeriksaan Neurologi
1. Tingkat kesadaran (secara kuantitatif)

2. Tanda-tandarangsangan otak (meningeal

sign)

3. Syaraf otak (Nervus Cranialis)

4. Fungsi motorik

5. Fungsi sensorik

6. Refleks
a. Refleks Fisiologis

b. Refleks Patologis

i. Pemeriksaan status mental

a. Kondisi emosi/perasaan

b. Orientasi

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c. Proses berfikir (ingatan, atensi, keputusan,
perhitungan) :

d. Motivasi

e. Persepsi

f. Bahasa

VIII. POLA KEBIASAAN SEHARI-HARI

A. Pola tidur/istirahat
1. Waktu tidur

2. Waktu bangun

3. Masalah tidur

4. Hal-hal yang mempermudah tidur

5. Hal-hal yang mempermudah pasien

terbangun

B. Pola Eliminasi
1. B A B

2. B A K

3. Kesulitan BAB/BAK

4. Upaya/cara mengatasi masalah tersebut

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 :

C. Pola makan dan minum

1. Jumlah dan jenis makanan

2. Waktu pemberian makanan

3. Jumlah dan jenis cairan

4. Waktu pemberian makanan

5. Pantangan

6. Masalah makan dan minum

a. Kesulitan mengunyah

b. Mual dan muntah

c. Upaya mengatasi masalah

:

D. Kebersihan diri (Personal Hygiene)

E. Pola kegiatan

Hasil pemeriksaan diagnostik/penunjang:

1. Diagnosa medis :

2. Pemeriksaan diagnostik/penunjang
- Laboratorium :

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 - Rontgen :

- ECG :

- USG :

- Lain-lain :

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 PELAKSANAAN DAN TERAPI

N NAMA OBAT DOS EFEK TERAPI

O IS

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 ANALISA DATA

N DAT ETIOLOGI MASALAH

O A

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DIAGNOSA KEPERAWATAN

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 INTERVENSI KEPERAWATAN

N SD SL SI
o. KI KI KI

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 FORMAT CATATAN PERKEMBANGAN KEPERAWATAN
N Diagnosa Tgl/ Implementasi
o. Keperawat Waktu
an
1. I 1. Mengobservasi karakteristik
durasi frekuensi, kualitas, intesitas
nyeri.
2. Mengidentifikasi skala nyeri
3. Mengidentifikasi faktor yang
memperberat nyeri
4. Memberikan teknik
nonfarmakologis
5. Memfasilitasi istrahat dan tidur
6. Menjelaskan penyebab, periode
dan pemicu nyeri
7. Menjelaskan strategi meredakan
nyeri.
8. Mengkolaaborasikan pemberian
obat analgetik
2 II
1. Mengidentifikasi kemampuan
dan kesiapan menerima informasi
2. Mengidentifikasi faktor yang
dapat meningkatkan dan
menurunkan perilaku hidup bersih
dan sehat
3. Menjadwalkaan penkes sesuai
dengan kesepakatan
4. Memberikan kesempatan untuk
bertanya
5. Menejelaskan faktor yang dapat
mempengaruhi kesehatan
6. Mengajarkan strategi untuk
3 III meningkatkan hidup bersih dan
sehat
1. Mengidentifikasi kemapuan
mengambil keputusan
2. Memonitor tanda ansietas
3. Menciptakan suasana terapeutik
untuk menumbuhkan kepercayaan
4. Memdengarkan dengan penuh
perhatian
5. Memotivasi mengidentifikasi
kecemasan
6. Menganjurkan keluarga untuk
tetap bersama pasien
7. Melatih kegiatan pengalihan
untuk mengurangi ketegangan
Evaluasi
S : klien mengatakan
nyeri dibagian bawah
perineum dan sekitaran
bawah abdomen
O : saat pengkajian nyeri
P ; jaahitan perineum
Q ; seperti tertusuk tusuk
R ; menjalar dibagian
genetalia dan abdomeen
S:3
T : saat beraktivitas
A : masalah belum teratasi
P : intervensi dilanjutkan
(1,2,3,4,5,6,)
S : klien mengatakan
kurang memahami tentang
1. Cara perawatan
payudara
2. Teknik menyusui
3. Nutrisi ibu dan bayi
O : saat dilakukan
pengkajian klien tampak
tidak mengetahui dan
terus menanyakan kepada
perawat
A: masalah belum teratasi
P: intervensi dilanjutkan
(2345)
S : pasien mengatakan
cemas dengan keadaan
bayinya
O : tampak merah di area
wajah bayi, dan klien
menanyakan terus hal
tersebut kepada perawat,
mata bayi tampak tertutup
dan banyak kotoran
dimata yang membuat ibu
bayi cemas dengan
kondisi tersebut
A : masalah belum teratasi
P : intervensi dilanjutkan
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 8. Melatih teknik relaksasi
9. Mengkolaborasikan pemberian
I obat anti axietas jikaa perlu
1. I
1. Mengobservasi karakteristik
durasi frekuensi, kualitas, intesitas
nyeri.
2. Mengidentifikasi skala nyeri
3. Mengidentifikasi faktor yang
memperberat nyeri
4. Memberikan teknik
nonfarmakologis
5. Memfasilitasi istrahat dan tidur
6. Menjelaskan penyebab, periode
dan pemicu nyeri
II
2.
1. Mengidentifikasi faktor yang
dapat meningkatkan dan
menurunkan perilaku hidup bersih
dan sehat
2. Menjadwalkaan penkes sesuai
dengan kesepakatan
3. Memberikan kesempatan untuk
bertanya
4. Menejelaskan faktor yang dapat
III mempengaruhi kesehatan
3.
1. Mengidentifikasi kemapuan
mengambil keputusan
2. Memonitor tanda ansietas
3. Menciptakan suasana terapeutik
untuk menumbuhkan kepercayaan
4. Memdengarkan dengan penuh
perhatian
5. Menganjurkan keluarga untuk
tetap bersama pasien
6. Melatih teknik relaksasi
(123468)
S : klien mengatakan
nyeri dibagian bawah
perineum dan sekitaran
bawah abdomen
O : saat pengkajian nyeri
P ; jaahitan perineum
Q ; seperti tertusuk tusuk
R ; menjalar dibagian
genetalia dan abdomeen
S:1
T : saat beraktivitas
A : masalah belum teratasi
P : intervensi dilanjutkan
(3,4,5,6,)
S : klien mengatakan
kurang memahami tentang
1. Cara perawatan
payudara
2. Teknik menyusui
3. Nutrisi ibu dan bayi
O : saat dilakukan
pengkajian klien tampak
tidak mengetahui dan
terus menanyakan kepada
perawat
A: masalah belum teratasi
P: intervensi dilanjutkan
(234)
S : pasien mengatakan
cemas dengan keadaan
bayinya
O : tampak merah di area
wajah bayi, dan klien
menanyakan terus hal
tersebut kepada perawat,
mata bayi tampak tertutup
dan banyak kotoran
dimata yang membuat ibu
bayi cemas dengan
kondisi tersebut
A : masalah belum teratasi
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P : intervensi dilanjutkan
(3468)

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