Masalah keperawatan :
Masalah keperawatan :
Kesadaran: ( ) composmentis ( ) delirium ( ) somnolen ( ) apatis ( ) koma
GCS: ( ) eye........ ( ) verbal ....... ( ) motorik...........
Pupil : ( ) isokor ( ) unisokor ( ) pinpoint ( ) medriasis
Refleks cahaya : ( ) ada ( ) tidak ada
Refleks fisiologis : ( ) patela (+/-) ( ) lain-lain ............
Reflek patologis : ( ) babinzky ( +/-) ( ) kerning ( +/-) ( ) lain-lain………
Refleks pada bayi : ( ) refleks rooting (+/-) ( ) refleks moro (+/-)
(khusus PICU/NICU ) ( ) refleks sucking (+/-) ( ) lain-lain……
Bicara : ( ) lancar ( ) cepat ( ) lambat
Tidur malam : …… jam tidur siang : .......... jam
Ansietas : ( ) ada ( ) tidak ada
Psiko-sosio-spiritual:
BRAIN
Masalah keperawatan :
Nyeri penggang : ( ) ada ( ) tidak ada
BAK : ( ) lancar ( ) inkontenensia ( ) anuri
Nyeri BAK : ( ) ada ( ) tidak ada
Frekuensi BAK :............. warna : .................. darah : ............... ( ) ada ( ) tidak ada
Kateter : ( ) ada ( ) tidak ada, urine out put ............
a. IVFD:
b. Obat:
c. Minum (jumlah dan jenis):
2. OUTPUT:
a. Urine:
b. Muntah:
c. IWL:
3. BALANCE CAIRAN: Input-(Output+IWL):
Lain-lain:..................
Masalah keperawatan :
TB : ......... cm BB : ............. Kg
Nafsu makan : ( ) mual ( ) muntah ( ) sulit menelan
Makan : frekuensi ............x/mnt. Jumlah :.........porsi
Minum : frekuensi ............x/mnt. Jumlah : .........cc/hr
Perut kembung: ( ) ya ( ) tidak ada
BOWEL
Masalah keperawatan :
Nyeri : ( ) ada ( ) tidak ada
Problem : ............................................................................................................................
Qualitas/quantitas : .............................................................................................................
Regio : ................................................................................................................................
Skala :..................................................................................................................................
Timing :...............................................................................................................................
Kekuatan otot : ...................................................................................................................
.............................................................................................................................................
BONE (Muskuloskeletal dan Integument )
Aktivitas : ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( ) 4
BONE (Muskuloskeletal dan Integument )
Makan/minum: ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( )4
Mandi : ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( ) 4
Toileting : ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( ) 4
Keterangan: ........................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Lain-lain:..............................................................................................................................
Masalah keperawatan :
(fokus pemeriksaan pada daerah trauma/ sesuai kasus non trauma)
Kepala wajah :
Inspeksi...............................................................................................................................................
Palpasi.................................................................................................................................................
Perkusi.................................................................................................................................................
Auskultasi............................................................................................................................................
.
Leher :
HEAD TO TOE
Inspeksi...............................................................................................................................................
Palpasi.................................................................................................................................................
Perkusi.................................................................................................................................................
Auskultasi............................................................................................................................................
.
Dada :
Inspeksi...............................................................................................................................................
Palpasi.................................................................................................................................................
Perkusi.................................................................................................................................................
Auskultasi............................................................................................................................................
.
Masalah keperawatan :
Ekstremitas :
Inspeksi...............................................................................................................................................
Palpasi.................................................................................................................................................
HEAD TO TOE
Perkusi.................................................................................................................................................
Auskultasi............................................................................................................................................
.
Masalah keperawatan :
TEST DIAGNOSTIK
.............................................................................................................................................
.............................................................................................................................................
Terapi medis saat ini : tgl .................
DIAGNOSTI
.............................................................................................................................................
TEST
Analisis Data
No. Hr/tgl/jam Data Subjektif Data Objektif Etiologi Masalah
Keperawatan
Intervensi Keperawatan
No. Hr/tgl/jam Diagnosa Tujuan Keperawatan Intervensi
Keperawatan Goal Objective Outcome Keperawatan
Label NOC Label NIC
Implementasi Keperawatan
No. Hr/Tgl Diagnosa Keperawatan Jam Implementasi Evaluasi Tanda
Keperawatan Keperawatan Tangan
(tulis apa yang S:
dikerjakan, O:
kerjakan apa yang A:
ditulis) P:
Nama Mahasiswa :
NIM :
Ruangan : No. reg :
Tanggal dikaji : Pkl. :
PENGKAJIAN
A. Identitas
Nama : Tgl. MRS :
Umur : Jam :
Suku/bangsa : Diangnosa :
Agama :
Alamat :
Pekerjaan :
Pendidikan :
Alasan MRS :
B. Nursing history
3. Primary Survey:
Airway :......................................................................................................
Breathing :......................................................................................................
Circulation :......................................................................................................
Disability :......................................................................................................
Exposure :…………………………………………………………………………………………………………
Foley Cateter :......................................................................................................
Gastric Tube :.....................................................................................................
Heart Rate :.....................................................................................................
4. Masalah keperawatan: ............................................................................................
5. Secondary Survey
a. Riwayat Penyakit
Sign & Simptom :................................................................................................
Alergi :................................................................................................
........................................................................................................................................
Medikasi :................................................................................................
........................................................................................................................................
Post Illnes :................................................................................................
........................................................................................................................................
Last Meal :................................................................................................
........................................................................................................................................
Event/Environtment :................................................................................................
........................................................................................................................................
b. Pemeriksaan Fisik Head to Toe: .....................................................................................
........................................................................................................................................
........................................................................................................................................
Mahasiswa,
Format Laporan Pendahuluan
A. Konsep Dasar Penyakit
1. Pengertian
2. Etiologi
3. Patofisiologi (Pathway)
4. Manifestasi klinis
5. Komplikasi
6. Pemeriksaan penunjang
7. Penatalaksanaan (farmakologi, non farmakologi)
B. Konsep Dasar Asuhan Keperawatan
1. Pengkajian keperawatan
a. Anamnesa:
b. Pemeriksaan fisik: (jika pada masalah keperawatan pada pathway ditegakkan sesuai
B1-B6 atau per sistem, maka pada pemeriksaan fisik disesuaikan dengan pathway)
2. Diagnosa keperawatan (tegakkan diagnosa keperawatan sesuai dengan pathway)
3. Intervensi keperawatan (buatkan dalam tabel sesuai dengan diagnosa keperawatan yang
ditegakkan)
4. Implementasi keperawatan
5. Evaluasi keperawatan