BUKU PEDOMAN

PRAKTIK KLINIK KEPERAWATAN DASAR

KOORDINATOR
Sulaiman, S. Ag., SST., MA

PRODI KEPERAWATAN ACEH UTARA

POLTEKKES KEMENKES ACEH
TAHUN 2023
LOG BOOK KEPERAWATAN DASAR
Asuhan Keperawatan Pada _________________________
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NAMA : __________________
NPM : __________________

POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN ACEH

PROGRAM STUDI DIPLOMA III KEPERAWATAN ACEH UTARA

TAHUN AKADEMIK 2023/2024

LAPORAN PENDAHULUAN

A. Konsep Dasar
1. Definisi / Pengertian

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2. Etiologi / Faktor Pencetus

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3. Klasifikasi
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4. Patofisiologi
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5. Gambaran Klinis
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6. Pemeriksaan Diagnostik
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7. Penatalaksanaan
a. Medis
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b. Keperawatan
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B. Asuhan Keperawatan
1. Pengkajian (Polafungsional)
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2. Diagnosa Keperawatan (minimal 3 diagnosa)
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3. Intervensi Keperawatan

ASUHAN KEPERAWATAN

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A. PENGKAJIAN
Tanggal Pengkajian :____________________________________________________

Tanggal Masuk : ____________________________________________________

Ruang/Kelas :____________________________________________________

Nomor Register : ____________________________________________________

DiagnosaMedis :____________________________________________________

1. IdentitasKlien
NamaKlien :____________________________________________________
Jeniskelamin :____________________________________________________
Usia :____________________________________________________
Status Perkawinan :____________________________________________________
Agama :____________________________________________________
Sukubangsa :____________________________________________________
Pendidikan :____________________________________________________
Bahasaygdigunakan :____________________________________________________
Pekerjaan : ____________________________________________________
Alamat : ____________________________________________________

2. Riwayat kesehatan (Ditulis sejak klien masuk rumah sakit sampai dengan sebelum
pengkajian dilakukan meliputi : data fokus, masalah keperawatan, tindakan keperawatan
mandiri serta kolaborasi dan evaluasi secara umum)
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3. RiwayatKeperawatan :
a. Riwayat kesehatan sekarang.
1) Keluhan utama : _____________________________________________________
2) Kronologis keluhan (Faktor pencetus, timbulnya keluhan ( mendadak, bertahap),
lamanya dan upaya mengatasi )
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b. Riwayat kesehatan masa lalu.
1) Riwayat Alergi (Obat, Makanan, Binatang, Lingkungan) :
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2) Riwayat Kecelakaan :
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3) Riwayat dirawat di RumahSakit (Kapan, alasan dan berapa lama) :
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4) Riwayat pemakaian obat :
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c. Riwayat Kesehatan Keluarga (Genogram dan Keterangan tiga generasi dari klien)
d. Penyakit yang pernah diderita oleh anggota keluarga yang menjadi factor risiko
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e. Riwayat Psikososial dan Spiritual

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9) Pola kebiasaan

N POLA KEBIASAAN
HAL YANG DIKAJI
O SEBELUM SAKIT DI RUMAH SAKIT
1. Pola Nutrisi
a. Frekuensi makan :…… X / hari
b. Nafsu makan : baik/tidak
Alasan :……..(mual, muntah,
sariawan)
c. Porsi makanan yang dihabiskan
d. Makanan yang tidak disukai
e. Makanan yang membuat alergi
f. Makanan pantangan
g. Makanan diet
h. Penggunaan obat-obatan sebelum
makan
i. Penggunaan alat bantu (NGT, dll)
2. Pola Eliminasi
a. B.a.k :
1) Frekuensi : ………. X / hari
2) Warna : …………………..
3) Keluhan : …………………..
4) Penggunaan alat bantu
(kateter, dll)
b. B.a.b :
1) Frekuensi :…………. X / hari
2) Waktu :
(Pagi / Siang / Malam / Tidak
tentu)

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 3) Warna : …………………..
4) Kosistensi : ……………….
5) Keluhan : …………………..
6) Penggunaan Laxatif : ………
3. Personal Hygiene
a. Mandi
1) Frekuensi :…………. X / hari
2) Waktu : Pagi/Sore/Malam
b. Oral Hygiene
1) Frekuensi :…………. X / ha
Makan
2) Waktu : Pagi /Siang/ Setelah
makan
c. Cuci rambut
1) Frekuensi :…………. X / mg
2) Waktu : Pagi /Siang/ Setelah
makan
4. Pola Istirahat dan Tidur
a. Lama tidur siang : …. Jam / hari
b. Lama tidur malam : …. Jam /
hari
c. Kebiasaan sebelum tidur : ……
5. Pola Aktivitas dan Latihan.
a. Waktu bekerja :
Pagi/Siang/Malam
b. Olah raga : ( ) Ya ( ) Tidak
c. Jenis olah raga : ……………
d. Frekuensi olahraga : … X /
minggu
e. Keluhan dalam beraktivitas
(Pergerakan tubuh/mandi/
Mengenakan pakaian/ Sesak
setelah beraktifitas dll)
6. Kebiasaan yang Mempengaruhi

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 Kesehatan
a. Merokok : Ya / Tidak
1) Frekuensi : …………………..
2) Jumlah : …………………..
3) Lama Pemakaian : ……..
b. Minuman keras / NABZA: Ya /
Tidak
1) Frekuensi : …………………..
2) Jumlah : …………………..
3) Lama Pemakaian : ……..

4. Pengkajian Fisik :
a. Pemeriksaan Fisik Umum :
1) Berat badan : ………………Kg (SebelumSakit : ………Kg)
2) Tinggi Badan : ………………cm
3) Tekanan Darah : ………………mmHg
4) Nadi : ………………X / menit
5) Frekuensi Nafas : ……………… X / menit
6) Suhu tubuh : ……………… ° C
7) Keadaan umum : ( ) Ringan ( ) Sedang ( ) Berat
8) Pembesaran kelenjar getah bening : ( ) Tidak ( ) Ya, Lokasi………..

b. Pemeriksaan Fisik
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. Data Penunjang (Pemeriksaan Diagnostik)

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6. Penatalaksanaan / therapy

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ANALISA DATA

NO DATA PENYEBAB MASALAH

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2. Diagnosa Keperawatan

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3. Intervensi Keperawatan

Diagnosa I
Tujuan :
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Kriteria Hasil :
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Intervensi/rasional
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2. _________________________________________________________________
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3. _________________________________________________________________
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Diagnosa II
Tujuan :
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KriteriaHasil :
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Intervensi/rasional
1. _________________________________________________________________
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2. _________________________________________________________________
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Diagnosa III
Tujuan :
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Intervensi/rasional
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4. CatatanPerkembangan

Tanggal /
Diagnosa Implementasi Evaluasi (SOAP)
Pukul

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Tanggal /
Diagnosa Implementasi Evaluasi (SOAP)
Pukul

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