COVER LAPORAN PENDAHULUAN

LAPORAN INDIVIDU
LAPORAN PENDAHULUAN DAN ASUHAN KEPERAWATAN
PASIEN DENGAN DIAGNOSA MEDIS ………………….

Disusun Untuk Memenuhi Tugas Laporan Individu Praktek Profesi

Keperawatan Gawat Darurat dan Kritis
Di Ruang ………..
RS ……….

Oleh:
Nama : ………………………….
NIM : ………………………….

PRODI PENDIDIKAN PROFESI NERS MALANG

JURUSAN KEPERAWATAN
POLITEKNIK KESEHATAN KEMENKES MALANG
TAHUN AJARAN 2023/2024

1
 LEMBAR PENGESAHAN

Laporan Pendahuluan dan Asuhan keperawatan pada Pasien dengan Diagnosa

Medis………………………………………….………. Di…………………………………

Periode ………………………………. s/d ……………………..…… Tahun Ajaran

…………………………………….

Telah disetujui dan disahkan pada tanggal …… Bulan……………… Tahun…………

Malang,
Preceptor Klinik Preceptor Akademik

_________________________ _________________________
NIP/NIK. NIP.

Mengetahui,
Kepala Ruang ……

_________________________
NIP/NIK.

2
 FORMAT LAPORAN PENDAHULUAN

Laporan pendahuluan memuat point-point sebagai berikut:

A. Masalah Kesehatan : (Diagnosa pasien)

B. Pengertian

C. Gejala dan Tanda

D. Pohon Masalah (Dibuat dalam bentuk bagan berdasarkan patofisiologi, prosedur

tindakan, evidence based). Nb: Khusus Pohon Masalah Wajib ditulis tangan.

E. Pemeriksaan Diagnostik

F. Penatalaksanaan Medis

G. Pengkajian Keperawatan

H. Daftar Diagnosa Keperawatan

(Berdasarkan pohon masalah menggunakan dasar buku SDKI)

I. Intervensi Keperawatan (Menggunanakn dasar SLKI dan SIKI)

J. Referensi

- Minimal 3 buku keperawatan, buku diagnose keperawatan

- Tidak boleh mengambil sumber dari internet yang tidak bisa
dipertanggungjawabkan,.

3
 FORMAT LAPORAN SEMINAR AKHIR GERBONG

Laporan seminar akhir gerbong memuat point-point sebagai berikut:

1. Cover luar
2. Cover dalam
3. Lembar pengesahan
4. Kata pengantar
5. Daftar isi
6. Daftar gambar/tabel/lampiran
7. BAB 1 Latar Belakang
8. BAB 2 Tinjauan Pustaka
9. BAB 3 Kasus Asuhan Keperawatan
10. BAB 4 Review Jurnal Dan Pembahasan
11. Penutup
12. Daftar Pustaka
13. Lampiran-Lampiran

Referensi:
- Review jurnal minimal 3 jurnal internasional dengan cara pemaparan hasil
minimal terdiri atas authors, tahun, sumber jurnal, metode (desain, sampel,
variabel, instrumen analisis), outcome, ringkasan hasil.
- Minimal 3-5 buku keperawatan yang terbit maksimal 10 tahun terakhir
- Tidak boleh mengambil sumber dari internet yang tidak bisa
dipertanggungjawabkan.

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 FORMAT ASUHAN KEPERAWATAN GAWAT DARURAT
IDENTITAS PASIEN Tanggal :
No.reg :
Nama : Tgl lahir Usia: Jenis Kelamin:
/ /  pria  wanita
Alamat : Agama: Jenis pembayaran:

Waktu kedatangan : Waktu Dead On Arrival (DOA):

diperiksa  Denyut nadi (-)
:  Refleks cahaya (-/-)
 EKG Asistole
Jam Penentuan Kematian:

Jenis Kasus : Tanggal dan jam Kejadian: Kondisi Diantar oleh:

 Trauma kedatangan:  Ambulance
Tempat Kejadian:  sadar  keluarga
 Non Trauma  tidak sadar  datang sendiri
Mekanisme Cedera:  rangsang verbal  polisi
 rangsang nyeri 
lain2 :________
_

Informasi diperoleh dari :  pasien  keluarga, nama :_________________  orang lain , nama : ________________

FALSE
TRIASE / RESUSITAS NON
EMERGENCY URGENT EMERGEN
KATEGORI I URGENT
CY
JALAN NAPAS  Sumbatan  Stridor/disstres  Bebas  Bebas  Bebas
 Henti  Napas >32x/menit  Napas 20-32  Napas  Napas
Napas  Wheezing x/menit Normal 16- Normal 16-
PERNAPASAN  Napas  Wheezing 20 x//menit 20 x//menit
<10x/menit
 Sianosis
 Henti  Nadi tidak teraba/lemah  Nadi 100-150  Nadi  Nadi
Jantung  Bradikardia (<50x/mnt) x/menit Normal Normal
 Nadi tidak  Takikardia (>150x/mnt)  TD Sistole  TD  Luka
teraba/lemah  Pucat >140 mmHg Normal Ringan
 Pucat  Akral Dingin  TD Diastole 
 Akral  CRT >2 setik >90 mmHg Perdarahan
Dingin  TD Sistole <100 mmHg  Perdarahan Ringan
SIRKULASI  GDA < 80  TD Diastole <60 mmHg sedang  Cedera
mg/dl  Nyeri akut (>8)  Muntah Kepala
 GDA >200  Perdarahan akut  dehidrasi ringan
mg/dl  multiple Fraktur  Kejang tapi  Muntah /
 Kejang  Suhu >39 C sadar diare tanpa
 Nyeri Sedang dehidrasi
 Nyeri
ringan
DISABILITY  GCS <9  GCS 9-12  GCS >12  GCS 15  GCS 15

AREA  P1  P2  P3
RESPON TIME
1 MENIT 10 MENIT 60 MENIT

5
Pengkajian Perawat, jam: Riwayat Penyakit Dahulu:
Keluhan utama (SAMPLE):  TB  Kanker  Infark Miokard
 PPOK  Hepatitis  Peny.Jantung
 DM  Hipertensi  Stroke
 Kejang  Asma
Lain2:___________

Riwayat Alergi:
 YA  TIDAK
Jenis Alergi:
Riwayat Penggunaan Obat:

Riwayat Makanan Terakhir dimakan:

Riwayat Pemakaian Alkohol:

 YA  TIDAK
Jml/hri:
Riwayat Merokok:
 YA  TIDAK
Jml/hari:

TB: cm
TD: mmHg Nadi: x/menit SUHU: C
BB: Kg
RR: x/menit SaO2: % GDA: mg/dl IMT:
Skala Nyeri Untuk Umur > 9 Tahun: Skala Nyeri Untuk Umur < 9 Tahun: NILAI SKALA
NYERI:
 0 (Tidak
Nyeri)
 1-3 (Ringan)
 4-6 (Sedang)
 7-10 (Berat))

Diagram kode diagram

A : Abrasi
B: Bruise
Bu : Burn
E : eritema
L : laserasi
P : Ptekie
Pu : Pressure ulcer
R : Rash
S : Scar
ST: stoma
U : Ulcer
O : other (tato,
amputasi, perubahan
warna)
Ket: ____

6
Pemeriksaan fisik head to toe (DCAPBTLS untuk Trauma): (D=Deformitas, C=Contution, A=Abration,
P=Penetration, B=Burns, T=Tenderness, L=Laceration, S=Swelling)

A. Kepala dan Leher:

B. Dada:

C. Perut:

D. Genitalia:

E. Panggul:

F. Tangan:

G. Kaki:

7
Penilaian Resiko Jatuh
MORSE FALL SCALE (MFS)/ SKALA JATUH DARI MORSE
NO PENGKAJIAN SKALA NILAI KET.
1. Riwayat jatuh: apakah lansia pernah jatuh dalam 3 bulan Tidak 0
terakhir? Ya 25
2. Diagnosa sekunder: apakah lansia memiliki lebih dari satu Tidak 0
penyakit? Ya 15
3. Alat Bantu jalan:
- Bed rest/ dibantu perawat 0
- Kruk/ tongkat/ walker 15
- Berpegangan pada benda-benda di sekitar 30
(kursi, lemari, meja)
4. Terapi Intravena: apakah saat ini lansia terpasang infus? Tidak 0
Ya 20
5. Gaya berjalan/ cara berpindah:
- Normal/ bed rest/ immobile (tidak dapat bergerak sendiri) 0
- Lemah (tidak bertenaga) 10
- Gangguan/ tidak normal (pincang/ diseret) 20
6. Status Mental
- Lansia menyadari kondisi dirinya 0
- Lansia mengalami keterbatasan daya ingat 15
Total Nilai
Keterangan:
Tingkatan Risiko Nilai MFS Tindakan
Tidak berisiko 0 - 24 Perawatan dasar
Risiko rendah 25 - 50 Pelaksanaan intervensi pencegahan jatuh standar
Risiko tinggi ≥ 51 Pelaksanaan intervensi pencegahan jatuh risiko tinggi

Skala Resiko Jatuh Humpty Dumpty untuk Pediatrik

Parameter Kriteria Nilai Skor
Usia < 3 Tahun 4
3-7 Tahun 3
7-13 Tahun 2
≥ 13 Tahun 1
Jenis Kelamin Laki-laki 2
Perempuan 1
Diagnosis Diagnosis neurologi 4
Perubahan Oksigen (diagnosis repiratorik, dehidrasi, anemia, 3
anoreksia, sinkop, pusing, dsb)
Gangguan perilaku/psikiatri 2
Diagnosis lainnya 1
Gangguan kognitif Tidak menyedari keterbatasan dirinya 3
Lupa akan keterbatasannya 2
Orientasi baik terhadap diri sendiri 1
Faktor lingkungan Riwayat jatuh/bayi diletakkan di tempat tidur dewasa 4
Pasien menggunakan alat bantu / bayi diletakkan dalam tempat tidur 3
bayi / perabot rumah
Pasien diletakkan ditempat tidur 2
Area diluar rumah sakit 1
Pembedahan/ sedasi/ Dalam 24 jam 3
anestesi Dalam 48 jam 2
>48 jam atau tidak menjalani pembedahan / sedasi / anestesi 1
Penggunaan Penggunaan Multiple: sedatif, obat hipnosis, barbiturat, fenotiazin, 3
Medikamentosa antidepresan, pencahar, diuretik, narkose
Penggunaan salah satu diatas 2
Penggunaan medikasi lainnya /tidak ada medikasi 1

Jumlah Skor Humpty Dumpty

Interpretasi
Skor 7-11: Resiko Rendah
Skor ≥ 12 : Resiko Tinggi

8
Pemeriksaan diagnostic jam : RENCANA PROSEDUR
 tidak ada  USG  orofaringeal airway  terapi nasogastrik
 darah lengkap  X Ray  nasofaringeal airway  kateter urin
 BUN  MRI  intubasi ETT  kateter vena sentral (CVP)
 enzim jantung  CT scan  terapi oksigen  perawatn Ob/Gyn
 glukosa  lain-lain  terapi nebulizer  perawatan orthopedic
 tes fungsi hati  urinalisis  CPR  terapi trombolitik
 gas darah arteri  tes kehamilan  IV fluid  perawatan luka
 alcohol dalam darah  oksmetri nadi  DC shock lain-lain :
 HIV serologi  EKG

HASIL PEMERIKSAAN PENUNJANG:

RENCANA TERAPI MEDIKASI:

DIAGNOSIS MEDIS:

9
 ANALISA DATA
DATA ETIOLOGI MASALAH KEPERAWATAN

10
DIAGNOSIS KEPERAWATAN (BERDASARKAN PRIORITAS)

11
 PERENCANAAN KEPERAWATAN
Masalah Keperawatan Tujuan & Kriteria Hasil Intervensi

12
 IMPLEMENTASI KEPERAWATAN
Jam Tindakan Paraf

13
 EVALUASI KEPERAWATAN
Jam Evaluasi Paraf

PERAWATAN  Rawat  Rawat Inap Pulang Paksa   Meninggal

LANJUTAN Jalan dirujuk
Bila Rawat Jalan/pulang paksa, Tanggal: Jam: Vital Sign Sebelum
transfer/rujuk/pulang:
Bila Rawat Inap, Transfer ke Ruang: TD:

Bila Meninggal, Tanggal: Jam: Nadi:

Penyebab:
RR:

Suhu:
Bila dirujuk/alih rawat, Tanggal: Jam:
SpO2:

GCS:
Malang,
Ttd Perawat

(……………………………)

14
 FORMAT ASUHAN KEPERAWATAN KRITIS
FORMAT PENGKAJIAN KEPERAWATAN
Tanggal MRS : Jam Masuk :
Tanggal Pengkajian : No. RM :
Jam Pengkajian : Diagnosa Masuk :
Hari rawat ke :

IDENTITAS KLIEN
1. Nama :
2. Jenis Kelamin :
3. Umur :
4. Status Kawin :
5. Suku/ Bangsa :
6. Agama :
7. Pendidikan :
8. Pekerjaan :
9. Alamat :
10. Sumber Biaya :

IDENTITAS KELUARGA PASIEN (Yang dapat Dihubungi)

1. Nama :
2. Jenis Kelamin :
3. Umur :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :
8. Hubungan dengan klien:

KELUHAN UTAMA
Keluhan utama:…… ………………………………………………………………………………………….
…………………………………………………………………………………………………………………
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................

RIWAYAT PENYAKIT SEKARANG

1. Riwayat Penyakit Sekarang:
……………………………………………………………………………….......................................................
……………………………………………………………………………………………………………...........
...............................................................................................................................................................................
……………………………………………………………………………………………………………...........
...............................................................................................................................................................................
……………………………………………………………………………………………………………...........
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................

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RIWAYAT PENYAKIT DAHULU
1. Pernah dirawat : ya tidak kapan :…… diagnosa :…………
2. Riwayat penyakit kronik dan menular ya tidak jenis……………………
Riwayat kontrol : .............................
Riwayat penggunaan obat :..............
3. Riwayat alergi:
Obat ya tidak jenis……………………
Makanan ya tidak jenis……………………
Lain-lain ya tidak jenis……………………

4. Riwayat operasi: ya tidak

- Kapan : ……………………
- Jenis operasi : ……………………

5. Lain-lain:
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis
:………………….....................................................................................................................................
- Genogram :

PERILAKU YANG MEMPENGARUHI KESEHATAN

Perilaku sebelum sakit yang mempengaruhi kesehatan:
Alkohol ya tidak keterangan……….....................
Merokok ya tidak
keterangan…………………….........................................................
Obat ya tidak
keterangan…..............................................................………………
Olah raga ya tidak
keterangan…..........................................................…………………

OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda tanda vital
S: N: T: RR :
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma

2. Sistem Pernafasan (B1)

a. RR:................................
b. Keluhan: sesak nyeri waktu nafas orthopnea
Batuk produktif tidak produktif
Sekret:…….. Konsistensi :......................
Warna:.......... Bau :.................................. Masalah Keperawatan :
c. Penggunaan otot bantu nafas:
......................................................................................................................................................................
......................................................................................................................................................................
........................
d. PCH ya tidak
e. Irama nafas teratur tidak teratur
f. Pleural Friction rub:.....................................................................................................................
g. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot
h. Suara nafas Cracles Ronki Wheezing
i. Alat bantu napas ya tidak

Jenis................................................ Flow..............lpm

16
 j. Penggunaan WSD:
- Jenis
: .....................................................................................................................................................
............
- Jumlah cairan
: ..................................................................................................................................................
- Undulasi
:...................................................................................................................................................
- Tekanan
: ..................................................................................................................................................

k. Tracheostomy: ya tidak
......................................................................................................................................................................
......................................................................................................................................................................
l. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................

3. Sistem Kardio vaskuler (B2)

a. TD : Masalah Keperawatan :
b. N :
c. Keluhan nyeri dada: ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
d. Irama jantung: reguler ireguler
e. Suara jantung: normal (S1/S2 tunggal) murmur
gallop lain-lain.....
f. Ictus
Cordis: .........................................................................................................................................................
....
g. CRT :.............detik
h. Akral: hangat kering merah basah pucat
panas dingin
i. Sikulasi perifer: normal menurun
j. JVP :.................................
k. CVP :.................................
l. CTR :.................................
m. ECG & Interpretasinya:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
n. Lain-lain :
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
.............................................................................................................. ............................ .........................

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4. Sistem Persyarafan (B3)
a. GCS : .................................................. Masalah Keperawatan :
b. Refleks fisiologis patella triceps biceps
c. Refleks patologis babinsky brudzinsky kernig
Lain-lain
d. Keluhan pusing ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................

e. Pemeriksaan saraf kranial:

N1 : normal tidak Ket.: ……..............................................................
N2 : normal tidak Ket.: ……..............................................................
N3 : normal tidak Ket.: ……..............................................................
N4 : normal tidak Ket.: ……..............................................................
N5 : normal tidak Ket.: ……..............................................................
N6 : normal tidak Ket.: ……..............................................................
N7 : normal tidak Ket.: ……..............................................................
N8 : normal tidak Ket.: ……..............................................................
N9 : normal tidak Ket.: ……..............................................................
N10 : normal tidak Ket.: ……..............................................................
N11 : normal tidak Ket.: ……..............................................................
N12 : normal tidak Ket.: ……..............................................................

f. Pupil anisokor isokor Diameter: ……/......

g. Sclera anikterus ikterus
h. Konjunctiva ananemis anemis
i. Isitrahat/Tidur :................. Jam/Hari Gangguan
tidur : ..............................................................
j. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
............................................................

5. Sistem perkemihan (B4)

Masalah Keperawatan
a. Kebersihan genetalia: Bersih Kotor
b. Sekret: Ada Tidak
c. Ulkus: Ada Tidak
d. Kebersihan meatus uretra: Bersih Kotor
e. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
Kemampuan berkemih:
Spontan Alat bantu,
sebutkan: .................................................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................

18
 f. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
g. Kandung kemih : Membesar ya tidak
h. Nyeri tekan ya tidak
i. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
j. Balance cairan:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................
k. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................
6. Sistem pencernaan (B5) Masalah Keperawatan :
a. TB :............... BB :................................
b. IMT :............... Interpretasi :................................

c. Mulut: bersih kotor berbau

d. Membran mukosa: lembab kering stomatitis
e. Tenggorokan:
sakit menelan kesulitan menelan
pembesaran tonsil nyeri tekan
f. Abdomen: tegang kembung ascites
g. Nyeri tekan: ya tidak
h. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
i. Peristaltik:.............. x/menit
j. BAB: ......................x/hari Terakhir tanggal : ............................................................................
k. Konsistensi: keras lunak cair lendir/darah
l. Diet: padat lunak cair
m. Diet Khusus:
......................................................................................................................................................................
......................................................................................................................................................................
n. Nafsu makan: baik menurun Frekuensi:.......x/hari
o. Porsi makan: habis tidak Keterangan:.......................
p. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................

19
 Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO

b. Keluhan nyeri ya tidak

P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................

c. Luka operasi: ada tidak

Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
d. Pemeriksaan penunjang lain : .........................
e. Lain-lain :
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................

8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Aurcicula
MAE
Membran
Tymphani
Rinne
Weber
Swabach

20
 b. Tes Audiometri
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................

c. Keluhan nyeri ya tidak

P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
d. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
e. Alat bantu dengar: .........................
f. Lain-lain :
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
....................................
7. Sistem muskuloskeletal (B6)
a. Pergerakan sendi: bebas terbatas
b. Kekuatan otot: Masalah Keperawatan :

c. Kelainan ekstremitas: ya tidak

d. Kelainan tulang belakang: ya tidak
Frankel: ................................................................................
e. Fraktur: ya tidak
- Jenis :...................
f. Traksi: ya tidak
- Jenis :...................
- Beban :...................
- Lama pemasangan :...................
g. Penggunaan spalk/gips: ya tidak
h. Pengkajian Nyeri
Keluhan nyeri: ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
i. Sirkulasi perifer: ..............................................

21
 j. Kompartemen syndrome ya tidak
k. Kulit: ikterik sianosis kemerahan hiperpigmentasi
l. Turgor baik kurang jelek
m. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
n. ROM : .................................................

o. Cardinal Sign : ................................................

p. Resiko Jatuh:
MORSE FALL SCALE (MFS)/ SKALA JATUH DARI MORSE
NO PENGKAJIAN SKALA NILAI KET.
1. Riwayat jatuh: apakah lansia pernah jatuh dalam 3 bulan Tidak 0
terakhir? Ya 25
2. Diagnosa sekunder: apakah lansia memiliki lebih dari Tidak 0
satu penyakit? Ya 15
3. Alat Bantu jalan:

- Bed rest/ dibantu perawat 0

- Kruk/ tongkat/ walker 15
- Berpegangan pada benda-benda di sekitar 30

(kursi, lemari, meja)

4. Terapi Intravena: apakah saat ini lansia terpasang infus? Tidak 0
Ya 20
5. Gaya berjalan/ cara berpindah:

- Normal/ bed rest/ immobile (tidak dapat bergerak 0

sendiri)
- Lemah (tidak bertenaga) 10
- Gangguan/ tidak normal (pincang/ diseret) 20
6. Status Mental

- Lansia menyadari kondisi dirinya 0

- Lansia mengalami keterbatasan daya ingat 15
Total Nilai
Keterangan:
Tingkatan Risiko Nilai MFS Tindakan
Tidak berisiko 0 - 24 Perawatan dasar
Risiko rendah 25 - 50 Pelaksanaan intervensi pencegahan jatuh standar
Risiko tinggi ≥ 51 Pelaksanaan intervensi pencegahan jatuh risiko tinggi

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

10. Sistem Integumen

a. Penilaian resiko decubitus
Kriteria Penilaian Nilai

22
 Aspek Yang 1 2 3 4
Dinilai
Persepsi Terbatas Sangat Keterbatasan Tidak Ada
Sensori Sepenuhnya Terbatas Ringan Gangguan
Kelembaban Terus Sangat Kadang2 Basah Jarang
Menerus Lembab Basah
Basah
Aktifitas Bedfast Chairfast Kadang2 Jalan Lebih Sering
jalan
Mobilisasi Immobile Sangat Keterbatasan Tidak Ada
Sepenuhnya Terbatas Ringan Keterbatasan
Nutrisi Sangat Kemungkinan Adekuat Sangat Baik
Buruk Tidak
Adekuat
Gesekan & Bermasalah Potensial
Tidak
Pergeseran Bermasalah
Menimbulkan
Masalah
NOTE: Pasien dengan nilai total < 16 maka dapat dikatakan Total Nilai
bahwa pasien beresiko mengalami dekubisus (pressure ulcers)
(15 or 16 = low risk, 13 or 14 = moderate risk, 12 or less = high
risk)

b. Warna Masalah Keperawatan :

c. Pitting edema: +/- grade:................
d. Ekskoriasis: ya tidak
e. Psoriasis: ya tidak
f. Pruritus: ya tidak
g. Urtikaria: ya tidak
h. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................

11. Sistem Endokrin

a. Pembesaran tyroid: ya tidak Masalah Keperawatan :
b. Pembesaran kelenjar getah bening: ya tidak
c. Hipoglikemia: ya tidak
d. Hiperglikemia: ya tidak
e. Kondisi kaki DM
- Luka gangren ya tidak
Jenis ................................................................................................................
- Lama luka ...............................................................................................
- Warna ...............................................................................................
- Luas luka ...............................................................................................
- Kedalaman ...............................................................................................
- Kulit kaki ...............................................................................................
- Kuku kaki ...............................................................................................
- Telapak kaki ...............................................................................................
- Jari kaki ...............................................................................................
- Infeksi ya tidak
- Riwayat luka sebelumya ya tidak
Jika ya:
- Tahun :
- Jenis Luka :
- Lokasi :
- Riwayat amputasi sebelumya ya tidak
Jika ya:
- Tahun :
- Lokasi :
f. ABI : ....................................................

23
 g. Lain-lain:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................

PENGKAJIAN PSIKOSOSIAL Masalah keperawatan :

a. Persepsi klien terhadap penyakitnya:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
Ekspresi klien terhadap penyakitnya
Murung/diam gelisah tegang marah/menangis
b. Reaksi saat interaksi kooperatif tidak kooperatif curiga

c. Gangguan konsep diri:

..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
d. Lain-lain:
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
PERSONAL HYGIENE & KEBIASAAN Masalah Keperawatan :
Jelaskan :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................

PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah

b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:

...............................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................

24
PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................

TERAPI MEDIS
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................
....................................................................................................................................................................................

25
DATA TAMBAHAN LAIN :
....................................................................................................................................................................................
....................................................................................................................................................................................

....................................................................................................................................................................................
....................................................................................................................................................................................

PERENCANAAN PULANG
- Tujuan Pulang:

- Transportasi Pulang:

- Dukungan Keluarga:

- Antisipasi bantuan biaya setelah pulang:

- Antisipasi masalah perawatan diri setelah pulang:

- Pengobatan:

- Rawat jalan ke:

- Hal-hal yang perlu diperhatikan di rumah:

Malang, 2022

(……………………………)

26
 ANALISA DATA

Nama Pasien :
Umur :
No. Register :
Hari/
Tgl/ DATA ETIOLOGI MASALAH
Jam

27
 DIAGNOSA KEPERAWATAN

Nama Pasien :
Umur :
No. Register :

1.
2.
3.
4. dst

28
 PRIORITAS MASALAH KEPERAWATAN

Nama Pasien :
No. Register :
Tanggal Tanggal Tanda
No. Diagnosa Keperawatan
Muncul Teratasi Tangan

29
 RENCANA ASUHAN KEPERAWATAN
Nama Pasien :
No. Register :
Hari/
No. Tgl/ DIAGNOSIS KEPERAWATAN LUARAN INTERVENSI
Jam

30
 IMPLEMENTASI
Nama Pasien :
No. Register :
Hari/
Tgl/ Diagnosa Kep. Jam Implementasi Paraf
Shift

31
 EVALUASI KEPERAWATAN
Nama Pasien :
No. Register :
Hari/
Tgl/ Diagnosa Kep. Jam Evaluasi (SOAP) Paraf
Shift

32
 FORMAT RESUME RUANGAN

Nama : Tanggal MRS :

No. RM : Tanggal Pengkajian :
Diagnosa Medis : Ruang :

Subjektif Objektif Analisa Planning Implementation Evaluation

Isi data subyektif Isi data obyektif Isi Diagnosa keperawatan Isi rencana tindakan Isi pelaksanaan tindakan Isi evaluasi berupa
yang bermasalah yang bermasalah keperawatan yang (1x8 jam) yang perawatan disertai jam S:
(data fokus) dari (data fokus), seperti muncul disertai pathway terdiri dari: Tujuan, pelaksanaannya.
pemeriksaan yang hasil pemeriksan etiologi Kriteria Hasil, dan
didapatkan, seperti pola aktifitas, intervensi
keluhan utama, pemeriksaan fisik,
riwayat penyakit pemeriksaan O:
sekarang, riwayat psikososial,
penyakit dahulu, pemeriksaan
riwayat akergi, dll spiritual,
pemeriksaan
penunjang
A:

P:

33
 FORMAT RESUME

Nama : Tanggal MRS :

No. RM : Tanggal Pengkajian :
Diagnosa Medis : Ruang :

Subjektif Objektif Analisa Planning Implementation Evaluation

34
35