FORMAT PENGKAJIAN

A. DATA UMUM
1. Identitas Pasien
Nama inisial klien : .........................................................
Umur : .........................................................
Jenis Kelamin : .........................................................
Agama : .........................................................
Pendidikan : .........................................................
Pekerjaan : .........................................................
Status Perkawinan : .........................................................
Sumber Informasi : .........................................................
Alamat : .........................................................
Tanggal masuk RS/RB : .........................................................
Nomor Rekam Medis : .........................................................
Diagnosa Medis : .........................................................
2. Penanggung Jawab
Nama : .................................................................................
Umur : .................................................................................
Jenis kelamin : .................................................................................
Pekerjaan : .................................................................................
Almat : .................................................................................
Hubungan dengan klien : .................................................................................
B. ALASAN MASUK RS/KELUHAN UTAMA
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C. PENGKAJIAN PRIMER
  Airway :
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Breathing :
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Circulation :
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Disability :
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Exposure :
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D. RIWAYAT KESEHATAN MASA LALU

Riwayat Penyakit :

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Riwayat perawatan :

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Riwayat pengobatan :
 ………………………………………………………………………………………………………………
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Riwayat pembedahan :

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Riwayat alergi :

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E. RIWAYAT KESEHATAN KELUARGA

Genogram (3 Generasi)

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F. PENGKAJIAN SEKUNDER
 Keadaan Umum : .................................................................................
 Kesadaran : .................................................................................
 Vital Sign : .................................................................................
 Pemeriksaan Fisik (Head to Toe) :
o Kepala dan rambut
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o Kulit
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o Kuku
 ………………………………………………………………………………………………
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o Mata/penglihatan
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o Hidung
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o Telinga
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o Mulut dan gigi
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o Leher
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o Dada
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o Abdomen
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 o Perineum dan genitalia
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o Ekstremitas atas dan bawah
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G. POLA KEGIATAN SEHARI-HARI

1. Nutrisi

No URAIAN SEBELUM MRS SAAT MASUK RS

2. Cairan

No URAIAN SEBELUM MRS SAAT MASUK RS

3. Eliminasi BAB

No URAIAN SEBELUM MRS SAAT MASUK RS

4. Eliminasi BAK

No URAIAN SEBELUM MRS SAAT MASUK RS

5. Istirahat Tidur

No URAIAN SEBELUM MRS SAAT MASUK RS

6. Aktifitas dan latihan

No URAIAN SEBELUM MRS SAAT MASUK RS

7. Personal hygiene

No URAIAN SEBELUM MRS SAAT MASUK RS

H. RIWAYAT PSIKO SOSIO SPRITUAL

 Pola koping
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 Harapan klien terhadap penyakitnya
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 Faktor stressor
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 Pengetahuan klien tentang penyakitnya
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 Adaptasi
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 Hubungan dengan anggota keluarga
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 Hubungan dengan masyarakat
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 Perhatian terhadap orang lain dan lawan bicara
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 Kegiatan keagamaan
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I. PEMERIKSAAN DIAGNOSTIK
HARI/TANGGAL HASIL
NO JENIS PEMERIKSAAN NILAI NORMAL
& JAM PEMERIKSAAN

J. PENATALAKSANAAN MEDIK
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Bulukumba, 2022

Mahasiswa,

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

NIM.
 RESUME KEPERAWATAN GAWAT DARURAT (UGD)

A. DATA UMUM
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B. ALASAN MASUK RS/KELUHAN UTAMA
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C. PENGKAJIAN PRIMER
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D. PENGKAJIAN SEKUNDER
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E. PEMERIKSAAN DIAGNOSTIK
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F. PENATALAKSANAAN MEDIK
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G. KLASIFIKASI DATA
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H. DIAGNOSA KEPERAWATAN (Minimal tiga)
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I. INTERVENSI (Minimal lima)
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J. IMPLEMENTASI
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K. EVALUASI (SOAP)
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L. ANALISA PERMASALAHAN
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Bulukumba, 2022

Mahasiswa,

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

NIM.
 RESUME KEPERAWATAN GAWAT DARURAT (OK)

A. DATA UMUM
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B. ALASAN MASUK RS/KELUHAN UTAMA
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C. PENGKAJIAN PRIMER
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D. PENGKAJIAN SEKUNDER (Pre,Intra&Post Operasi)
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E. PEMERIKSAAN DIAGNOSTIK
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F. PENATALAKSANAAN MEDIK (Pre,Intra&Post Operasi)
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G. KLASIFIKASI DATA (Pre,Intra&Post Operasi)
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H. DIAGNOSIS KEPERAWATAN (Minimal tiga) (Pre,Intra&Post Operasi)
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I. INTERVENSI (Pre,Intra&Post Operasi)
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J. IMPLEMENTASI (Pre,Intra&Post Operasi)
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K. EVALUASI (SOAP) (Pre,Intra&Post Operasi)
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………

Bulukumba, 2022

Mahasiswa,

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

NIM.
 KLASIFIKASI DATA
Nama Pasien :

Umur/J. Kelamin :

Ruangan/Kamar :

Diagnosa Medis :

DATA SUBJEKTIF DATA OBJEKTIF

ANALISA DATA
 Nama Pasien :

Umur/J. Kelamin :

Ruangan/Kamar :

Diagnosa Medis :

NO DATA ETIOLOGI MASALAH KEPERAWATAN

DIAGNOSIS KEPERAWATAN
Nama Pasien :

Umur/J. Kelamin :
 Ruangan/Kamar :

Diagnosa Medis :

NO DIAGNOSIS KEPERAWATAN TGL DITEMUKAN TGL TERATASI

DATA FOKUS
Nama Pasien :

Umur/J. Kelamin :

Ruangan/Kamar :

Diagnosa Medis :
 PEDOMAN RESUME JURNAL

Ruangan : Preseptor Klinik :

Hari/Tanggal : Preseptor Institusi :
Jam :
Nama Mahasiswa : 1. ……………………………
2……………………………
3…………………………….. dst

1. Populasi
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2. Intervensi
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3. Comparation
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4. Out Come
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5. Time
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Pembimbing Institusi Pembimbing Klinik

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PEDOMAN LAPORAN SEMINAR

A. PENDAHULUAN
 1. Latar Belakang
2. Tujuan:
a. Tujuan Umum
b. Tujuan Khusus
3. Manfaat
B. PEMBAHASAN
1. Konsep Dasar Medis
2. Konsep dasar keperawatan
3. Patoflodiagram
4. Asuhan keperawatan
C. PENUTUP
1. Kesimpulan
2. Saran
D. DAFTAR PUSTAKA

Keterangan:

- Laporan dibuatkan Power point

- Laporan dijilid dengan sampul warna merah
 INTERVENSI KEPERAWATAN
Nama Pasien : Ruangan/Kamar :
Umur/J. Kelamin : Diagnosa Medis :

DIAGNOSIS KEPERAWATAN TUJUAN INTERVENSI

DIAGNOSA KEPERAWATAN TUJUAN INTERVENSI

 IMPLEMENTASI KEPERAWATAN
Nama Pasien : Ruangan/Kamar :
Umur/J. Kelamin : Diagnosa Medis :
 Hari/Tanggal :

NO DIAGNOSA KEPERAWATAN JAM IMPLEMENTASI

NO DIAGNOSA KEPERAWATAN JAM IMPLEMENTASI

 EVALUASI KEPERAWATAN (SOAP)
Nama Pasien : Ruangan/Kamar :
Umur/J. Kelamin : Diagnosa Medis :
Hari/Tanggal :

NO DIAGNOSA KEPERAWATAN JAM EVALUASI

NO DIAGNOSA KEPERAWATAN JAM EVALUASI