LAPORAN PENDAHULUAN

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 FORMAT PENGKAJIAN DAN ANALISIS TINDAKAN STASE
KEPERAWATAN DASAR PROFESI ITKES WIYATA HUSADA
SAMARINDA

Nama mahasiswa : ……………………………………

Tempat praktek : ……………………………………
Tanggal : ……………………………………

I. IDENTITAS DIRI KLIEN

Inisial nama : ……………………….…….… Suku : ………………….…………....

Umur : ……………………….…….… Pendidikan : …………….…………………

J. kelamin : ………………………..……… Pekerjaan : …………………………….…

Alamat : ……………………………..… Lama bekerja : .………………...………….…

……………………………….. Tanggal MRS : ………………….……………...

Status : …………………………….…. Tanggal Pengkajian : …………………………...

Agama : ………………………….…..… Sumber Informasi : …………………………..

II. RIWAYAT PENYAKIT

1. Keluhan utama saat masuk RS: .
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2. Riwayat penyakit sekarang:

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3. Riwayat Penyakit Dahulu

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4. Genogram:

III. PENGKAJIAN SAAT INI (MULAI HARI PERTAMA SAUDARA MERAWAT

KLIEN)
Persepsi dan pemeliharaan kesehatan (Pengetahuan tentang penyakit/perawatan)
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1. Pola nutrisi/metabolic Program diit RS:

a. Intake makanan
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b. Intake cairan
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2. Pola eliminasi
a. Buang air besar
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b. Buang air kecil
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3. Pola aktifitas dan latihan:

Kemampuan perawatan diri 0 1 2 3 4

Makan/minum

Mandi

Toileting

Berpakaian

Mobilitas di tempat tidur

Berpindah

Ambulasi/ROM

0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4:
tergantung total

3. Oksigenasi:
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4. Pola tidur dan istirahat (lama tidur, gangguan tidur, perawasan saat bangun tidur)

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5. Pola persepsual (penglihatan, pendengaran, pengecap, sensasi):

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6. Pola persepsi diri (pandangan klien tentang sakitnya, kecemasan, konsep diri)

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7. Pola seksualitas dan reproduksi (fertilitas, libido, menstuasi, kontrasepsi, dll.)

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8. Pola peran hubungan (komunikasi, hubungan dengan orang lain, kemampuan keuangan):

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9. Pola managemen koping-stess (perubahan terbesar dalam hidup pada akhir-akhir ini):
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10. Sistem nilai dan keyakinan (pandangan klien tentang agama, kegiatan keagamaan, dll)

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IV. PEMERIKSAAN FISIK

TD : mm/Hg R : x/m

N : x/menit S : C

BB/TB Sebelum sakit : .…kg/…cm BB/TB Sesudah sakit : .…kg/…cm

1. Sistem saraf
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2. Sistem persepsi sensori

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3. Sistem limfatik
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4. System imun
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5. Sistem respirasi
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6. Sistem kardiovaskular
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7. Sistem pencernaan
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8. Sistem endokrin
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9. Sistem musculoskeletal
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10. System integument

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11. Sistem urinary

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V. DATA PENUNJANG
1. Laboratorium
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2. Radiologi
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3. Pemeriksaan penunjang lain

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VI. TERAPI

1. Diet

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2. Obat-obatan

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 VII. ANALISA DATA
No DATA ETIOLOGI PROBLEM
1. Data subjektif :
Dst

Data objektif :

VIII. DIAGNOSA KEPERAWATAN

1 .………………………………………………………………………………………
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1X. INTERVENSI KEPERAWATAN

NO DIAGNOSA TUJUAN INTERVENSI

1.