Lampiran Buku Panduan

Program Pendidikan Profesi Ners

Stase Keperawatan Medikal Bedah

Untuk Mahasiswa S1 Keperawatan Program Pendidikan Profesi Ners dan

Pembimbing Klinik

Penyusun:

Nur wahid ramadhan

P2305055

TIM Keperawatan Medikal Bedah

Profesi Ners ITKES Wiyata Husada Samarinda

PROGRAM STUDI PROFESI NERS

ITKES WIYATA HUSADA
SAMARINDA
2023
 Identitas Mahasiswa

Paspoto
4x6

Nur Wahid Ramadhan

Nama :

NIM :
P2305055

Jalur :

Kelompok :

Periode Praktik :

Alamat :

HP :

Panduan Penyusunan Laporan & Penilaian Kinerja 2

Lampiran-Lampiran

1. Format Pengkajian Keperawatan

2. Format Rencana Asuhan Keperawatan
3. Format Catatan Keperawatan
4. Format Subjektif, Objektif, Analisis, Planning (SOAP)
5. Format Analisa Keterampilan Tindakan Keperawatan
6. Format Penyusunan Laporan Resume Keperawatan di Ruang Operasi (IBS)
7. Format Penyusunan Laporan Resume Keperawatan di Ruang HD
8. Format Penyusunan Laporan Resume Keperawatan di Ruang Kemoterapi
9. Pedoman Analisis Jurnal Serta Presentasi/Seminar
10. Pedoman Laporan Studi Kasus Serta Presentasi/Seminar
11. Format Penyusunan Refleksi Diri
12. Format Penilaian Proses Praktik Klinik/ Perilaku Profesional
13. Format Penilaian LP
14. Format Penilaian Laporan Kasus/Resume Keperawatan
15. Format Penilaian DOPS
16. Format Penilaian SOCA
17. Format Penilaian Ujian Praktik
18. Format Daftar Topik Diskusi
19. Format Penyusunan Activity Daily Living
20. Daftar Target Keterampilan Klinik KMB
21. Lembar Bukti Pengumpulan Tugas
22. Jadwal Praktik Stase KMB

Panduan Penyusunan Laporan & Penilaian Kinerja 3

 FORMAT ASUHAN KEPERAWATAN KEPERAWATAN MEDIKAL BEDAH
PROFESI NERS ITKES WIYATA HUSADA SAMARINDA

Nama mahasiswa : Nur Wahid Ramadhan

Tempat praktek : Ruangan Cempaka
Tanggal : Selasa, 5.12.2023

I. Identitas diri klien

Nama : Maskur Suku : Jawa

Umur : 72 Tahun Pendidikan : SMA

Jemis kelamin : Laki-Laki Pekerjaan : Wirahusaha

Alamat : Suryanat Air Hitam Lama bekerja : 11 Tahun

Tangal masuk RS : 25 Agustus 2023

Status perkawinan : Menikah Tanggal Pengkajian : 5.12.2023

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

II. Riwayat penyakit

1. Keluhan utama saat masuk RS:

Nyeri kaki sebelah kanan habis operasi setelah di tabrak kendaraan bermotor

2. Riwayat penyakit sekarang:

Pusing dan Nyeri kaki di sebelah kanan

Panduan Penyusunan Laporan & Penilaian Kinerja 4

 3. Riwayat Penyakit Dahulu
: Anemia, sering susah tidur dan gelish

Genogram:

Tn.M mengatakan ada riwayat hipertensi dan dari orang tua laki laki memiliki riwayat jantung.
Genogram :
Keterangan
Laki-Laki Meninggal

Perempuan Meninggal

Pasien

Anak

Tinggal Serumah
Hubungan Saudara/orangtua

4. Diagnosa medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah dilakukan:
: Hasil LAB
Injeksi lewat pd
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................

Panduan Penyusunan Laporan & Penilaian Kinerja 5

III. Pengkajian saat ini (mulai hari pertama saudara merawat klien)
1. Persepsi dan pemeliharaan kesehatan

Pengetahuan tentang penyakit/perawatan

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

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

2. Pola nutrisi/metabolic

Intake makanan:
: pasien mengatakan nafsu makan membaik dikasih pihak rumah sakit makan nasi sayur
dan lauk pauk
..........................................................................................................................................................................................
..........................................................................................................................................................................................

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

Intake cairan:
: Teh hangat dan air putih
RL 500 TPM
..........................................................................................................................................................................................
..........................................................................................................................................................................................

..........................................................................................................................................................................................
..........................................................................................................................................................................................
3. Pola eliminasi
a. Buang air besar
Lembek dan normal

................................................................................................................................................................................
................................................................................................................................................................................
b. Buang air kecil
: Kuning dikit berkeruh
.................................................................................................................................................................................

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

Panduan Penyusunan Laporan & Penilaian Kinerja 6

4. 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
Oksigenasi:

Pasien bernafas normal tanpa alat bantu bernapasan 18x/m

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

..........................................................................................................................................................................................
5. Pola tidur dan istirahat
(lama tidur, gangguan tidur, perawasan saat bangun tidur)
Biasa 1 atau 2 jam tidur dan susah tidur gelisah kalo mau tidur lagi
..........................................................................................................................................................................................
..........................................................................................................................................................................................

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

Penglihatan normal tidak ada tanda atau gejala gangguan pada pengliatan, bisa
mendengar dengan baik tidak ada tanda atau gejala pada pendengaran tersebut
..........................................................................................................................................................................................

..........................................................................................................................................................................................
7. Pola persepsi diri
(pandangan klien tentang sakitnya, kecemasan, konsep diri)
: Nyeri di sebelah kaki kanan dan merasa cemas dan pasien menganggap bahwa
penyakit yang diderita saat ini adalah cobaan dari pencipta-Nya.

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

Panduan Penyusunan Laporan & Penilaian Kinerja 7

 8. Pola seksualitas dan reproduksi
(fertilitas, libido, menstuasi, kontrasepsi, dll.)
Pasien mengatakan mengalami hambatan dalam menjalankan peran seksual reproduksi
..........................................................................................................................................................................................
..........................................................................................................................................................................................

9. Pola peran hubungan

(komunikasi, hubungan dengan orang lain, kemampuan keuangan):

Pasien mampu berkomunikasi dengan baik, dengan keluarga maupun dengan
orang lain.pasien menggunakan kartu BPJS untuk berobat maupun dirawat
di rumah sakit.

..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
10. Pola managemen koping-stess

(perubahan terbesar dalam hidup pada akhir-akhir ini):

Pasein mengatakan setelah operasi agak membaik kaki sebelah kanan nya
..........................................................................................................................................................................................
..........................................................................................................................................................................................

..........................................................................................................................................................................................
11. Sistem nilai dan keyakinan
(pandangan klien tentang agama, kegiatan keagamaan, dll)

: Sholat 5 waktu ( Islam )

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

IV. Pemeriksaan fisik

(cephalocaudal) yang meliputi : Inspeksi, Palpasi, Perkusi dan Auskultasi
keluhan yang dirasakan saat ini

Pasien mengatakan nyeri kaki sebelah kanan

..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
o
TD: 129/76 mm/H P: 18 x/m N: 78 x/m S: 36,3 C
BB/TB : 46 kg 160 cm

Panduan Penyusunan Laporan & Penilaian Kinerja 8

Kepala:

: bentuk simetris, tidak ada benjolan, tidak ada lesi, rambut berwarna hitam,
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
Mata dan Telinga (Penglihatan dan pendengaran)

a. Penglihatan

 Berkurang  Ganda  Kabur  Buta/ gelap

pupil mengecil pada saat tekena cahaya, tidak ada kelainan pada mata, tidak
terdapat benjolan maupun lesi, konjungtiva tidak anemis.

 Visus: dioptri
 Sklera ikterik : (ya/tidak)
 Konjungtiva : (anemis/ tidak anemis)

 Nyeri : (ya/tidak), intensitas : 4

 Kornea : jernih/keruh/berbintik
 Alat bantu : tidak ada/lensa kontak/kaca mata
b. Pendengaran
√ Normal  Berdengung  Berkurang  Alat bantu  Tuli

keadaan telinga bersih, kedua telingan kanan dan kiri simetris, nyeri pada saat palpasi tidak ada,
fungsi pendengaran baik terbukti pasien mendengar waktu diajak komunikasi

Hidung:

Keadaan hidung bersih, batang hidung simetris, frekuensi pernapasan 32x/m,

bentuk dada simetris kanan dan kiri tidak ada keluhan nyeri, gerakan dada

kanan dan kiri simetris, tidak ada sianosis.

Mulut/Gigi/Lidah:

Bibir, mukosa lembab,

Leher :

Batang leher simetris, tidak ada benjolan, tidak ada nyeri tekan, tidak terdapat pembengkakan

Kelenjar getah bening

Panduan Penyusunan Laporan & Penilaian Kinerja 9

Respiratori
a. Dada :
Perkembangan dada kiri dan kanan simetris, tidak terdapat jejas, tidak terdapat nyeri tekan
Tidak ada benjolan,
b. Batuk : ya/tidak; produktif/tidak produktif

Karakteristik Sputum .........................................................................................................................................

c. Napas bunyi : vesikuler/lainnya, jelaskan
...................................................................................................................................................................................
...................................................................................................................................................................................

...................................................................................................................................................................................
 Sesak napas saat :
 Ekspirasi  Inspirasi  Istirahat  Aktivitas

Tipe pernapasan :

 Perut √  Dada  Biot

 Kussmaul  Cynestokes  Lainnya

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

.........................................................................................................................................................................
.........................................................................................................................................................................
Frekuensi nafas : Type equation here . 20 x/mnt
Penggunaan otot-otot asesori: (ya/tidak), Napas Cuping Hidung:......................................

Fremitus: ......................................................................................................................................................
.........................................................................................................................................................................

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

Sianosis: (ya/tidak)
 Keluhan Lain:
.........................................................................................................................................................................
.........................................................................................................................................................................

.........................................................................................................................................................................
Kardiovaskular
Riwayat Hipertensi: ............................................................... Masalah jantung……………..
Demam Rematik: 2 tahun yang lalu ...................................................................

Bunyi Jantung: Frekuensi: ................................................. Irama………………….

Panduan Penyusunan Laporan & Penilaian Kinerja 10

 Kualitas……………………………….. Murmur ………………………..

 Nyeri dada, Intensitas : Palpitasi

 Pusing  Cianosis
 Capillary refill :

 Riwayat Keluhan lainnya

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

 Edema, lokasi : grade :

 Hematoma, lokasi :
...............................................................................................................................................................................
................................................................................................................................................................................

Neurologis
Rasa ingin pingsan/ pusing:........................................................................................................................
Sakit Kepla: Lokasi nyeri ........................................................................Frekuensi ...................................
 GCS : Eye = 4 Verbal = 6 Motorik = 5

 Pupil : isokor/unisokor
 Reflek cahaya :
 Sinistra : +/- cepat/lambat
 Dextra : +/- cepat/lambat

 Bicara :
 Komunikatif  Aphasia  Pelo 

...................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
 Keluhan lain

 Kesemutan  Bingung  Tremor √  Gelisah  Kejang

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

 Koordinasi ekastemitas

√  Normal  Paralisis, Lokasi : Plegia, Lokasi :

Panduan Penyusunan Laporan & Penilaian Kinerja 11

  Keluhan lain:
.....................................................................................................................................................................
.......................................................................................................................................................................
.......................................................................................................................................................................

.......................................................................................................................................................................
Integumen
 Warna kulit

 Kemerahan  Pucat  Sianosis  Jaundice √  Normal

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

 Kelembaban :

 Lembab √  Kering

 Turgor : elastis / tidak elastic

 > 2 detik √  < 2 detik

Keluhan lain :
...........................................................................................................................................................................

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

Abdomen
Palpasi: Nyeri Tekan: tidak ada nyeri saat di tekan
Auskultasi: Bising usus: 15x/Menit
Inspeksi : Asites tidak ada lesi
Perkusi : Tympani

Panduan Penyusunan Laporan & Penilaian Kinerja 12

 Muskuloskeletal
 Nyeri otot/tulang, lokasi : intensitas :

 Kaku sendi, lokasi :

 Bengkak sendi, lokasi :
 Fraktur (terbuka/tertutup), lokasi :
 Alat bantu, jelaskan :

 Pergerakan terbatas, jelaskan :

 Keluhan lain, jelaskan :
Nyeri kaki sebelah kanan habis operasi setelah di tabrak kendaraan bermotor
.........................................................................................................................................................................

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

Seksualitas
Aktif melakukan hubungan seksual:..................................................................................................................
..........................................................................................................................................................................................

Penggunaan alat kontrasepsi:..............................................................................................................................

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

Masalah/kesulitan seksual: ....................................................................................................................................

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

Perubahan terakhir dalam frekuensi: ................................................................................................................

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

Wanita:
Usia Menarche :…………… lamanya siklus:……………..durasi:………………..

Periode menstruasi terakhir:……………………..Menopouse:……………………

Melakukan pemeriksaan payudara sendiri: ....................................................................................................

PAP smear terakhir: ..................................................................................................................................................

Pria
Rabas penis :……………………….Gangguan prostat:……………………………
Sirkumsisi :…………………………Vasektomi:…………………………………..

Impoten :…………………………….Ejakulasi dini:………………………………

Panduan Penyusunan Laporan & Penilaian Kinerja 13

V. Program terapi:
Injeksi Ceftriaxon 1 gr
Injeksi Anrain
Ranitidin 50 mg
Pct Infus 1 gr

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

................................................................................................................................................................................................
................................................................................................................................................................................................
Hasil Pemeriksaan Penunjang dan Laboratorium
(dimulai saat anda mengambil sebagai kasus kelolaan, cantumkan tanggal pemeriksaan,

dan kesimpulan hasilnya)

Pemarisaan Hasil unit

Hematologi

Laju endap darah 50 mm/jam

Kimia Klinik

Hemoglobin 13,1 9/dl

Glokosa sewaktu 100 mg/dl

Ureum 36,0 mg/dl

Creatinin 1,2 mg/dl

Sgot 17 u/l

Sgpt 15 u/l

Imuno Serologi

Ab HIV non Reatif

HB Ag non Reatif Coi

Samarinda,......................2023
Perawat

(...............................................)

Panduan Penyusunan Laporan & Penilaian Kinerja 14

VI. Analisa Data

No Data Penunjang Kemungkinan Penyebab Masalah

1. Data Subjektif :
Nyeri pada kaki kanan
dst

Agen Pencedera fisik Nyeri Akut

Data Objektif :
Kesadaran pasien normal terpasang oref di
kaki sebelah kanan
TD : 129/76
N : 78
P : 18
S : 36,3

2. DS:
Pasien mengatakan nyeri saat di
gerakan , pasien menguluh sulit
beraktivitas pasien dibantu oleh
keluarga nya
Gangguan Muskuloketal Gangguan Mobilitas fisik

DO:
Pasien terlihat terbaring di tempat
tidur Pasien susah mengerakkan kaki
sebelah kanan karena nyeri

Panduan Penyusunan Laporan & Penilaian Kinerja 15

 3. DS.
Pasien Mengatakan Nyeri pada bekas
Pada luka operasi saat bergerak

Sirkulasi Integritas kulit

DO.
Terdapat luka Operasi Orif di kaki
kanan tampak bengkak di kaki sebelah
kanan dan tampak berdarah

VII. Diagnosa Keperawatan

1. Nyeri Akut . Pasien Mengatakan nyeri pada kaki di sebelah kanan Pasien dampak meringis, tampak menahan nyeri

2. Gangguan Mobilitas . Pasien Mengatakan Nyeri saat bergerak pasien mengeluh salis bergerak dan beraktivitas dan
pasein terbaring di tempat tidur
3. Gangguan Integritas kulit/jaringan pasien mengatakan nyeri pada bekas luka operasi ssat bergerak kaki kanan
pasien terlihat bengkak

Panduan Penyusunan Laporan & Penilaian Kinerja 16

 RENCANA KEPERAWATAN

DIAGNOSA KEPERAWATAN
NO TUJUAN (NOC)/ (SLKI) INTERVENSI (NIC)/ (SIKI)
/MASALAH KOLABORASI
(NANDA/SDKI)
Nyeri Akut (D.0077) Tingkat Nyeri (L.08066) Manajemen Nyeri (I.08238)
1 Setelah diberikan intervensi keperawatan Observasi :
selama 3x24 jam maka tingkat nyeri menurun 1.1 Identifikasi lokasi karakteristik durasi
Dst Kriteria Hasil frekuensi, kualitas intensitas nyeri.
1. Keluhan nyeri 5 1.2 Identifikasi skala nyeri
2. Meringis 5
1.3 Indentifikasi respon nyeri non verbal .
3. Sikap protektif
4. Gelisah 5
1.4 Identifikasi faktor yang memperberat dan
5. Kesulitan tidur 5 memperingan nyeri
1.5 Identifikasi pengetahuan dan kenyakinan.
Tentang nyeri.
Terapeutik
1.6 berikan teknik nonvarmakologis untuk
megurangi rasa nyeri
1.7 kontrol lingkungan yang memperberat
rasa nyeri
1.8 Fasilitas istirahat dan tidur
Edukasi
1.9 jelaskan penyebab periode, dan pemicu
nyeri
1.10 jelaskan strategi merehkan nyeri
Kolaborasi
1.11 Kolaborasi pemberian analgetik jika
perlu
2 Gangguan Mobilitas fisik (D.0054)
3
Gangguan integritas Kulit
Mobilitas fisik (l.05042)
Setelah diberikan intervensi
keperawatan selama 3x24 jam maka
mobilitas fisik meningkat dengan
kreteria
1.1 pergerakan ektramitas 4 (cukup
meningkat )
1.2 kekuatan otot 4 (cukup meningkat)
1.3 rentang gerak ROM 4 (cukup
menigkat)
1.4 nyeri 5 (menurun)
1.5 kaku sendi 5 (menurun)
1.6 kelemahan fisik 5 (menurun)
Integritas kulit dan jaringan
Setelah dilakukan intervensi keperawatan
3x24jam diharapkan intgritas kulit dan
jaringan menignkat, dengan kriteria hasil :
Nyeri 2 (cukup meningkat)
Kemerahan 2 (cukup meningkat)
Jaringan parut 2 (cukup meningkat)
Nekrosis 2 (cukup meningkat)
Dukungan mobilisasi
Observasi
Identifikasi adanya nyeri atau keluhan fisik
lainnya
Identifikasi toleransi fisik melakukan
pergerakan
Terapeutik
Fasilitasi mobilitas dengan alat bantu
Fasilitasi melakukan pergerakan, jika perlu
Libatkan keluarga untuk membantu pasien
dengan meningkatkan pergerakan
Edukasi
Anjurkan melakukan mobilisasi dini
Ajarkan mobilisasi sederhana yang harus
dilakukan (mis, duduk ditempat tidur)
Jelaskan
Perawatan Integritas Kulit
Observasi
Identifikasi penyebab gangguan integritas
kulit
Terapeutik
Hindari produk berbahan dasar alkohol pada
kulit
Edukasi
Anjurkan menggunakan pelembab
Anjurkan mandi dan menggunakan sabun
secukupnya
Anjurka meningkatkan asupan nutrisi

Perawatan Luka
Observasi
Monitor karakteristik luka
Monitor tanda-tanda infeksi

Terapeutik
Lepaskan balutan dan plaster secara
perlahan
Bersihkan dengan cairan NaCl atau
pembersih nontoksik
Berikan salep yang sesuai kekulit/lesi, jika
perlu
Pasang balutan sesuai jenis luka
Pertahankan teknik steril saat melakukan
perawatan luka

Edukasi
Jelaskan tanda dan gejala infeksi
Anjurkan mengkonsumsi makanan tinggi
protein dan kalori

Panduan Penyusunan Laporan 16

& Penilaian Kinerja
 Catatan Perkembangan

Nama Klien : Umur :

No RM : Ruang :

Hari/Tgl No. Dx Implementasi Evaluasi (SOAP) Paraf

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

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

Panduan Penyusunan Laporan & Penilaian Kinerja 17

Pandua