FORMAT LAPORAN NERS

A. FORMAT LAPORAN PENDAHULUAN

1. DIAGNOSA (MEDIK)
2. ETIOLOGI
3. PATOFISIOLOGI

4. MANIFESTASI KLINIS
5. KLASIFIKASI
6. PENATALAKSANAAN
7. KOMPLIKASI
8. PROGNOSIS
9. WEB OF CAUTION
10. ASUHAN KEPERAWATAN
FOKUS PENGKAJIAN (RIWAYAT KEPERAWATAN,
PEMERIKSAAN FISIK DAN TEST DIAGNOSTIC).
11. DIAGNOSA KEPERAWATAN
12. INTERVENSI KEPERAWATAN (TUJUAN, KRITERIA HASIL,
INTERVENSI DAN RASIONAL).
13. DAFTAR PUSTAKA (TEKS BOOK, JURNAL)

B. FORMAT LAPORAN KASUS (ASUHAN KEPERAWATAN)

I. PENGKAJIAN
1. IDENTITAS PASIEN
1. RIWAYAT KEPERAWATAN
2. PEMERIKSAAN FISIK (POLA GORDON)
3. PEMERIKSAAN PENUNJANG
4. MASALAH KEPERWATAN
II. ANA
LISA DATA
III. DIA
GNOSA KEPERAWATAN
IV. INTE
RVENSI
1. PRIORITAS MASALAH
2. TUJUAN DAN HASIL YANG DIHARAPKAN
3. RENCANA TINDAKAN DAN RASIONAL
V. IMP
LEMENTASI (TINDAKAN KEPERAWATAN, DISCHARGE
PLANNING, LAPORAN TIMBANG TERIMA)
VI. EVA
LUASI / PERKEMBANGAN

PANDUAN POLA FUNGSIONAL KESEHATAN (GORDON)

No Pola Fungsi Data yang harus dikaji
Kesehatan
1 Persepsi Kesehatan Penjelasan mengenai status kesehatannya
dan Managemen Promosi kesehatan: mengatur pola makanan dan
Kesehatan minuman, latihan dan olahraga teratur, gaya hidup yang
dijalankan, manajemen stress.
Persepsi pasien mengenai kesehatan secara umum (baik,
sedang, jelek)
Perlindungan kesehatan
Perlindunga sehatan program skrining, kunjungan pusat
pelayanan kesehatan yang profesional, diet, latihan dan
olah raga, manajemen stress, istirahat, faktor ekonomi.
Pemeriksaan diri sendiri, payudara, testis, tekanan darah
rutin, gula darah, dll
Pengetahuan tentang pemeriksaan diri sendiri.
Riwayat penyakit sebelumnya (alergi, penyakit,
pembedahan, penyakit kronis, riwayat medis keluarga)
Apa yang diketahui mengenai penyakitnya? Tindakan
yang dilakukan untuk mengurangi tanda dan gejala.
Hasilnya bagaimana?
Riwayat imunisasi
Perokok dan menggunakan alkohol.
Hal yang dilakukan untuk menjaga kesehatan (merokok,
menggunakan obat-obatan atau pemeriksaan
SADARI????
Perilaku untuk mengatasi masalah kesehatan: diet, latihan
dan olah raga, pengobatan.
Berpartisipasi dalam perawatan kesehatan
Sedang dalam masa pengobatan penyakit (mendapatkan
obat-obatan)
Kecelakaan (dirumah, kerja dan berkendara)
Safe environtment, detektor asap rokok, dll.

Pemeriksaan: penampilan keadaan umum secara lengkap.

2 Nutrisi dan Kebiasaan jumlah makan dan minuman ringan (snack).

Metabolisme
 jenis dan jumlah makanan dan minuman sehari-hari
(jelaskan)
Frekuensi makan dan minum (pola makan 3 hari terakhir
atau 24 jam terakhir)
Suplemen yang digunakan (vitamin, tipe snack)
Kepuasan akan berat badan
Faktor-faktor yang berhubungan: aktivitas yang
dilakukan, penyakit (akut/kronis) dan stress.
Faktor pencernaan:
- Nafsu makan, rasa nyaman saat makan, kesulitan
menelan, mual/muntah, alergi makanan.
Riwayat yang berhubungan dengan masalah
fisik/psikologis (diet, masalah kulit; lesi, kering,
penyembuhan luka yang lama).
Masalah pada gigi.
Pemeriksaan:
- Berkaitan dengan keadaan umum, kulit, rambut, kuku,
abdomen.
- Kaji penampilan umum ( well nourished, well developed,
over weight, under weight )
- Kulit: bony prominence, lesi, perubahan warna,rash,
scars, ekimosis, diaporesis kelembaban.
- Membran mukosa: warna, kelembaban, lesi
- Kaji braden scale
- Gigi: penampilan umum, gigi yang hilang.
- TB, BB dan BMI
- Suhu tubuh
- Monitoring gula darah
- IV dan parenteral (jenis, jumlah).
- Kaji turgor kulit
- Monitor body temperature
- Observasi kondisi mulut, bibir, mebran mukosa, Lidah
(warna dan kebersihannya)
- Observasi kondisi gigi, ada / tdk masalah gusi,
perdarahan
- Lihat integritas rambut dan kuku
- Catat intake oral dan cairan intravena

3 Eliminasi Kebiasaan pola BAK:

- Frekuensi, warna, jumlah, warna, bau, nyeri, nocturia,
kemampuan mengontrol BAK dan perubahan lainnya.
- Penggunaan alat bantu urine catheter, ureterostomy.

Kebiasaan pola BAB:

Frekuensi, warna, jumlah, warna, jumlah, konsistensi,
nyeri, obstipasi, konstipasi, kemampuan mengontrol
 BAB dan perubahan lainnya.
- Penggunaan laksatif/enema
- Penggunaan alat bantu ekstrotory: drainage, suction,
colcostomy dll.
Kemampuan perawatan diri: kebersihan diri dan kamar
mandi.

Pemeriksaan
- Ada indikasi: pemeriksaan urine/ feses/warna drainage
dan konsistensi.
- Pemeriksaan fisik (Inspeksi, Palpasi, Perkusi,
Auskultasi) yang berkaitan dengan: abdomen, genitalia
dan prostat
- Abdomen: termasuk inspeksi abdomen, peristaltik
usus, flatus, softnes, distensi, massa, hemoroid, drain
atau alat bantu lain.

4 Aktivitas dan Latihan Muskuloskeletal

Aktivitas yang dilakukan setiap hari.
Pola latihan?? Tipe? Reguler??
Latihan pada saat waktu senggang? Anak-anak: bermain.
Tidak mempunyai tenaga untuk melakukan aktivitas?
Riwayat yang berhubungan dengan masalah
fisik/psikologis: deformitas, amputasi.
Kemampuan perawatan diri untuk:
Makan, berpakaian, memasak, mandi, toileting,
mobilisasi, bed mobility dan home maintenance.
Functional Level Codes:
- Level 0: mandiri
- Level I: menggunakan alat bantu
- Level II: menggunakan bantuan atau observasi dari
orang lain
- Level III: menggunakan bantuan atau observasi dari
orang lain dan menggunakan alat bantu
- Level IV: tergantung total
Penggunaan alat bantu: kruk, prostetik, kursi roda,
tongkat dll.

Cardiovaskuler
Nadi (teratur/tidak)
Tekanan darah
Ekstermitas:
Suhu, capilarry refill, Homans sign, warna kuku,
distribusi rambut (normal/abnormal).

Respirasi
 Inspeksi dada
- Pernafasan (rate, kedalaman, regular/irregular, dyspnea)
- Batuk: kering/sputum
Auskultasi dada (crackles, ronchi, friction rub, rales,
wheezing)
Palpasi dan Perkusi
Chest tube, trakeostomy.
Oksigenasi

Neurologi

Pemeriksaan:
- Pengkajian perkembangan fisik
- Pemeriksaan fisik
- Mendemonstrasikan kemampuan untuk:
- Makan, berpakaian, memasak, mandi, belanja, toileting,
mobilisasi, bed mobility dan home maintenance.
- Skala kekuatan otot
- Kemampuan untuk merawat diri: berpakaian, mandi,
kekamar mandi, makan.

Aktivitas 0 1 2 3 4
Makan
Mandi
Berpakaian
Toileting
Mobilisasi
ditempat tidur
Ambulasi
Keterangan :
4 : Mandiri
3 : Membutuhkan Alat Bantu
2 : Membutuhkan Pertolongan (Bantuan, Pengawasan)
1 : Membutuhkan Pertolongan dan Alat Bantu
0 : Ketergantungan
5 Tidur dan Istirahat Kebiasaan tidur sehari-hari:
Jumlah/lama waktu tidur
Jam tidur dan bangun
Kegiatan yang dilakukan sebelum tidur (membaca,
nonton TV, mandi, mendengarkan musik dll)
Lingkungan saat akan tidur (gelap, terang tenang, ramai
dll)
 Tingkat kesegaran sebelum tidur.
Menggunakan obat tidur
Gangguan saat tidur? Mimpi buruk, terbangun awal
Persepsnggi terhadap kualitas dan kuantitas tidur.

Pemeriksaan:
- Observasi keadaan umum

6 Kognitif dan Persepsi Menggambarkan penginderaan khusus: penglihatan,

pendengaran, rasa, sentuh, bau.
Penggunaan alat bantu: kaca mata, alat bantu dengar.
Perubahan dalam penglihatan, pendengara, perasa,
pembau.
Tingkat kesadaran
Mood (subjektive), afek (objektive)
Perubahan/penurunan fungsi dalam penginderaan.
Tingkat orientasi: orang, waktu, tempat.
Persepsi dan manajemen nyeri (skala, lokasi,
waktu/durasi, karakteristik)
Kapan nyeri yang dirasakan?
Faktor pencetus nyeri?
Faktor yang mengurangi nyeri?
Fungsi kognisi dalam memori istilah, ingatan jangka
pendek, ingatan jangka panjang
Komunikasi; bahasa utama, bahasa lain, tingkat
pendidikan, kemampuan membaca dan menulis
Kemampuan memecahkan masalah dan mengambil
keputusan.
Mengidentifikasi kehilangan/perubahan yang besar
dalam hidup.

Pemeriksaan:
- Test Orientasi: waktu, tempat dan orang.
- Test membaca dan berkomunikasi
- survey keadaan umum, panca indra & neurologis

7 Persepsi Diri dan Penampilan/keadaaan.

Konsep Diri keadaan sosial : pekerjaan , situasi keluarga, kelompok
sosial.
identitas personal : penjelasan tentang diri sendiri,
 kekuatan dan kelemahan yang dimiliki
keadaan fisik : segala sesuatu yang berkaitan dengan
tubuh, yang disukai dan tidak disukai.
harga diri ; perasaan mengenal diri sendiri, penilaian diri
sendiri.
Perubahan dalam tubuh yang tidak dapat diterima.
Masalah pada pasien.
Ancaman terhadap konsep diri : Perubahan yang
dirasakan pada diri sendiri semenjak sakit, perubahan
peran
Pemeriksaan:
- Survey keadaan umum

8 Peran dan Hubungan Gambaran mengenai peran yang berkaitan dengan

keluarga, teman-teman dan rekan. kerja
Kepuasan/ketidak puasan menjalankan peran
Efek terhadap status kesehatan
Pentingnya keluarga
Struktur dan dukungan keluarga
Proses pengambilan keputusan dalam keluarga Tinggal
bersama keluarga/sendiri.
Masalah dan/keprihatinan dalam keluarga
Pola membesarkan anak
Status pekerjaan.
hubungan dekat dan Hubungan dengan orang lain
Interaksi bersama keluarga
Berpartisipasi dalam kegiatan sosial
Apakah penyakit dapat menyebabkan perubahan yang
sangat besar terhadap pola peran dan hubungan.
Merasa kecukupan akan kondisi sosial ekonomi
(keuangan).
Merasa (terisolasi) oleh tetangga sekitar.

Pemeriksaan:
- survey keadaan umum
- Interaksi dengan anggota keluarga atau orang lain
(jika ada).

9 Seksualitas dan Masalah atau problem seksual

Reproduksi Gambaran perilaku seksual: perilaku seksual yang
aman.
Penggunaan alat kontrasepsi? Riwayat Keluarga
Berencana:
- Pernah/ tidak pernah menggunakan alat kontrasepsi
 - Jenis kontrasepsi yang digunakan (kapan mulai
menggunakan kontrasepsi tersebut, keluhan yang
dialami selama menggunakan alat kontrasepsi
tersebut
Pengetahuan tentang seksualitas dan reproduksi
Dampak pada status kesehatan
Wanita
- Waktu punya anak, Riwayat menstruasi : umur
menarche, durasi, frekwensi, keteraturan, masalah
- Riwayat reproduksi, hamil terakhir, Riwayat
melahirkan kembar, kelaianan congenital atau
kelainan genetic
Cara mencegah penularan PMS
Riwayat PMS
Persepsi pemeriksaan payudara sendiri (SADARI) dan
testis sendiri.

Pemeriksaan:
- Pemeriksaan genitalia, payudara dan rektum.

10 Koping dan Perubahan besar dalam hidup dalam 1-2 tahun ini.
Managemen Stress Penyebab stress belakangan ini
Gambaran umum dan spesifik respon
Perubahan, masalah saat ini, kejadian yang menyebabkan
stress atau perhatian
Krisis saat ini missal; sakit atau hospitalisasi
Tingkat stress saat ini
Metode/strategi koping yang biasa digunakan terhadap
stress selain alcohol atau obat
Pengetahuan dan penggunaan tehnik managemen stress.
Hubungan antara manajemen stres terhadap dinamika
keluarga.
Derajat kesuksesan dari strategi koping saat ini
Persepsi dari tingkat toleransi stress
Ketika mendapatkan masalah yang besar dalam hidup,
apakah dapat menanganinya?
Persepsi tentang status keamanan di rumah (episode
kekerasan fisik/emosional)
11 Nilai dan Agama
Kepercayaan Latar belakang budaya/etnik
Tujuan kehidupan, apa yang dianggap penting bagi klien
dan keluarga.
Keparcayaan spiritual yang berpengaruh terhadap
pengambilan keputusan dan praktek kesehatan
Derajat dari tujuan pencapaian hidup
 Persepsi tentang kepuasan dengan hidup, dan jalan hidup
Pentingnya agama/spiritualitas
Kepercayaan cultural yang berpengaruh dengan
kesehatan dan nilai
Spiritualitas/agama yang berpengaruh terhadap status
kesehatan.
Kepercayaan cultural yang merefleksikan pilihan pada
promosi kesehatan dan pencegahan penyakit

Keluhan utama saat pengkajian :

Keluhan yang dirasakan pasien saat melakukan pengkajian

Riwayat kesehatan :
Riwayat Kesehatan/Penyakit sekarang :
Riwayat atau kronologi, tindakan yang sudah dilakukan, terapi yang diberikan pada
pasien, dari awal munculnya gejala, sampai pasien dibawa ke rumah sakit.
Riwayat Kesehatan/Penyakit dahulu :
Penyakit yang pernah diderita pasien dan atau penyakit yang berhubungan dengan penyakit
pasien saat ini, riwayat tindakan medis, riwayat obat yang pernah di konsumsi, riwayat
alergi pasien.
Riwayat Kesehatan/Penyakit keluarga :
Penyakit yang pernah diderita keluarga dan atau penyakit yang berhubungan dengan
penyakit pasien saat ini,
Genogram :
Susunan anggota keluarga yang dibuat dalam bentuk diagram dengan definisi bentuk-
bentuk tertentu ( laki2: kotak, perempuan: bulat) minimal 3 generasi.
 FORMAT PENGKAJIAN
KEPERAWATAN MEDIKAL BEDAH

Nama Preceptee
NIM
RS/ Ruangan
Tanggal Pengkajian
Jam Pengkajian

IDENTITAS PASIEN
Nama Pasien
Umur
No. Register
Jenis Kelamin
Suku Bangsa
Pekerjaan
Pendidikan
Alamat

Tanggal MRS
Diagnosa Medis

STATUS KESEHATAN
Keluhan saat MRS
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Keluhan utama saat pengkajian :

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Riwayat kesehatan :
1. Riwayat Kesehatan/Penyakit sekarang :
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2. Riwayat Kesehatan/Penyakit dahulu :

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3. Riwayat Kesehatan/Penyakit keluarga :
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4. Genogram
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5. Vital Signs:

Tekanan Darah : ................................................... ..

Frekuensi Pernapasan : ................................................... ..
Temperature : ................................................... ..
Nadi : ................................................... ..
Berat Badan : ................................................... ..
Tinggi Badan : ................................................... ..
Analysis of nutritional status:
Weight less
Normal weight
Overweight
 Risk of Obesity
Obesity
Obesity II

POLA FUNGSI KESEHATAN :

1. Pola penatalaksanaan kesehatan / persepsi sehat
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Pemeriksaan fisik yang menunjang
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Masalah Keperawatan
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2. Pola Nutrisi Metabolik

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Pemeriksaan fisik yang menunjang
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Masalah Keperawatan
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3. Pola Eliminasi
a. Eliminasi Alvi
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Pemeriksaan fisik yang menunjang

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b. Eliminasi Uri
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Pemeriksaan fisik yang menunjang

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Masalah Keperawatan
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4. Pola Istirahat dan tidur

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Pemeriksaan fisik yang menunjang

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Masalah Keperawatan
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5. Pola Aktifitas - Latihan

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Pemeriksaan fisik yang menunjang
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Masalah Keperawatan
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6. Pola kognitif perseptual keadekuatan alat sensori

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Pemeriksaan fisik yang menunjang
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Masalah Keperawatan
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7. Pola konsep diri dan persepsi diri

Pola persepsi
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Konsep diri
a. Gambaran diri
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b. Harga diri
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 c. Ideal diri
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d. Peran diri
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e. Identitas diri
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Masalah Keperawatan
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8. Pola Reproduksi Seksual

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Pemeriksaan fisik yang menunjang

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Masalah Keperawatan
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9. Pola hubungan peran

Persepsi klien tantang pola hubungan

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Persepsi klien tentang peran dan tanggung jawab

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Masalah Keperawatan
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10. Mekanisme Koping

Kemampuan mengendalian stress

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Sumber pendukung
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Masalah Keperawatan
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11. Pola tata nilai dan kepercayaan

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Masalah Keperawatan
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PEMERIKSAAN PENUNJANG

1. Pemeriksaan Laboratorium
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2. Pemeriksaan Radiologi
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3. Pemeriksaan Lain lain

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4. Terapi dan Diet.

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DAFTAR MASALAH KEPERAWATAN

1
2
3
4
5
6
7

Surabaya,
Preceptee

(.)
 ANALISA DATA

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

DATA ETIOLOGI PROBLEM

 DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

Nama Pasien : No. Register :

Umur : Diagnosa Medis :
NO DIAGNOSA KEPERAWATAN TTD
 RENCANA KEPERAWATAN

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

NO DIAGNOSA TUJUAN KRITERIA HASIL INTERVENSI RASIONAL

KEPERAWATAN
 IMPLEMENTASI

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

TANGGAL / JAM IMPLEMENTASI TTD

 EVALUASI

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

TGL / DIAGNOSE EVALUASI

JAM KEPERAWATAN