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BUKU PANDUAN PRAKTIK KLINIK KEPERAWATAN KEPERAWATAN MEDIKAL BEDAH
”ISLAMI, BERKEMAJUAN DAN INOVATIF”
PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KESEHATAN IKesT MUHAMMADIYAH PALEMBANG 2020 Panduan Praktik Klinik KMB
1
DAFTAR MAHASISWA PSIK IKesT MUHAMMADIYAH PALEMBANG PRAKTIK KLINIK KEPERAWATAN MEDIKAL BEDAH 21 Desember – 8 Januari 2020
No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
Nama Nyayu Hamidah Agustina Aef Abdul Hidayat Afri Yani Ahmad Buchori Aldi Firmansyah Alvin Juniawan Amalia Rosa Kencana Amirul Hajj Andi Apriyanti Andre Gibran Andri Kurniawan Anggi Wahyuni Putri Anisa Dwi Rizki Safitri Anom Budi Widjaya Aprilia Dwi Andani Ario Suganda Arista Reresari Atika Nurfitria Atika Syuri Ayu Yulia Barlian Bayu Yudha Samudra Cici Mulyani Cissinstia Putri Damayanti Citra Andera Putri Citra Mega Tazmadi Dea Surya Kartika Dede Setiawan Dela Amelia Nur Saleha Della Apriyanti Desta Elfani Deta Arinda Putri Dhora Surya Amanda Diana Novita Diki Anuwari Dimas Prayoga Dini Yuliarti Dinny Dwi Haryanti Duwi Marda Lenny Dwi Mega Lestari Dwi Pawestri Handayani Dwi Putra Setiawan Panduan Praktik Klinik KMB
NIM 21117001 21117003 21117004 21117006 21117007 21117008 21117009 21117010 21117011 21117012 21117013 21117014 21117015 21117016 21117017 21117018 21117019 21117020 21117021 21117022 21117023 21117024 21117025 21117026 21117027 21117028 21117029 21117030 21117031 21117032 21117033 21117034 21117035 21117037 21117038 21117039 21117040 21117041 21117042 21117043 21117044 21117045
Kelas A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A 2
Pembimbing Yulius Tiranda, P.hD
Sukron, S.Kep.Ns, MNS
Suratun, S.Kep.Ns, M.Kep
Sukron, S.Kep.Ns, MNS
Yulius Tiranda, P.hD
43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92
Eka Kurnia Sari Eka Neviana Meri Rizki Sani Ella Rusnida Enjel Fanecha Difa Ersunni Anti Es Jumiati Feni Wulandari Fuji Lestari Geryl Genoneva Frans Gian Anggraini Gina Hartina Hani Nur Azizah Batubara Helison Heni Bayu Putri Heny Anggraini Hermawati Hesti Yuniarti Hondini Pratama Icha Ilhami Nadion Indah Ayu Hoca Jeihan Archya Karina Aurellia Hidaya Kartika Ulfa Alfiyah Larisa Lestari Ningsih Liza Apriani Ludiya M. Lutfi Ricky Pratama M. Ikhlas Kesatria Pratama Mareta Sari Mawar Anggela Meireza Mentari Damaiyanti Mifta Huljannah Mirza Alepandi Monica Ayu Stevani Mutiara Fransiska Nasri Morsalin Nila Wahyuni Nur Azizah Nursyamsi Oktariani Nurul Hidayah Nurul Maesya Pariska Rahma Dia Popy Pratama Rahma Arifah Putri Rahmadiya Rendra Ramadhoni Panduan Praktik Klinik KMB
21117046 21117047 21126109 21117048 21117049 21117050 21117051 21117053 21117054 21117055 21117056 21117057 21117058 21117059 21117060 21117062 21117063 21117064 21117065 21117066 21117067 21117068 21117070 21117071 21117072 21117073 21117074 21117075 21117076 21117077 21117078 21117079 21117080 21117081 21117082 21117083 21117084 21117085 21117086 21117087 21117088 21117089 21117090 21117091 21117092 21117093 21117094 21117095 21117096 21117097
A A A B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B
Suratun, S.Kep.Ns, M.Kep
Sukron, S.Kep.Ns, MNS
Suratun, S.Kep.Ns, M.Kep
Yulius Tiranda, P.hD
Suratun, S.Kep.Ns, M.Kep
3
93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134
Ranti Agustini Raudhiatul Azzahra Ridia Lokarina Ririn Agustin Rizky Amrin Sidiq Safitri Selvi Suci Hayati Seni Mariska Sheli Sulistia Ningsih Shelly Nugraha Shindi Prima Utami Shinta Prima Dewi Sici Safitri Siti Jamilah Sri Inda Rahayu Sri Wahyuni Susanti Suwindri Syarah Huda Tasya Tia Novelia Tiara Amelia Tias Ridho Perdana Tinne Agustien Herda Tinti Tri Cahyani Tuti Dwi Sopiyati Vickha Septiany Wella Oktarama Weni Dwi Cahyani Weny Kusuma Widya Winda Claudya Novayanti Windah Anisyah Windy Puspita Utami Wisma Wardani Yeni Septiani Yola Alfina Yolanda Dwi Nita Yosa Nanda Fermata Yuli Nopita Sari Yuti Sartika
Panduan Praktik Klinik KMB
21117098 21117099 21117100 21117101 21117102 21117103 21117104 21117105 21117106 21117107 21117108 21117110 21117111 21117112 21117113 21117114 21117115 21117116 21117117 21117118 21117119 21117120 21117121 21117122 21117123 21117124 21117125 21117128 21117129 21117130 21117131 21117132 21117133 21117134 21117135 21117136 21117137 21117138 21117139 21117140 21117141 21117142
C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C
Yulius Tiranda, P.hD
Sukron, S.Kep.Ns, MNS
Yulius Tiranda, P.hD
Suratun, S.Kep.Ns, M.Kep
Sukron, S.Kep.Ns, MNS
4
Penugasan Praktik Klinik KMB (21 Desember 2020 – 8 Januari 2021) NO 1
PENUGASAN KETERANGAN 2 resume kuliah pakar ( Ujian Resume dibuat setelah kuliah pakar dengan tema: resume 1 dan resume 2)
1. Perawatan Luka Pada Pasien Covid-19 oleh Bpk. Jhon Peri, S.Kep, Ns, M.Kep, Praktisi Rumah Sakit Dr. Rivai Abdullah Palembang. 2. Menejemen Nyeri Pada Pasien Fraktur oleh : Ibu. Romlah Dewi, S.Kep.Ns, M.Kes, Praktisi Rumah Sakit Muhammadiyah Palembang
2
1 Laporan Pendahuluan (Ujian LP akan dibagikan oleh pembimbing masing-masing
3 4
Pre dan Post), 1 Laporan Kasus (1x ujian) 10 Kompetensi (1 x ujian)
sesuai dengan kasus kasus akan dibagikan oleh pembimbing masing-masing 10 kompetensi akan dibagikan melalui video beserta daftar tiliknya, kemudian mahasiswa ujian 1 kompetensi yang dipilih secara acak oleh pembimbing. Palembang, Desember 2020 Penanggung Jawab dto Sukron, S.Kep.Ns, MNS NBM: 1268645
Panduan Praktik Klinik KMB
5
LAPORAN LENGKAP PRAKTIK KLINIK KEPERAWATAN MEDIKAL BEDAH
Oleh : NAMA
:
NIM
:
PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KESEHATAN IKesT MUHAMMADIYAH PALEMBANG 2020
Panduan Praktik Klinik KMB
6
LAPORAN PENDAHULUAN “ASUHAN KEPERAWATAN PASIEN ..............................”
Oleh : NAMA
:
NIM
:
PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KESEHATAN IKesT MUHAMMADIYAH PALEMBANG 2020
Panduan Praktik Klinik KMB
7
LAPORAN PENDAHULUAN PRAKTIK KEPERAWATAN KMB IKesT MUHAMMADIYAH PALEMBANG JUDUL KASUS 1. 2. 3. 4. 5. 6. 7. 8.
9.
Definisi Penyakit Etiologi Anatomi dan Fisiologi (dilengkapi gambar) Patofisiologi dan Patoflow Manifestasi klinik Pemeriksaan penunjang Penatalaksanaan Medis dan Keperawatan Asuhan Keperawatan (Teoritis) a. Pengkajian teoritis (Primary Survey dan Secondary Survey) b. Diagnosa Keperawatan c. Nursing Care Plan (NCP) terdiri dari Tujuan/Outcome (NOC) dan Intervensi (NIC) Daftar Pustaka
Panduan Praktik Klinik KMB
8
Lampiran Formulir Asuhan Keperawatan/Status Klinis
PENGKAJIAN FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KEPERAWATAN MEDIKAL BEDAH IKesT MUHAMMADIYAH PALEMBANG I.
Identitas Klien Inisial Klien Usia Jenis Kelamin Alamat No telepon Status Agama Suku Pendidikan Pekerjaan Lama bekerja
II.
:
……………………
: : : : : : : : : :
…………………… …………………… …………………… …………………… …………………… …………………… …………………… …………………… …………………… ……………………
No RM Tgl. Masuk Tgl. Pengkajian Sumber informasi Keluarga terdekat Alamat & No telp Diagnosa Medis
: : : : : : :
…………………… …………………… …………………… …………………… …………………… …………………… .................................
Riwayat Kesehatan A. Status Kesehatan Saat Ini Keluhan utama
: …………………………………………………................……….. : ………………………………………………………….................. …………………………………………………………..................
Faktor Predisposisi
: ………………………………………………………….................. : …………………………………………………………................ …………………………………………………................……….. ………………………………………………………….................. …………………………………………………………..................
Faktor Presipitasi
………………………………………………………….................. : …………………………………………………................……….. ………………………………………………………….................. ………………………………………………………….................. …………………………………………………………..................
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B. Riwayat Kesehatan Saat Ini (PQRST) Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ..........................................................................................................................................................................
C. Riwayat Kesehatan Terdahulu 1. Penyakit yang pernah dialami:
2.
a.
Kecelakaan
:…....………………………………
b.
Operasi (jenis dan waktu
:……………………………………
c.
Penyakit (kronis dan akut)
:……………………………………
d.
Terakhir masuk RS
: ……………………………………
Alergi (obat, makanan, plester, dsb) ………………………………………………………………………………………………………….. ………………………………………………………………………………………………………….
3.
Kebisasaan
4.
a. Merokok : ………………….. b. Kopi : ………………….. c. Alkohol : ………………….. Obat-obatan yang digunakan
Jenis
Frekuensi
Jenis ……………………….. …………………..........
Jumlah ………………….. ………………….. …………………..
Lamanya ……………………….. …………………...........
Lamanya ………………….. ………………….. …………………..
Dosis ……………………….. …………………..........
D. Riwayat Keluarga ..........................................................................................................................................................................
Panduan Praktik Klinik KMB
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.......................................................................................................................................................................... Genogram
E. Catatan Penanganan Kasus (Dimulai saat pasien di rawat di ruang rawat sampai pengambilan kasus kelolaan) .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ..........................................................................................................................................................................
III. Pengkajian Keperawatan (12 Domain NANDA) 1. Peningkatan Kesehatan Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ........................................................................................................................................................................
2. Nutrisi Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........…..
Panduan Praktik Klinik KMB
11
Masalah keperawatan: ........................................................................................................................................................................
3. Eliminasi Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ........................................................................................................................................................................ 4. Aktivitas/Istirahat Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ........................................................................................................................................................................
5. Persepsi/Kognitif Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ........................................................................................................................................................................
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6. Persepsi Diri Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ........................................................................................................................................................................
7. Peran Hubungan Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ........................................................................................................................................................................
8. Seksualitas Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ........................................................................................................................................................................
9. Toleransi/Koping Stress
Panduan Praktik Klinik KMB
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Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ........................................................................................................................................................................
10. Prinsip Hidup Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ........................................................................................................................................................................
11. Keselamatan/Perlindungan Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ........................................................................................................................................................................
12. Kenyamanan
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14
Data Subjektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........…..
Data Objektif
: …………………………………………………................……...........….. …………………………………………………................……...........….. …………………………………………………................……...........….. Masalah keperawatan: ........................................................................................................................................................................
IV. Pengkajian Review of System dan Pemeriksaan Fisik 1.
Sistem Respirasi a. Data Subjektif
......................................................................................................................................... ......................................................................................................................................... b. Data Objektif Inspeksi
: …………………………………………………................……...........…...........
Palpasi
: …………………………………………………................……...........…..
Perkusi
: …………………………………………………................……...........…..
Auskultasi
: …………………………………………………................……...........…. Masalah keperawatan: ........................................................................................................................................................................
2.
Sistem Kardiovaskuler a.
Data Subjektif
......................................................................................................................................... ......................................................................................................................................... b.
Data Objektif Inspeksi
: …………………………………………………................……...........…...........
Palpasi
: …………………………………………………................……...........…..
Perkusi
: …………………………………………………................……...........….. 15 Panduan Praktik Klinik KMB
Auskultasi : Masalah keperawatan:
…………………………………………………................……...........….
........................................................................................................................................................................
3.
Sistem Persarafan a.
Data Subjektif
......................................................................................................................................... ......................................................................................................................................... b.
Data Objektif XII Syaraf Cranial
: …………………………………………………................……
Refleks Fisiologis
: …………………………………………………................……
Refleks Patologis
: …………………………………………………................…
Masalah keperawatan: ........................................................................................................................................................................
4.
Sistem Perkemihan a.
Data Subjektif
......................................................................................................................................... ......................................................................................................................................... b.
Data Objektif Inspeksi
: …………………………………………………................……...........…...........
Palpasi
: …………………………………………………................……...........…..
Perkusi
: …………………………………………………................……...........…..
Auskultasi
: …………………………………………………................……...........…. Masalah keperawatan: ........................................................................................................................................................................
5.
Sistem Pencernaan a.
Data Subjektif
......................................................................................................................................... Panduan Praktik Klinik KMB
16
......................................................................................................................................... b.
Data Objektif Inspeksi
: …………………………………………………................……...........…...........
Palpasi
: …………………………………………………................……...........…..
Perkusi
: …………………………………………………................……...........…..
Auskultasi
: …………………………………………………................……...........…. Masalah keperawatan: ........................................................................................................................................................................
6.
Sistem Muskuloskeletal a. Data Subjektif
......................................................................................................................................... ......................................................................................................................................... b.
Data Objektif Inspeksi
: …………………………………………………................……...........…...........
Palpasi
: …………………………………………………................……...........…..
Masalah keperawatan: ........................................................................................................................................................................ ........................................................................................................................................................................ 7.
Sistem Integumen a.
Data Subjektif
......................................................................................................................................... ......................................................................................................................................... b.
Data Objektif Inspeksi
: …………………………………………………................……...........…...........
Palpasi
: …………………………………………………................……...........…..
Masalah keperawatan: ........................................................................................................................................................................
8.
Sistem Endokrin
Panduan Praktik Klinik KMB
17
a.
Data Subjektif
......................................................................................................................................... ......................................................................................................................................... b.
Data Objektif Inspeksi
: …………………………………………………................……...........…...........
Palpasi
: …………………………………………………................……...........…..
Masalah keperawatan: ........................................................................................................................................................................
9.
Sistem Penginderaan a.
Penglihatan 1) Data Subjektif
......................................................................................................................................... ......................................................................................................................................... 2) Data Objektif Inspeksi
: …………………………………………………................……...........…...........
Palpasi
: …………………………………………………................……...........…..
Masalah keperawatan: ........................................................................................................................................................................
b.
Pendengaran 1) Data Subjektif
......................................................................................................................................... ......................................................................................................................................... 2) Data Objektif Inspeksi
: …………………………………………………................……...........…...........
Palpasi
: …………………………………………………................……...........…..
Panduan Praktik Klinik KMB
18
Masalah keperawatan: ........................................................................................................................................................................ ........................................................................................................................................................................ c.
Penghidu 1) Data Subjektif
......................................................................................................................................... ......................................................................................................................................... 2) Data Objektif Inspeksi
: …………………………………………………................……...........…...........
Palpasi
: …………………………………………………................……...........…..
Masalah keperawatan: ........................................................................................................................................................................ ........................................................................................................................................................................ c.
Pengkajian Psikososial
a.
Persepsi klien terhadap penyakitnya ................................................................................................................................................................. .................................................................................................................................................................
Masalah keperawatan: ........................................................................................................................................................................ ........................................................................................................................................................................ b.
Reaksi saat interaksi Kooperatif…………
Tidak kooperatif………….
Jelaskan :
......................................................................................................................................... ......................................................................................................................................... Masalah keperawatan: ........................................................................................................................................................................ ........................................................................................................................................................................ c.
Status emosional Tenang……..
Cemas……
Menarik Diri…
.
Marah…….
… Tidak sabar……
lainnya:…………..
Jelaskan :
Panduan Praktik Klinik KMB
19
......................................................................................................................................... V.
Pemeriksan Penunjang (Laboratorium, Radiologi, Ekg dll). Tanggal Pemeriksaan:
VI. Terapi
No
Nama Obat
Dosis
Golongan
Rute
Indikasi
Kontraindikasi
ANALISA DATA DATA/PROBLEM
ETIOLOGI
MASALAH KEPERAWATAN
DAFTAR MASALAH KEPERAWATAN 1....................................................................................................................... 2....................................................................................................................... 3........................................................................................................................
PRIORITAS MASALAH KEPERAWATAN 1.
......................................................................................................................
2.
......................................................................................................................
3.
......................................................................................................................
Panduan Praktik Klinik KMB
20
.
DIAGNOSA KEPERAWATAN (PES) 1.
......................................................................................................................
2.
......................................................................................................................
3.
......................................................................................................................
Panduan Praktik Klinik KMB
21
.
RENCANA KEPERAWATAN Nama pasien : Umur : Jenis kelamin: N Diagnosa Keperawatan o
Tujuan dan Kriteria Hasil NOC :................................................................
Rencana keperawatan Intervensi NIC :.................................................
1.
1.
2.
2.
3.
1
3.
4.
2
4.
5.
3 4 5
5.
No Kriteria
Awal Tujuan
Indikator : 1 Gangguan ekstrem 2 Berat 3 Sedang 4 Ringan 5 Tidak ada gangguan
IMPLEMENTASI& EVALUASI KEPERAWATAN Panduan Praktik Klinik KMB
Rasional
22
Nama pasien Umur No.
: : DIAGNOSA
Hari, Tgl &Jam
IMPLEMENTASI
Hari, Tgl &Jam
EVALUASI S:
O:
A:
P:
I:
Panduan Praktik Klinik KMB
23
PARA F
EVALUASI / CATATAN PERKEMBANGAN Nama pasien Umur Jenis kelamin No RM
DIAGNOSA
: : : : TANGGAL & WAKTU
EVALUASI S : O : A : P :
Panduan Praktik Klinik Keperawatan Gawat darurat
PARAF
FORM PRE CONFERENCE
Name of Student : Advisor : Time : No.
Room : Date: Performance
Score
Score of
Pre Conference
1
The preface report
1. Definition
70
10
The input applying (respond, opinion, idea towards the problem in discussion ) ( pemberian masukan : tanggapan, pendapat, ide terhadap hal yang didiskusikan )
10
The respond applying (cognitive and active) towards the given input ( pemberian respon : kognitif dan aktif, terhadap masukan yang diberikan)
10
2. Etiology 3. Clinical Manifestation 3. Pathofisiology 4. Complication 5. Implementation 6. Pathways 7. Observation Chart : a.
Assessment
b.
DX nursing
c.
Nursing Intervention
2 3 4
The result delivery from completely observation chart. ( penyampaian hasil dari asuhan keperawatan yang telah dilakukan)
Rating : Based on system or rating standard in clinic Stikes Muhammadiyah Palembang , namely : A ≥ 80, B = 70-79, C =56-69, D= 40-55, E ≤ 40 Preceptor
……………………………
Panduan Praktik Klinik Keperawatan Kritis
Evidence
FORM POST CONFERENCE Name of Student : Advisor : Time :
Room : Date:
No.
Performance
Score
Score of Post Conference
The preface report 1
1. Definition
70
10
2. Etiology 3. Clinical Manifestation 3. Pathofisiology 4. Complication 5. Implementation 6. Pathways 7. Observation Chart : a.
Assessment
b.
DX nursing
c.
Nursing Intervention
2
The result delivery from completely observation chart. ( penyampaian hasil dari asuhan keperawatan yang telah dilakukan)
3
The input applying (respond, opinion, idea towards the problem in discussion ) ( pemberian masukan : tanggapan, pendapat, ide terhadap hal yang didiskusikan )
4
The respond applying (cognitive and active) towards the given input ( pemberian respon : kognitif dan aktif, terhadap masukan yang diberikan)
10
10
Rating : Based on system or rating standard in clinic Stikes Muhammadiyah Palembang , namely : A ≥ 80, B = 70-79, C =56-69, D= 40-55, E ≤ 40 Preceptor
……………………………
Panduan Praktik Klinik Keperawatan Kritis
Evidence
FORM SCORING CASE REPORT LAPORAN PENILAIAN LAPORAN KASUS Student’s Name NPM Day/Date Time No. 1.
2.
3.
4.
5.
: : : : Scoring aspects (Aspek yang dinilai)
Assestment (Pengkajian) 1. Collecting the subjective and objective data (Mengumpulkan data subyektif dan obyektif) 1. Writing type of data completely (Menuliskan jenis data secara lengkap) 2. Completing the writing data (Melengkapi data penulisan) 3. Collecting the support data (Mengumpulkan data penunjang) 4. Writing the nursing problem and cooperation (Menuliskan masalah keperawatan dan kolaborasi) Nursing Diagnose (Diagnosa Keperawatan) 1. The right diagnose formula (Rumusan diagnosa benar) 2. Nursing diagnose based on client’s condition (Diagnosa keperawatan sesuai kondisi klien) Planning (Perencanaan) 1. Analyzing the data (Menganalisa data) 2. Priority the problem (Memprioritaskan masalah) 3. Formulating nursing problem (Merumuskan masalah keperawatan) 4. Writing the objective (Menuliskan tujuan) 5. Writing the evaluation criteria (Menuliskan kriteria evaluasi yang bisa diukur) 6. Explaining the action solution of patient’s nursing operational problem (Menguraikan tindakan untuk penyelesaian masalah keperawatan pasien bersifat operasional) 7. Explaining the rasional action (Menguraikan rasional tindakan) 8. Documentation of nursing care planning (Pendokumentasian rencana asuhan keperawatan) Implementation (Implementasi) 1. Using therapeautic communication (Menggunakan komunikasi terapeutik) 2. Involving client, family, officer in intervention (Melibatkan klien, keluarga, petugas dalam intervensi) 3. Using the instrument efficiently (Menggunakan alat secara efisiensi/sesuai kebutuhan) 4. Paying attention to quality instrument (Memperhatikan kualitas alat (steril/bersih) 5. The effective and effecient action steps (Langkah-langkah tindakan sesuai dengan prinsip, efektif & efesiensi) 6. Doing cooperation with other profession (Melakukan kolaborasi dengan profesi lain) 7. Documentation of nursing action (Pendokumentasian tindakan keperawatan) Evaluation (Evaluasi) 1. Writing the formative evaluation (Menuliskan evaluasi formatif (SOAP)) 2. Writing the sumative evaluation (Menuliskan evaluasi sumatif) 3. Documentation index (Mencatat di indeks/pendokumentasian)
Score
The Last Score
Informasi
20
10
20
30
10
Scoring : According to the scoring standart system of education clinic PSIK STIKES Muhammadiyah Palembang, namely A ≥ 80, B = 70-79, C = 56- 69, D = 40-55, E ≤ 40 (Sesuai sistem atau standar penilaian pendidikan klinik PSIK STIKES Muhammadiyah Palembang, yaitu: A ≥ 80, B = 70-79, C = 56-69, D = 40-55, E ≤ 40 Preceptor
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Panduan Praktik Klinik Keperawatan Kritis
Panduan Praktik Klinik Keperawatan Kritis
