Format Pengkajian Kmb
20
Nama mahasiswa : .................. ...................... Tgl/jam pengkajian : .................. ...................... Diagnosa medis : .................. ...................... ................. ....................... Tgl/jam MRS : .................. ...................... No. RM : .................. ...................... Ruangan/kelas : .................. ...................... No.kamar : ................. ....................... I. IDENTITAS 1. Nama : ................................................ ............................................................... ...... 2. Umur : ................................................ ............................................................... ...... 3. Jenis kelamin : ............................................................. ........................................................ 4. Status : ................................................ ............................................................... ...... 5. Agama : ................................................ ............................................................... ...... 6. Suku/bangsa : ............................................................. ........................................................ 7. Bahasa : ................................................ ............................................................... ...... 8. Pendidikan : ................................................ ............................................................... ...... 9. Pekerjaan : ................................................ ............................................................... ...... PENGKAJIAN KEPERAWATAN ASUHAN KEPERAWATAN MEDIKAL BEDAH PRODI DIII KEPERAWATAN UNIVERSITAS BONDOWOSO
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Transcript of Format Pengkajian Kmb
Nama mahasiswa : ........................................Tgl/jam pengkajian : ........................................Diagnosa medis : ........................................
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Tgl/jam MRS : ........................................No. RM : ........................................Ruangan/kelas : ........................................No.kamar : ........................................
I. IDENTITAS1. Nama : .....................................................................................................................2. Umur : .....................................................................................................................3. Jenis kelamin : .....................................................................................................................4. Status : .....................................................................................................................5. Agama : .....................................................................................................................6. Suku/bangsa : .....................................................................................................................7. Bahasa : .....................................................................................................................8. Pendidikan : .....................................................................................................................9. Pekerjaan : .....................................................................................................................10. Alamat dan no. telp : .....................................................................................................................11. Penanggung jawab : .....................................................................................................................
II. RIWAYAT SAKIT DAN KESEHATAN1. Keluhan utama :
.........................................................................................................................................................2. Riwayat penyakit sekarang :
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.........................................................................................................................................................3. Riwayat penyakit dahulu :
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.........................................................................................................................................................4. Riwayat kesehatan keluarga :
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.........................................................................................................................................................5. Susunan Keluarga (Genogram) :
PENGKAJIAN KEPERAWATANASUHAN KEPERAWATAN MEDIKAL BEDAH
PRODI DIII KEPERAWATAN UNIVERSITAS BONDOWOSO
: Laki-laki: Perempuan: Laki-laki meninggal: Perempuan meninggal: Garis pernikahan: Garis keturunan: Tinggal serumah: Pasien
6. Riwayat alergi :....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
III. POLA FUNGSI KESEHATAN1. Persepsi Terhadap Kesehatan (Keyakinan Terhadap Kesehatan & Sakitnya)
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2. Pola Aktivitas Dan Latihana. Kemampuan perawatan diri
AktivitasSMRS MRS
0 1 2 3 4 0 1 2 3 4MandiBerpakaian/berdandanEliminasi/toiletingMobilitas di tempat tidurBerpindahBerjalanNaik tanggaBerbelanjaMemasakPemeliharaan rumah
Skor 0 = mandiri1 = alat bantu2 = dibantu orang lain
3 = dibantu orang lain & alat4 = tergantung/tidak mampu
Alat bantu : ( ) tidak ( ) kruk ( ) tongkat( ) pispot disamping tempat tidur ( ) kursi roda
b. Kebersihan diriDi rumahMandi : ........................ /hrGosok gigi : ........................ /hrKeramas : .................... /mggPotong kuku : .................... /mgg
Di rumah sakitMandi : ........................ /hrGosok gigi : ........................ /hrKeramas : .................... /mggPotong kuku : .................... /mgg
c. Aktivitas sehari-hari...................................................................................................................................................
d. Rekreasi...................................................................................................................................................
e. Olahraga : ( ) tidak ( ) ya...................................................................................................................................................
Keterangan:
3. Pola Istirahat Dan TidurDi rumahWaktu tidur : Siang ..............-...............
Malam ............-...............Jumlah jam tidur : ..................................
Di rumah sakitWaktu tidur : Siang ..............-...............
Malam ............-...............Jumlah jam tidur : ..................................
Masalah di RS : ( ) tidak ada ( ) terbangun dini ( ) mimpi buruk( ) insomnia ( ) Lainnya, ...............................
4. Pola Nutrisi – Metabolika. Pola makan
Di rumahFrekuensi : .........................Jenis : .........................Porsi : .........................Pantangan : .........................Makanan disukai : .........................
Di rumah sakitFrekuensi : ..................................Jenis : ..................................Porsi : ..................................Diit khusus : ..................................
Nafsu makan di RS : ( ) normal ( ) bertambah ( ) berkurang( ) mual ( ) muntah, .............. cc ( ) stomatitis
Kesulitan menelan : ( ) tidak ( ) yaGigi palsu : ( ) tidak ( ) yaNG tube : ( ) tidak ( ) ya
b. Pola minumDi rumahFrekuensi : .........................Jenis : .........................Jumlah : .........................Pantangan : .........................Minuman disukai : .........................
Di rumah sakitFrekuensi : ..................................Jenis : ..................................Jumlah : ..................................
5. Pola Eliminasia. Buang air besar
Di rumahFrekuensi : ..................................Konsistensi : ..................................Warna : ..................................
Di rumah sakitFrekuensi : ..................................Konsistensi : ..................................Warna : ( ) kuning
( ) bercampur darah ( ) lainnya, ..............
Masalah di RS: ( ) konstipasi ( ) diare ( ) inkontinenKolostomi : ( ) tidak ( ) ya
b. Buang air kecilDi rumahFrekuensi : ..................................Konsistensi : ..................................Warna : ..................................
Di rumah sakitFrekuensi : ..................................Konsistensi : ..................................Warna : ..................................
Masalah di RS: ( ) disuria ( ) nokturia ( ) hematuria( ) retensi ( ) inkontinen
Kolostomi : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari
6. Pola Kognitif PerseptualBerbicara : ( ) normal ( ) gagap ( ) bicara tak jelasBahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya, ....................................Kemampuan membaca : ( ) bisa ( ) tidak
Tingkat ansietas : ( ) ringan ( ) sedang ( ) berat ( ) panikSebab, ...................................................................................................
Kemampuan interaksi : ( ) sesuai ( ) tidak, ...................................................................Vertigo : ( ) tidak ( ) yaNyeri : ( ) tidak ( ) ya
Bila ya, P : .................................................................................................................................Q : .................................................................................................................................R : .................................................................................................................................S : .................................................................................................................................T : .................................................................................................................................
7. Pola Konsep Diri....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
8. Pola KopingMasalah utama selama MRS (penyakit, biaya, perawatan diri)........................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Kehilangan perubahan yang terjadi sebelumnya...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................Kemampuan adaptasi...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9. Pola Seksual – ReproduksiMenstruasi terakhir : .....................................................................................................................Masalah menstruasi : .....................................................................................................................Pap smear terakhir : .....................................................................................................................Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidakMasalah seksual yang berhubungan dengan penyakit : ...............................................................
10. Pola Peran – HubunganPekerjaan : ......................................................................................................Kualitas bekerja : ......................................................................................................Hubungan dengan orang lain : ......................................................................................................Sistem pendukung : ( ) pasangan ( ) tetangga/teman ( ) tidak ada
( ) lainnya, .................................................................................Masalah keluarga mengenai perawatan di RS : .............................................................................
11. Pola Nilai – Kepercayaan Agama : ................................................................................................Pelaksanaan ibadah : ................................................................................................Pantangan agama : ( ) tidak ( ) ya, ................................................................Meminta kunjungan rohaniawan : ( ) tidak ( ) ya
IV. PENGKAJIAN PERSISTEM (Review of System)1. Tanda-Tanda Vital
a. Suhu : ................... °C lokasi : ......................b. Nadi : ................... /menit irama : ...................... pulsasi : ......................c. Tekanan darah : ................... mmHg lokasi : ......................d. Frekuensi nafas : ................... /menit irama : ......................e. Tinggi badan : ................... cmf. Berat badan : SMRS ................... kg MRS .................... kg
2. Kepala............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3. Mata ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4. Telinga............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
5. Hidung............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
6. Mulut ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
7. Leher............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
8. Dada:
Jantung: .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Paru:..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9. Abdomen...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
10. Urogenital...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
11. Ekstremitas...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
12. Kulit dan kuku...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
13. Keadaan lokal..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
V. PEMERIKSAAN PENUNJANG1. Laboratorium
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.........................................................................................................................................................3. Lain-lain
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VI. TERAPI.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
......................... ,...................................Mahasiswa
(...............................)
ANALISA DATA
Nama klien : ..............................................Umur : ..............................................
Ruangan/kamar : ..............................................No. RM : ..............................................
No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)
PRIORITAS MASALAH
Nama klien : ..............................................Umur : ..............................................
Ruangan/kamar : ..............................................No. RM : ..............................................
No. Masalah KeperawatanTanggal Paraf
(Nama Perawat
Ditemukan Teratasi
RENCANA KEPERAWATAN
No. Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi Rasional
TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN
No.WaktuTgl/jam
Tindakan TTWaktuTgl/jam
Catatan Perkembangan(SOAP)
TT
