Format Pengkajian Kmb

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA BADAN PENGEMBANGAN DAN PEMBERDAYAAN SUMBER DAYA MANUSIA KESEHATAN

POLITEKNIK KESEHATAN KALIMANTAN TIMUR

Direktorat Jalan Kurnia Makmur No. 64 Rt. 24 Kel. Harapan Baru Kecamatan Loa Janan Ilir No. Telp (0541) 7091774

Jurusan Keperawatan, Jurusan Kebidanan, Jurusan Analis Kesehatan

Jalan Wolter Monginsidi No. 38 Samarinda – Kalimantan Timur, Kode Pos 75123, Telepon (0541) 738153, 768522 Fax : (0541)768523

Program Studi Diploma III Kebidanan Balikpapan, Jalan Sorong No. 9 RT.081 Gunung Pipa Balikpapan Utara Telepon : (0542) 424704

Fax : (0542) 415551. Surat Elektronik : [email protected] Laman : http://poltekkes-kaltim.ac.id

FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Tanggal MRS A. Identitas

1. Identitas Klien

Nama

: ………………………………… L/P

Tempat/tgl lahir

: …………………………………

Golongan darah

: A/O/B/AB

Pendidikan terakhir

: SD/SMP/SMA/DI/DII/DIII/DIV/S1/S2/S3

Agama

: Islam/Prostestan/Katolik/Hindu/Budha/Konghucu

Suku

: …………………………………

Status perkawinan

: kawin/belum/janda/duda (cerai : hidup/mati)

Pekerjaan

: …………………………………

Alamat Tanggal Masuk RS No. Reg Tanggal Pengkajian Jam Masuk

: ………………………………… :.................................................... :.................................................... :.................................................... :....................................................

Diagnosa medik

:

a) ……………………. Tanggal : ……………………. b) ……………………. Tanggal : ……………………..

c) ……………………. Tanggal : …………………….

2. Identitas Penanggung jawab

Nama

: …………………………………

Umur

: …………………………………

Jenis kelamin Agama Suku

: ………………………………… : ………………………………… :…………………………………

Hubungan dgn pasien : …………………………………

Pendidikan terakhir

: …………………………………

Pekerjaan

: …………………………………

Alamat

: …………………………………

KELUHAN UTAMA

1.

Keluhan utama:………………………………………………………………………………………………………..

RIWAYAT PENYAKIT SEKARANG

1. Riwayat Penyakit Sekarang:

………………………………………………………………………………...................................................................

…………………………………………………………………………………………………………….......................

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

…………………………………………………………………………………………………………….......................

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

…………………………………………………………………………………………………………….......................

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

RIWAYAT PENYAKIT DAHULU

1. Pernah dirawat : ya 2. Riwayat penyakit kronik dan menular

tidak ya

kapan :…… diagnosa :………… tidak jenis……………………

Riwayat kontrol : .............................

Riwayat penggunaan obat :..............

3. Riwayat alergi:

Obat Makanan Lain-lain

ya ya ya

tidak tidak tidak

jenis…………………… jenis…………………… jenis……………………

4. Riwayat operasi:

ya

tidak

-

Kapan

: ……………………

Jenis operasi : ……………………

5. Lain-lain:

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

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

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

RIWAYAT KESEHATAN KELUARGA

Ya

tidak

-

Jenis :…………………..................................................................................................................................... Genogram :

PERILAKU YANG MEMPENGARUHI KESEHATAN

Perilaku sebelum sakit yang mempengaruhi kesehatan:

Alkohol

ya

tidak

keterangan……….....................

Masalah Keperawatan :

Merokok

ya

tidak

keterangan…………………….........................................................

Obat

ya

tidak

keterangan…..............................................................………………

Olah raga

ya

tidak

keterangan…..........................................................…………………

Kenyamanan/ nyeri

Nyeri :

ya

tidak

P :..............................................................................................................

Q :................................................................... ...........................................

R :................................................................... ...........................................

S :................................................................... ...........................................

T :................................................................... ...........................................

Masalah Keperawatan :

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

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

Status fungsional/ aktivitas dan Barthel Indeks

No

Fungsi

Skor

Uraian

Nilai Skor

1

Mengendalikan

rangsang

defekasi

0

Tak terkendali/ tak teratur (perlu pencahar)

(BAB)

1

Kadang- kadang tak terkendali

2

Mandiri

2

Mengendalikan rangsang berkemih

0

Tak terkendali/ pakai kateter

(BAK)

1

Kadang- kadang tak terkendali (1x24jam)

2

Mandiri

3

Membersihkan

diri

(cuci

muka,

0

Butuh pertolongan orang lain

sisir rambut, sikat gigi)

1

Mandiri

4

Penggunaan jamban, masuk dan

0

Tergantung pertolongan orang lain

keluar (melepaskan, memakai celana, membersihkan, menyiram)

1

Perlu pertolongan pada beberapa kegiatan tetapi dapat mengerjakan sendiri beberapa kegiatan yang lain

2

Mandiri

5

Makan

0

Tidak mampu

1

Perlu ditolong memakan makanan

2

Mandiri

6

Berubah sikap dari berbaring ke

0

Tidak mampu

duduk

1

Perlu banyak bantuan untuk bisa duduk (2

orang)

2

Bantuan (2 orang)

3

Mandiri

7

Berpindah / berjalan

0

Tidak mampu

1

Bisa (pindah) dengan kursi roda

2

Berjalan dengan bantuan 1 orang

3

Mandiri

8

Memakai baju

0

Tidak mampu

1

Sebagian di bantu (misalnya mengancing baju)

2

Mandiri

9

Naik turun tangga

0

Tidak mampu

1

Butuh pertolongan

2

Mandiri

10

Mandi

0

Tergantung orang lain

1

Mandiri

Total Skor

Keterangan Tingkat Ketergantungan:

20 12 – 19 9 – 11 5–8 0–4

: Mandiri : Ketergantungan ringan : Ketergantungan sedang : Ketergantungan berat : Ketergantungan total

OBSERVASI DAN PEMERIKSAAN FISIK

1.

Keadaan Umum:

Posisi pasien : …..........................................................…………………

Alat Medis/ invasif terpasang : …...........................................................

Tanda Klinis yang mencolok:

sianosis

Perdarahan

2.

Kesadaran:

S: Kesadaran

N:

T: Compos Mentis

RR : Apatis

Somnolen

Sopor

Koma

Kuantitaif : GCS

E=

V=

M=

3.

Tanda tanda vital

Masalah Keperawatan :

S : ................

N : .............

T : ................

RR : .................

Masalah Keperawatan :

MAP=

Tekanan Sistol + ( 2 x diastolik) 3

= ..................mmHg

4.

Sistem Pernafasan (B1)

a. RR:................................

b. Keluhan:

sesak

nyeri waktu nafas

orthopnea

Batuk Sekret:…….. Warna:..........

produktif

tidak produktif Konsistensi :...................... Bau :..................................

c. Penggunaan otot bantu nafas:

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

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

d. Bentuk dada:

Simetris

asimetris

Barrel

funnel

pigeon

Frekuensi...........................................

e. f. g. h. i.

Irama nafas

teratur tidak teratur Pleural Friction rub:..................................................................................................................... Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot Suara nafas Cracles Ronki Wheezing Alat bantu napas ya tidak

Jenis................................................ Flow..............lpm

j. Palpasi:

Vocal fremitus : Anterior dada .........................................Pasterior dada..........................................................

Ekspansi paru : Anterior dada .........................................Pasterior dada..........................................................

k. Penggunaan WSD:

-

Jenis : ................................................................................................................................................................. Jumlah cairan : .................................................................................................................................................. Undulasi :................................................................................................................................................... Tekanan : ..................................................................................................................................................

l. Tracheostomy:

ya

tidak

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

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

m. Lain-lain:

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

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

5.

Sistem Kardio vaskuler (B2)

a. Keluhan nyeri dada:

ya

tidak

P :...................................................................

Masalah Keperawatan :

Q R S T

:................................................................... :................................................................... :................................................................... :...................................................................

b. Irama jantung:

reguler

ireguler

c. Suara jantung:

normal (S1/S2 tunggal)

murmur

gallop

lain-lain.....

d. Ictus Cordis: ............................................................................................................................................................

e. CRT :.............detik

f. Sianosis: .............................................

g. Jari tabuh: ya/ tidak

h. Perkusi:

Batas atas : .........................................................................................................................................................

Batas bawah: ......................................................................................................................................................

Batas kanan: .........................................................................................................................................................

Batas kiri .........................................................................................................................................................

i. Akral:

hangat

kering

merah

basah

pucat

panas

dingin

j. Sikulasi perifer:

normal

menurun

k. Auskultasi

BJ II- Aorta: .........................................................................................................................................................

BJ II- Pulmonal: .................................................................................................................................................

BJ I- Trikuspidalis: ...............................................................................................................................................

BJ I – Mitral .........................................................................................................................................................

l. JVP m. CVP n. CTR

:................................. :................................. :.................................

o. ECG & Interpretasinya:

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

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

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

p. Lain-lain :

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

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

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

6.

Sistem Persyarafan (B3)

a. Fungsi Orientasi, Memory dan Kognisi Memory : Panjang Pendek

Masalah Keperawatan :

Perhatian Bahasa :

: Baik

Dapat mengulang Tidak dapat mengulang Tidak (ket:….…………………………)

Kognisi :

Baik

Tidak

Orientasi

:

Orang

Tempat

Waktu

b. GCS

: ..................................................

c. Tanda Rangsang meningeal: Kaku kuduk

brudzinsky

Lainnya..............................................................

d. Pengkajian Refleks

Refleks fisiologis

patella

triceps

biceps

Laiinya ..............................................................

Refleks patologis

babinsky

Chaddok

Gordon

Lain-lain ..............................................................

e. Keluhan pusing

ya

tidak

Tingkatan Kekuatan Reflek 0= Tidak ada refleks

1+= Hipoaktif

2+=Normal

3+=Hiperaktif

4+=Hiperaktif dengan klonus teres menerus

f.

Pemeriksaan saraf kranial:

N1 : N2 : N3 : N4 : N5 :

normal

tidak

Ket.: ……..............................................................

normal

tidak

Ket.: ……..............................................................

normal

tidak

Ket.: ……..............................................................

normal

tidak

Ket.: ……..............................................................

normal

tidak

Ket.: ……..............................................................

N6 :

normal

tidak

Ket.: ……..............................................................

N7 : N8 : N9 : N10 : N11 : N12 :

normal

tidak

Ket.: ……..............................................................

normal

tidak

Ket.: ……..............................................................

normal

tidak

Ket.: ……..............................................................

normal

tidak

Ket.: ……..............................................................

normal

tidak

Ket.: ……..............................................................

normal

tidak

Ket.: ……..............................................................

g. Pengkajian Fungsi Sensorik:

Nyeri tusuk

Suhu

Sentuhan

Lainnya:

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

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

h. Pengkajian fungsi motorik

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

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

i. j. k. l.

Pupil

anisokor anikterus

Sclera Konjunctiva ananemis Isitrahat/Tidur :................. Jam/Hari

isokor ikterus

Diameter: ……/......

anemis Gangguan tidur : ..............................................................

m. Lain-lain:

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

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

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

7.

Sistem perkemihan (B4) a. Kebersihan genetalia:

Bersih

Kotor

Masalah Keperawatan

b. c. d. e.

Sekret: Ada Ulkus: Ada Kebersihan meatus uretra: Bersih Keluhan kencing: Ada

Tidak Tidak Kotor Tidak

Bila ada, jelaskan:

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

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

f. Kemampuan berkemih:

Spontan

Alat bantu, sebutkan:

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

Jenis :............................................

Ukuran Hari ke

:............................................ :............................................

g. Produksi urine : …………..

ml/jam

Warna Bau

:............…… :......………..

h. Kandung kemih :

Membesar

ya

tidak

Nyeri tekan

ya

tidak

i.

Intake cairan

oral : ……… cc/hari

parenteral : ……… cc/hari

j. Balance cairan:

Intake

Jumlah

Output

Jumlah

Minum peroral Cairan infus Obat IV NGT Makanan (1 kalori=0,4 ml/

:

ml/hr

Urine (0,5 -1 ml/kg BB/jam)

:

ml/hr

:

ml/hr

Drain

:

ml/hr

:

ml/hr

IWL (10-15 ml/kg BB/24 jam)

:

ml/hr

:

ml/hr

Diare

:

ml/hr

:

ml/hr

Muntah

:

ml/hr

perhari)

Perdarahan

Feses (1x=200 ml/hari)

:

ml/hr

Total

:

ml/hr

Total

:

ml/hr

l. Balance Cairan ..........................................................................................................................................................

m. Lain-lain:

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

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

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

8.

Sistem pencernaan (B5)

a. TB

:...............

BB

:................................

b. IMT

:...............

Interpretasi

:................................

bersih

kotor

berbau

lembab

kering

stomatitis

c. Mulut: d. Membran mukosa:

Masalah Keperawatan :

e. Tenggorokan:

sakit menelan pembesaran tonsil

kesulitan menelan nyeri tekan

f. Abdomen:

tegang

kembung

ascites

g. Inspeksi:

Bentuk: ................................................................. Bayangan vena: ....................................................

Benjolan/ massa: ...................................................

h. Nyeri tekan:

ya

tidak

Titik Mc Burney.........................................

Lainnya..........................................................................

i.

Luka operasi:

ada

tidak

Tanggal operasi Jenis operasi Lokasi Keadaan Drain -

:................ :................ :................ :................ : ada

tidak

Jumlah

:...................

Warna

:...................

Kondisi area sekitar insersi

:...................

j.

Peristaltik:.............. x/menit k. BAB: ......................x/hari l. Konsistensi: keras

Terakhir tanggal : ............................................................................ lunak cair lendir/darah

m. Hepar : ...........................................................................

n. Lien: .............................................................................

o. Ginjal: ..........................................................................

Nyeri ketuk : ya/ Tidak

p. Pemeriksaan asites: .................................................... shifting dullness: ............................................

q. Diet: padat

lunak

cair

Status Nutrisi

Parameter

Skor

Apakah pasien mengalami penurunan BB yang tidak di inginkan selama 6 bulan

a. Tidak ada penurunan

0

b. Tidak yakin..tidak tahu/ terasa baju lebih longgar

1

c. jika ya, berapa penurunan tersebut:

2

1 – 5 kg

2

6 – 10 kg

1

11 – 15 kg

3

> 15 kg

4

Apakah asupan makan berkurang karena tidak nafsu makan

a. Ya

1

b. Tidak

0

Total skor

Keterangan: Bila skor ≥ 2 dan atau pasien dengan diagnosis/ kondisi dilakukan pengkajian

lebih lanjut oleh dietisien, bila skor ≤ 2 skrining ulang 7 hari.

r. Diet Khusus:

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

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

s. Nafsu makan: t.

Porsi makan:

baik habis

menurun tidak

Frekuensi:.......x/hari Keterangan:.......................

u. Lain-lain:

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

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

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

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

9.

Sistem Penglihatan

a. Pengkajian segmen anterior dan posterior

Masalah Keperawatan :

OD

OS

Visus

Palpebra

Conjunctiva

Kornea

BMD

Pupil

Iris

Lensa

TIO

b. Keluhan nyeri

ya

tidak

P Q R S T

:................................................................... :................................................................... :................................................................... :................................................................... :...................................................................

c. Luka operasi:

ada

tidak

Tanggal operasi Jenis operasi Lokasi Keadaan

:................ :................ :................ :................

d. Pemeriksaan penunjang lain : .........................

e. Lain-lain :

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

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

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

8. Sistem pendengaran

a.

Pengkajian segmen anterior dan posterior

Masalah Keperawatan :

OD

OS

Aurcicula

MAE

Membran

Tymphani

Rinne

Weber

Swabach

Jurusan Keperawatan, Jurusan Kebidanan: Jalan Wolter Monginsidi No. 38 Samarinda – Kalimantan Timur, Kode Pos 75123, Telepon (0541) 738153

Jurusan Analis Kesehatan : Jalan Kurnia Makmur No. 64 Rt. 24 Kel. Harapan Baru Kec. Loa Janan Ilir

Program Studi Diploma III Kebidanan Balikpapan, Jalan Sorong No. 9 RT.081 Gunung Pipa Balikpapan Utara Telepon : (0542) 424704 Fax : (0542) 415551

b.

Tes Audiometri

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

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

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

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

c. Keluhan nyeri

ya

tidak

P :................................................................... Q :................................................................... R :................................................................... S :................................................................... T :...................................................................

d. Luka operasi:

ada

tidak

Tanggal operasi Jenis operasi Lokasi

:................ :................ :................

Keadaan

:................

e. Alat bantu dengar: .........................

f. Lain-lain :

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

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

...

10. Sistem muskuloskeletal (B6)

a. Pergerakan sendi: b. Kekuatan otot:

bebas

c. Kelainan ekstremitas: ya d. Kelainan tulang belakang: ya

terbatas Masalah Keperawatan : tidak tidak

Frankel: ................................................................................

e. Fraktur: ya

tidak

-

Jenis

:...................

f. Traksi: ya

tidak

-

Jenis Beban Lama pemasangan

:................... :................... :...................

g. Penggunaan spalk/gips: h. Keluhan nyeri: ya

ya tidak

tidak

P :................................................................... Q :................................................................... R :................................................................... S :................................................................... T :...................................................................

i.

Sirkulasi perifer: .............................................. j. Kompartemen syndrome ya tidak

11. Sistem Integumen

a. Kulit: b. Turgor c. Luka operasi:

ikterik

sianosis

baik

kurang

ada

tidak

kemerahan jelek

hiperpigmentasi

Tanggal operasi Jenis operasi Luas luka

:................ :................ : Panjang_______cm

Diameter _________cm

Derajat luka

:..................

Warna dasar luka

: Merah

Kuning

Hitam

Tipe eksudat/cairan luka: ............................................

Gua : ada/ tidak, Ukuran...............................

Tepi Luka: ..........................................................

Jaringan granulasi: ...................................%

Edema sekitar luka: ...........................

Tanda infeksi Lokasi

: ya / tidak : beri tanda [x]

Keadaan :................ Drain : ada - Jumlah - Warna - Kondisi area sekitar insersi

tidak :................... :................... :...................

d. ROM e. Cardinal Sign

: ................................................. : ................................................

f. Lain-lain:

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

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

a. Penilaian resiko decubitus

Aspek Yang

Kriteria Penilaian

Nilai

Dinilai

1

2

3

4

Persepsi Sensori

Terbatas

Sangat Terbatas

Keterbatasan

Tidak Ada

Sepenuhnya

Ringan

Gangguan

Kelembaban

Terus Menerus

Sangat Lembab

Kadang-kadang

Jarang Basah

Basah

Basah

Aktifitas

Bedfast

Chairfast

Kadang-kadang

Lebih Sering

Jalan

jalan

Mobilisasi

Immobile

Sangat Terbatas

Keterbatasan

Tidak Ada

Sepenuhnya

Ringan

Keterbatasan

Nutrisi

Sangat Buruk

Kemungkinan

Adekuat

Sangat Baik

Tidak Adekuat

Gesekan &

Bermasalah

Potensial

Tidak

Pergeseran

Bermasalah

Menimbulkan

Masalah

NOTE: Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien beresiko

Total Nilai

mengalami dekubisus (pressure ulcers)

(15 or 16 = low risk, 13 or 14 = moderate risk, 12 or less = high risk)

b. Warna :

c. Edema Ekstrimitas :

d. Pitting edema: +/- grade:................

Ekstermitas atas

RU RL

+1 +1

+2 +2

+3 +3

+4 +4

LU LL

+1 +1

+2 +2

+3 +3

+4 +4

Ekstermitas Bawah

RU RL

+1 +1

+2 +2

+3 +3

+4 +4

LU LL

+1 +1

+2 +2

+3 +3

+4 +4

Other..............

Penilaian Edema:

+1 +2 +3 +4

: Kedalaman 1 – 3 mm, waktu kembali 3 detik : Kedalaman 3 – 5 mm, waktu kembali 5 detik : Kedalaman 5 – 7 mm, waktu kembali 7 detik : Kedalaman > 7 mm, waktu kembali > 7 detik

Masalah Keperawatan :

e. f. g. h.

Ekskoriasis: Psoriasis: Pruritus: Urtikaria:

ya ya ya ya

tidak tidak tidak tidak

i. Lain-lain:

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

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

11. Sistem Endokrin

a. Pembesaran tyroid: b. Pembesaran kelenjar getah bening: c. Hipoglikemia: d. Hiperglikemia:

ya

tidak

ya

tidak

ya

tidak

Nilai GDA ..........................

ya

tidak

Nilai GDA ..........................

e. Kondisi kaki DM

-

Luka gangren

ya

tidak

Jenis ................................................................................................................

Masalah Keperawatan :

-

Lama luka

-

Warna

-

Luas luka

-

Kedalaman

-

Kulit kaki

-

Kuku kaki

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

-

Telapak kaki ...............................................................................................

-

Jari kaki

-

Infeksi

-

Riwayat luka sebelumya

............................................................................................... ya

tidak

ya

tidak

Jika ya:

-

Tahun

:

Jenis Luka

:

Lokasi

:

-

Riwayat amputasi sebelumya

ya

tidak

Jika ya:

-

Tahun Lokasi

: :

f. ABI : ....................................................

g. Lain-lain:

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

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

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

12. Seksualitas dan Reproduksi

a.

Payudara : benjolan= ada/ tidak*

Masalah keperawatan :

Kehamilan: ya/ tidak*

b.

Genetalia :

Wanita: Flour albus

: ya/ tidak*

Prolaps uteri

: ada/ tidak*

Pria: Masalah prostat

: ada/ tidak*

13. Keamanan Lingkungan (Penilaian pasien resiko jatuh dengan skala morse pada pasien dewasa)

Skor

Faktor Resiko

Skala

Hasil

Skala

Riwayat jatuh yang baru/dalam 3 bulan terakhir

Ya Tidak

25 0

Diagnosa sekunder lebih 1 diagnosa

Ya Tidak

15 0

Berpegangan pada benda- benda sekitar

30

Menggunakan alat bantu

Kruk, tongkat, walker

15

Bedrest/ dibantu/ perawat

0

Menggunakan IV dan cateter

Ya Tidak

20 0

Gangguan (pincang/ diseret)

20

Kemampuan berjalan

Lemah

10

Normal/ bedrest/ immobilisasi

0

Status mental

Tidak sadar akan kemampuan Orientasi sesuai kemampuan diri

15 0

Total Skor

Kesimpulan: Kategori pasien: ....................................................................................................................................

Resiko Sedang Rendah

= ≥ 45 = 25 – 44 = 0 – 24

Masalah keperawatan :

PENGKAJIAN PSIKOSOSIAL

a. Persepsi klien terhadap penyakitnya:

Masalah keperawatan :

Cobaan Tuhan

Hukuman

lainya

b. Ekspresi klien terhadap penyakitnya

Murung/diam

gelisah

tegang

marah/menangis

c. Reaksi saat interaksi

kooperatif

tidak kooperatif

curiga

d. Gangguan konsep diri:

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

e. Lain-lain:

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

PERSONAL HYGIENE & KEBIASAAN

a. Mandi .........................x/ hari b. Keramasa Mandi ..............x/ hari

f. Ganti pakaian ..............x/ hari g. Sikat gigi ..............x/ hari

Masalah Keperawatan :

c. Memotong kuku:.......................

d. Merokok

ya

tidak

e. Alkohol

ya

tidak

PENGKAJIAN SPIRITUAL

a. Kebiasaan beribadah

Masalah Keperawatan :

-

Sebelum sakit

sering

kadang- kadang

tidak pernah

Selama sakit

sering

kadang- kadang

tidak pernah

b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:

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

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

Jurusan Keperawatan, Jurusan Kebidanan: Jalan Wolter Monginsidi No. 38 Samarinda – Kalimantan Timur, Kode Pos 75123, Telepon (0541) 738153

Jurusan Analis Kesehatan : Jalan Kurnia Makmur No. 64 Rt. 24 Kel. Harapan Baru Kec. Loa Janan Ilir

Program Studi Diploma III Kebidanan Balikpapan, Jalan Sorong No. 9 RT.081 Gunung Pipa Balikpapan Utara Telepon : (0542) 424704 Fax : (0542) 415551

PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)

HASIL PEMERIKSAAN

JENIS PEMERIKSAAN

NO

TGL…

TGL …

TGL …

TGL ..

TGL …

NILAI NORMAL

PEMERIKSAAN DIAGNOSTIK (EKG, X-Ray, USG dll)

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

TERAPI YANG DIBERIKAN

Nama Obat

Kandungan/Isi

Bentuk/Sediaan

Kekuatan

Dosis/Aturan

Rute/Cara

Obat

Pakai

Pemberian

DATA TAMBAHAN LAIN :

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

Balikpapan, ……………..20...

Perawat

(……………………………)

DATA FOKUS

1. DATA SUBJEKTIF:

2. DATA OBJEKTIF:

Tanggal, ..........................

Perawat,

---------------------------------------------

ANALISA DATA

Nama No. Reg

: :

Ruang Tanggal

: :

No

Data

Etiologi

Masalah Kep.

Prioritas Masaalah

1. ........................................................................................................................................................................ 2. ........................................................................................................................................................................ 3. ........................................................................................................................................................................ 4. ........................................................................................................................................................................ 5. ........................................................................................................................................................................ 6. ........................................................................................................................................................................

RENCANA TINDAKAN KEPERAWATAN

Nama No. Reg

: :

Ruang Tanggal

: :

No. Dx. Kep.

Diagnosa Keperawatan

Tujuan Dan Kriteria Hasil

Intervensi Keperawatan

Yang Membuat Intervensi

----------------------------------

TINDAKAN KEPERAWATAN

Nama No. Reg

:

Ruang

:

:

Tanggal

:

NO

HARI/TGL / JAM

TINDAKAN KEPERAWATAN

EVALUASI TINDAKAN

TTD

EVALUASI

Nama No. Reg

:

Ruang

:

:

Tanggal

:

No.

Waktu

Catatan Perkembangan (SOAP)

TTD

(Tgl/ Jam)