Format Askep KMB
PENGKAJIAN DASAR KEPERAWATAN
Nama
Mahasiswa : Tempat
Praktik :
NIM : Tgl.
Praktik :
A.
Identitas Klien
Nama :.......................................................... No. RM :..................................................
Usia :.................. tahun Tgl. Masuk :..................................................
Jenis kelamin :.......................................................... Tgl. Pengkajian :..................................................
Alamat :.......................................................... Sumber informasi :..................................................
No. telepon :.......................................................... Nama klg. dekat yg bisa dihubungi:...........................
Status
pernikahan :.......................................................... ...................................................
Agama :.......................................................... Status :..................................................
Suku :.......................................................... Alamat :..................................................
Pendidikan :.......................................................... No. telepon :..................................................
Pekerjaan :.......................................................... Pendidikan :..................................................
Lama
berkerja :.......................................................... Pekerjaan :..................................................
B.
Status kesehatan Saat Ini
1. Keluhan Utama
a. Saat MRS :......... ...................................................................................................
.....……………………………………………............................................
........... .............................................................................................. .... .……………………………………………………………………………….
b. Saat
Pengkajian :.................................. .……………
…………………………………………………………..
..............................................................................................................
………………………………………………………………………………..
.……………………………………………………………………………….
................................................................................................................
2. Riwayat
Kesehatan Saat ini
......................................................................... ………………………………………………………………………………..
.......................................................................... ……………………………………………………………………………….
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
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...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
C.
Riwayat Kesehatan
Terdahulu
1. Penyakit yg pernah
dialami:
a. Kecelakaan (jenis &
waktu) :..................................................................................................................................
b. Operasi (jenis &
waktu) :..................................................................................................................................
c. Penyakit:
·
Kronis :..................................................................................................................................................................... ......................................................................................................................................................................
·
Akut :.....................................................................................................................................................................
d. Terakhir masuki RS :..................................................................................................................................
2.
Alergi
(obat, makanan, plester, dll):
Tipe
Reaksi
Tindakan
....................................................................... ............................................................... .........................................................
....................................................................... ............................................................... .........................................................
3. Imunisasi:
( ) BCG ( ) Hepatitis
( ) Polio ( ) Campak
( ) DPT ( ) .......................
4.
Kebiasaan:
Jenis Frekuensi Jumlah
Lamanya
Merokok ............................................... ....................................................... .............................................
Kopi ............................................... ....................................................... .............................................
Alkohol ............................................... ....................................................... .............................................
5.
Obat-obatan
yg digunakan:
Jenis Lamanya Dosis
....................................................................... ............................................................... .........................................................
....................................................................... ............................................................... .........................................................
D.
Riwayat Keluarga
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
GENOGRAM
E.
Riwayat Lingkungan
Jenis Rumah Pekerjaan
·
Kebersihan ........................................................................... .................................................................
·
Bahaya kecelakaan ........................................................................... .................................................................
·
Polusi ........................................................................... .................................................................
·
Ventilasi ........................................................................... .................................................................
·
Pencahayaan ........................................................................... .................................................................
F.
Pola Aktifitas-Latihan
Rumah Rumah
Sakit
·
Makan/minum ....................................................................... .............................................................
·
Mandi ....................................................................... .............................................................
·
Berpakaian/berdandan ....................................................................... .............................................................
·
Toileting ....................................................................... .............................................................
·
Mobilitas di tempat tidur ....................................................................... .............................................................
·
Berpindah ....................................................................... .............................................................
·
Berjalan ....................................................................... .............................................................
·
Naik tangga ....................................................................... .............................................................
Pemberian
Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang
lain, 4 = tidak mampu
G.
Pola Nutrisi Metabolik
Rumah Rumah
Sakit
·
Jenis diit/makanan ............................................................... .........................................................
·
Frekuensi/pola ............................................................... .........................................................
·
Porsi yg dihabiskan ............................................................... .........................................................
·
Komposisi menu ............................................................... .........................................................
·
Pantangan ............................................................... .........................................................
·
Napsu makan ............................................................... .........................................................
·
Fluktuasi BB 6 bln. terakhir ............................................................... .........................................................
·
Jenis minuman ............................................................... .........................................................
·
Frekuensi/pola minum ............................................................... .........................................................
·
Gelas yg dihabiskan ............................................................... .........................................................
·
Sukar menelan (padat/cair) ............................................................... .........................................................
·
Pemakaian gigi palsu (area) ............................................................... .........................................................
·
Riw. masalah penyembuhan luka ............................................................... .........................................................
H.
Pola Eliminasi
Rumah Rumah
Sakit
·
BAB:
-
Frekuensi/pola ....................................................................... ..........................................................
-
Konsistensi ....................................................................... ..........................................................
-
Warna & bau ....................................................................... ..........................................................
-
Kesulitan ....................................................................... ..........................................................
-
Upaya mengatasi ....................................................................... ..........................................................
·
BAK:
-
Frekuensi/pola ....................................................................... ..........................................................
-
Warna & bau ....................................................................... ..........................................................
-
Kesulitan ....................................................................... ..........................................................
-
Upaya mengatasi ....................................................................... ..........................................................
I.
Pola Tidur-Istirahat
Rumah Rumah
Sakit
·
Tidur siang:Lamanya ............................................................... .............................................................
-
Jam …s/d… .....
-
Kenyamanan stlh. tidur .....
·
Tidur malam: Lamanya ............................................................... .............................................................
-
Jam …s/d… .....
-
Kenyamanan stlh. tidur .....
-
Kebiasaan sblm. tidur .....
-
Kesulitan .....
-
Upaya mengatasi .....
J.
Pola Kebersihan Diri
Rumah Rumah
Sakit
·
Mandi:Frekuensi ................................................................... .........................................................
-
Penggunaan sabun ........................................................
·
Keramas: Frekuensi ................................................................... .........................................................
-
Penggunaan shampoo ........................................................
·
Gosok gigi: Frekuensi ................................................................... .........................................................
-
Penggunaan pasta gigi ........................................................
·
Ganti baju:Frekuensi ................................................................... .........................................................
·
Memotong kuku: Frekuensi ................................................................... .........................................................
·
Kesulitan ................................................................... .........................................................
·
Upaya yg dilakukan ................................................................... .........................................................
K.
Pola Toleransi-Koping
Stres
1. Pengambilan
keputusan: ( ) sendiri ( ) dibantu orang lain, sebutkan,......................................................................
2. Masalah utama terkait
dengan perawatan di RS atau penyakit (biaya, perawatan diri, dll):..........................................
……………………………………………………………………………………………………………
3. Yang biasa dilakukan
apabila stress/mengalami masalah:...................................................................................................
4. Harapan setelah menjalani
perawatan:.....................................................................................................................................
5. Perubahan
yang dirasa setelah sakit:........................................................................................................................................
L.
Konsep Diri
1. Gambaran diri:..............................................................................................................................................................................
2. Ideal diri:.......................................................................................................................................................................................
3. Harga diri:.....................................................................................................................................................................................
4. Peran:
5. Identitas diri..................................................................................................................................................................................
M.
Pola Peran & Hubungan
1. Peran dalam keluarga..................................................................................................................................................................
2. Sistem
pendukung:suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain,
sebutkan:..........................................
......................................................................................................................................................
3. Kesulitan
dalam keluarga: ( ) Hub. dengan orang tua ( ) Hub.dengan pasangan
( ) Hub. dengan sanak saudara ( ) Hub.dengan anak
( ) Lain-lain sebutkan,.................................................................................................
4. Masalah
tentang peran/hubungan dengan keluarga selama perawatan di RS:..................................................................
.........................................................................................................................................................................................................
5. Upaya yg
dilakukan untuk mengatasi:.....................................................................................................................................
N.
Pola Komunikasi
1. Bicara: (
) Normal ( )Bahasa utama:..............................................
(
) Tidak jelas
( ) Bahasa
daerah:............................................
(
) Bicara berputar-putar
( ) Rentang
perhatian:.....................................
( ) Mampu mengerti pembicaraan
orang lain( ) Afek:.................................................................
2. Tempat tinggal: ( ) Sendiri
( ) Kos/asrama
( ) Bersama orang lain, yaitu:............................................................................................................
3. Kehidupan keluarga
a. Adat istiadat yg dianut:.........................................................................................................................................................
b. Pantangan & agama yg
dianut:...........................................................................................................................................
c. Penghasilan
keluarga: ( ) <
Rp. 250.000 ( ) Rp.
1 juta – 1.5 juta
( ) Rp. 250.000 – 500.000 ( ) Rp. 1.5 juta – 2 juta
( ) Rp.
500.000 – 1 juta ( ) >
2 juta
O.
Pola Seksualitas
1. Masalah dalam hubungan
seksual selama sakit: ( ) tidak
ada (
) ada
2. Upaya yang dilakukan
pasangan:
( )
perhatian ( ) sentuhan
( ) lain-lain, seperti, .............................................................................
P.
Pola Nilai &
Kepercayaan
1. Apakah Tuhan, agama,
kepercayaan penting untuk Anda, Ya/Tidak
2. Kegiatan agama/kepercayaan
yg dilakukan dirumah (jenis & frekuensi):........................................................................
.........................................................................................................................................................................................................
3. Kegiatan agama/kepercayaan
tidak dapat dilakukan di RS:.................................................................................................
4. Harapan klien terhadap perawat
untuk melaksanakan ibadahnya:......................................................................................
Q.
Pemeriksaan Fisik
1. Keadaan Umum:..........................................................................................................................................................................
.........................................................................................................................................................................................................
.........................................................................................................................................................................................................
·
Kesadaran:..............................................................................................................................................................................
·
Tanda-tanda vital: - Tekanan darah :……… mmHg -
Suhu :………oC
- Nadi :……... x/menit - RR :……… x/menit
·
Tinggi badan: ....................................................... cm Berat Badan:....................................... kg
2. Kepala & Leher
a. Kepala:
b. Mata:
c. Hidung:
d. Mulut & tenggorokan:
e. Telinga:
f.
Leher:
3. Thorak & Dada:
·
Jantung
-
Inspeksi:............................................................................................................................................................................ ............................................................................................................................................................................................
-
Palpasi:.............................................................................................................................................................................. ............................................................................................................................................................................................
-
Perkusi:............................................................................................................................................................................. ............................................................................................................................................................................................
-
Auskultasi:........................................................................................................................................................................ ............................................................................................................................................................................................
·
Paru
-
Inspeksi:............................................................................................................................................................................ ............................................................................................................................................................................................
-
Palpasi:.............................................................................................................................................................................. ............................................................................................................................................................................................
-
Perkusi:............................................................................................................................................................................. ............................................................................................................................................................................................
-
Auskultasi:........................................................................................................................................................................ ............................................................................................................................................................................................
4. Payudara & Ketiak
.............................................................................................................................................................................................
5. Punggung & Tulang
Belakang
.............................................................................................................................................................................................
6. Abdomen
·
Inspeksi:..................................................................................................................................................................................
.................................................................................................................................................................................................. ..................................................................................................................................................................................................
·
Palpasi:....................................................................................................................................................................................
..................................................................................................................................................................................................
·
Perkusi:....................................................................................................................................................................................
.................................................................................................................................................................................................. ..................................................................................................................................................................................................
·
Auskultasi:..............................................................................................................................................................................
..................................................................................................................................................................................................
7. Genetalia & Anus
·
Inspeksi:..................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
·
Palpasi:....................................................................................................................................................................................
8. Ekstermitas
·
Atas:.........................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
·
Bawah:.....................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
9. Sistem Neurologi
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
10. Kulit & Kuku
·
Kulit: .......................................................................................................................................................................................
………………………………………………………………………………………………………...
………………………………………………………………………………………………………...
·
Kuku: …………………………………………………………………………………………………
…………………………………………………………………………………..…………………….
…………………………………………………………………………………………………………
R.
Hasil Pemeriksaan
Penunjang
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S.
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T.
Persepsi Klien Terhadap
Penyakitnya
...............................................................................................................................................................................................................
...............................................................................................................................................................................................................
2. Analisa Data
A. ANALISA DATA
Nama Pasien :
Umur :
No. Register :
|
DATA PENUNJANG
|
ETIOLOGI
|
MASALAH KEPERAWATAN
|
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B.
DIAGNOSA KEPERAWATAN
DAFTAR DIAGNOSA KEPERAWATAN
BERDASARKAN PRIORITAS
|
No
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Diagnosa Keperawatan
|
Tanggal Ditemukan
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Tanggal Teratasi
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C.
PERENCANAAN
RENCANA ASUHAN KEPERAWATAN
Diagnosa Keperawatan No.
Tujuan
Kriteria Hasil
NOC
|
No.
|
Indikator
|
1
|
2
|
3
|
4
|
5
|
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Keterangan Penilaian :
1 : idak sesuai
2 : g tidak
sesuai
3 : adang tidak
sesuai
4 : ang tidak
sesuai
5 : esuai
Intervensi NIC
2.
Tujuan, Kriteria Standar, Interensi, Rasional
IMPLEMENTASI
Nama Klien : Tanggal
Pengkajian :
No Reg : Diagnosa
Medis :
|
Tgl
|
No.
Dx. Kep.
|
Jam
|
Tindakan
Keperawatan
|
Respon
Klien
|
TTD
& Nama Terang
|
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|
|
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D.
PELAKSANAAN
CATATAN PERKEMBANGAN (PROGRESS NOTE)
Diagnosa Keperawatan No.
NOC :
|
No.
|
Indikator
|
Tanggal Observasi dan Hasil
|
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1
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2
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3
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4
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S
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1
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2
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3
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4
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S
|
1
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2
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3
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4
|
S
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Keterangan Penilaian :
-
: tidak sesuai
+ : sesuai yang diharapkan
S : Skoring
Keterangan Skoring :
1 : -
2 : 1+
3 : 2+
4 : 3+
5 : 4+
E.
EVALUASI
EVALUASI
|
Hari/Tanggal
Jam
|
No.
Dx Kep
|
Evaluasi
|
TTD
|
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