Panduan KMB IV PDF
Panduan KMB IV PDF
DISUSUN OLEH :
Nama : ______________________________________________
NIM : ______________________________________________
Alamat : ______________________________________________
KATA PENGANTAR
Dengan memanjatkan Puji syukur kepada Tuhan Yang Maha Esa atas
berkat dan karuniaNya, maka buku panduan Praktikum Belajar Klinik/Lapangan
AKPER HKBP Balige dapat diselesaikan.
Buku panduan ini disusun sebagai pedoman bagi mahasiswa dan dosen
pembimbing Keperawatan Medikal Bedah IV dalam melaksanakan praktek
belajar klinik dalam menerapkan asuhan keperawatan Medikal Bedah IV
tentang asuhan kepada klien gangguan system persyarafan, endokrin,
perkemihan , muskuloskletal , immunitas dan integumen. Buku panduan ini
diharapkan dapat diharapkan dapat memberikan arahan bagi mahasiswa
dalam pencapaian kompetensi dalam menyelesaikan mata ajar keperawatan
Medical Bedah IV.
Akhir kata, tim penulis mengucapkan terima kasih kepada semua pihak
yang telah membantu dalam menyelesaikan buku panduan ini.Masukan dan
kritikan yang membangun sangat diharapkan untuk penyempurnaan panduan
praktek klinik keperawatan medical bedah II ini.
Penyusun
Daftar isi
Halaman
DAFTAR ISI i
KATA PENGANTAR ii
BAB I : PENDAHULUAN 1
a.Metode Pembelajaran
b.Tata Tertib
BAB V : EVALUASI 9
DAFTAR LAMPIRAN :
PENDAHULUAN
C.ALOKASI WAKTU
Waktu Pelaksanaan di RSU HKBP setiap hari Kamis s/d Sabtu ( jadwal terlampir ) dan
di RSUH Adamm Malik 1 Bulan tgl 3 Agustus s/d 01 Juli 2012 dimana Mahasiswa
dibagi dalam 6 (enam) kelompok (nama-nama terlampir).
A.TUJUAN
Pada akkhir praktek klinik keperawatan medical bedah II, mahasiswa/i diharapkan
A. METODE PEMBELAJARAN
Beberapa cara bimbingan yang digunakan dalam proses bimbingan ini bervariasi
dengan penekanan pada bimbingan yang interaktif dan individual untuk
mengembangkan kemandirian dan tanggung jawab mahasiswa. Cara memberikan
bimbingan tersebut juga mendorong penggunaan berbagai macam strategi kreatif.
Strategi kreatif tersebut meliputi : pengajaran interaktif dalam pertemuan sebelum
praktik dan sesudah praktik, studi kasus, belajar mandiri, observasi, pengajaran
afektif dan pemberian pekerjaan rumah.
B. TATA TERTIB
Peserta didik yang mengikuti praktek belajar lapangan mematuhi tata tertib dibawah
ini :
1. Tiap peserta didik mentaati peraturan yang terdapat dalam buku panduan praktik
klinik Akademi Keperawatan HKBP Balige
2. Pembimbing klinik berkewajiban dan berhak untuk mengingatkan peserta didik
yang melalaikan tata tertib
3. Kehadiran peserta didik dalam praktik klinik 100%
4. Memakai seragam sesuai peraturan yang ditetapkan AKPER HKBP Balige
5. Praktek belajar lapangan berlangsung selam 2 minggu mulai Mahasiswa tidak
diperkenankan meninggalkan tempat praktik sebelum jam 17.00 WIB.
Dinas pagi : pukul 08.00 – 14.00 WIB
Dinas sore : pukul 14.00 – 21.00 WIB
Dinas malam : pukul 21.00 – 08.00 WIB
6. Peserta didik yang tidak mengikuti praktik klinik harus melaporkan
ketidakhadirannya kepada koordinator mata ajar atau pembimbing klinik
7. Peserta didik harus mengganti waktu praktik yang ditinggalkan dihari lain atas
persetu juan pembimbing klinik, dengan ketentuan :
Dengan alasan sakit (surat dokter) sesuai dengan hari yang ditinggalkan
Tanpa alasan, mengganti 1 minggu untuk 1 hari yang ditinggalkan
Kegiatan praktik keperawatan medical bedah IV dilakukan selama 1 bulan . Secara umum
kegiatan dan proses pembelajaran klinik dapat dilihat pada table rancangan pembelajaran
dibawah ini .
EVALUASI
A. TUJUAN EVALUASI
Secara umum evaluasi praktek klinik keperawatan medical bedah II bertujuan untuk
menilai kompetensi mahasiswa dalam menerapkan asuhan keperawatan pada klien
gangguan system persyarafan, endokrin, perkemihan, muskuloskletal, immunitas dan
integument dengan menerapkan proses keperawatan.
C. KRITERIA KELULUSAN
Mahasiswa dinyatkan lulus jika :
1. Mendapat nilai minimal 60 pada hasil penilaian evaluasi proses dan minimal 70
pada evaluasi akhir
2. Kehadiran praktek klinik /lapangan 100 %
3. Mematuhi semua tata tertib termasuk tata tertib yang terdapat di buku panduan
praktek klinik akademi keperawatan HKBP Balige
4. Memenuhi target prosedur minimal
operatif 2. 2.
3. 3.
4. 4.
5. 5.
2 Melakuan Pengangkatan 1. 1.
2. 2.
DI RSU …………………………….
NAMA :
NPM :
TANGGAL : S/D
RUANGAN
Nilai = total 10
Petunjuk :
3.Kriteria penilaian : A= Sangat Baik ( 80-100), B = Baik ( 70-79), C = Cukup (60-69), D = Kurang (50-59), E =
Gagal (40-49)
Balige,
Clinical Instructor/Pembimbing
( )
DI RSU …………………………….
NAMA :
NPM :
TANGGAL : S/D
RUANGAN
Nilai = total 10
Petunjuk :
3.Kriteria penilaian : A= Sangat Baik ( 80-100), B = Baik ( 70-79), C = Cukup (60-69), D = Kurang (50-59), E =
Gagal (40-49)
Balige,
Clinical Instructor/Pembimbing
DI RSU …………………………….
NAMA :
NPM :
TANGGAL : S/D
RUANGAN
Nilai = total 10
Petunjuk :
3.Kriteria penilaian : A= Sangat Baik ( 80-100), B = Baik ( 70-79), C = Cukup (60-69), D = Kurang (50-59), E =
Gagal (40-49)
Balige,
Clinical Instructor/Pembimbing
( )
DI RSU …………………………….
NAMA :
NPM :
TANGGAL : S/D
RUANGAN
Nilai = total 10
Petunjuk :
3.Kriteria penilaian : A= Sangat Baik ( 80-100), B = Baik ( 70-79), C = Cukup (60-69), D = Kurang (50-59), E =
Gagal (40-49)
Balige,
Clinical Instructor/Pembimbing
( )
DI RSU …………………………….
NAMA :
NPM :
TANGGAL : S/D
RUANGAN
Nilai = total 10
Petunjuk :
3.Kriteria penilaian : A= Sangat Baik ( 80-100), B = Baik ( 70-79), C = Cukup (60-69), D = Kurang (50-59), E =
Gagal (40-49)
Balige,
Clinical Instructor/Pembimbing
( )
DI RSU …………………………….
NAMA :
NPM :
TANGGAL : S/D
Nilai = total 10
Petunjuk :
3.Kriteria penilaian : A= Sangat Baik ( 80-100), B = Baik ( 70-79), C = Cukup (60-69), D = Kurang (50-59), E =
Gagal (40-49)
Balige,
Clinical Instructor/Pembimbing
( )
DI RSU …………………………….
NAMA :
TANGGAL : S/D
RUANGAN
Nilai = total 10
Petunjuk :
3.Kriteria penilaian : A= Sangat Baik ( 80-100), B = Baik ( 70-79), C = Cukup (60-69), D = Kurang (50-59), E =
Gagal (40-49)
Balige,
Clinical Instructor/Pembimbing
( )
NAMA :
NPM :
TANGGAL : S/D
RUANGAN
Nilai = total 10
Petunjuk :
3.Kriteria penilaian : A= Sangat Baik ( 80-100), B = Baik ( 70-79), C = Cukup (60-69), D = Kurang (50-59), E =
Gagal (40-49)
Balige,
Clinical Instructor/Pembimbing
( )
Nama Mahasiswa :
NPM :
Ruangan :
Dosen Pembimbing
( )
KELOMPOK : TOPIK :
NAMA ANGGOTA : 1.
2.
3.
4.
5.
6.
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
NIM : .................................................
Ruangan : ……………………………….
Patofisiologi
2. Fisik
3. Studi Diagnostik
4. Laboratorium
Terapi Farmakologi :
1.
2.
3.
4.
5.
7.
8.
9.
10.
INTERVENSI RASIONAL
Kab.Tobasa – Sumut
FORMAT PENGKAJIAN
I. BIODATA
A.IDENTITAS PASIEN
Nama : ..................................................
No.Register : ..................
Umur : ..................................................
Agama : ..................................................
Pendidikan : ..................................................
Pekerjaan : ..................................................
Alamat : ..................................................
B.PENANGGUNG JAWAB
Nama : ..................................................................
Alamat : ..................................................................
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2.Quantity / Quality
A. Bagaimana dirasakan
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B.Bagaimana dilihat
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A. Dimana lokasinya
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B. Apakah Menyebar
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Buku Panduan Praktek Klinik Keperawatan Medical Bedah IV Page 37
5. Time ( Kapan mulai timbul dan bagaimana tejadinya )
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D. Lamanya Dirawat :
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E. Alergi :
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F. Immunisasi :
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A.Orang Tua
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B.Saudara Kandung
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Keterangan :
: Laki-laki
: Perempuan
: Meninggal
: Pasien
: Tinggal serumah
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C.Konsep diri
1. Body Image :
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2. Ideal diri :
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3. Harga diri :
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4. Peran diri :
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5. Personal Identity :
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D. Keadaan emosi :
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I.Kegemaran
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J.Daya Adaptasi
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VII.Spritual :
A.Keadaan Umum :
TD : ................................. RR : ............................................
TB : ................................. BB : ............................................
Bentuk :……………………………………………………………………………………………
Ukuran :……………………………………………………………………………………………
Posisi : ……………………………………………………………………………………………
Keadaan rambut / warna : ……………………………………………………………………………………………
Kebersihan : ……………………………………………………………………………………………
2.Mata / Penglihatan
Bentuk : ……………………………………………………………………………………………
Sklera : ……………………………………………………………………………………………
Konjunctiva : ……………………………………………………………………………………………
Posisi : ……………………………………………………………………………………………
Ketajaman penglihatan : ……………………………………………………………………………………………
3.Hidung / Penciuman
Bibir : ……………………………………………………………………………………………
Mukosa gusi : ……………………………………………………………………………………………
Lidah : ……………………………………………………………………………………………
Tonsil / faring : ……………………………………………………………………………………………
Buku Panduan Praktek Klinik Keperawatan Medical Bedah IV Page 41
Peradangan : ……………………………………………………………………………………………
Perdarahan : ……………………………………………………………………………………………
Kebersihan : ……………………………………………………………………………………………
Bau : ……………………………………………………………………………………………
Fungsi pengecapan : ……………………………………………………………………………………………
Kemampuan berbicara : ……………………………………………………………………………………………
Kemampuan menelan : ……………………………………………………………………………………………
6.Integumen ( Kulit )
Warna : …………………………………………………………………………………………
Turgor : ………………………………………………………………………………………
Kebersihan : …………………………………………………………………………………………
Kelainan pada kulit :……………………………………………………………………………………………
7.Leher
8.Thorax/dada
Palpasi :……………………………………………………………………………………………
…………………………………………………………………………………………
Perkusi : ……………………………………………………………………………………………
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Auscultasi :
a.Irama denyut jantung ....... .....…………………………………………………………………
8.Abdoment
Inspeksi : ……………………………………………………………………………………………
Auskultasi : ……………………………………………………………………………………………
…………………………………………………………………………………………
Perkusi : ……………………………………………………………………………………………
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Palpasi :
- Tanda – tanda nyeri tekan
- Benjolan /massa
- Tanda – tanda ascites
- Hepar
- Lien
- Titik Mc.Burney
Kebersihan perineum` :
………………………………………………………………………………………………
Peradangan :
………………………………………………………………………………………………
Perdarahan :
………………………………………………………………………………………………
10.Ektremitas atas
11.Extremitas bawah
12.Neurologis :
a.Tingkat Kesadaran :
Nervus Olfaktorius ( NI )
………………………………………………………………………………………………
Nervus Trigeminus ( NV )
Buku Panduan Praktek Klinik Keperawatan Medical Bedah IV Page 44
………………………………………………………………………………………………
c.Fungsi motorik :
d.Fungsi sensorik :
Test getaran
………………………………………………………………………………………………
Graphesthesia Test
………………………………………………………………………………………………
Topognosis test
………………………………………………………………………………………………
e.Refleks
Refleks Trisep
………………………………………………………………………………………………
Refleks Brachioradialis
………………………………………………………………………………………………
Refleks Patelar
………………………………………………………………………………………………
Refleks Plantar
………………………………………………………………………………………………
f.Refleks Patologis :
……………………………………………………………………………………………………………………………………………………………
Persepsi
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Bahasa
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1 a.Makan :
Diet
Komposisi
Frequensi
Makanan yang disukai
Selera makan
Makanan pantangan
Jenis
Jumlah per hari
Minuman yang disukai
Minuman pantangan
2 Tidur :
3 a.Eliminasi B A K :
Frequensi
Jumlah
Warna
Bau
Kelainan
Lain - lain
b.Eliminasi B A B :
Frequensi
Jumlah
Konsistensi
Warna
Bau
Kelainan
Lain – lain
c.Personal hygiene :
Kebiasaan mandi
Pemeliharaan gigi dan
mulut
Pemeliharaan rambut
Pemeliharaan kuku
Masalah dalam
melaksanakan personal
hygiene
Diagnosa medis
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2. Rontgen:
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3.E C G:
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3. USG:
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4. Lain-lain
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ASUHAN KEPERAWATAN