DISUSUN OLEH :
Nama : ______________________________________________
NIM : ______________________________________________
Alamat : ______________________________________________
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 II dalam melaksanakan praktek
belajar klinik dalam menerapkan asuhan keperawatan Medikal Bedah II
tentang asuhan kepada klien gangguan system pernafasan, cardiovaskuler,
integument. Buku panduan ini diharapkan dapat diharapkan dapat
memberikan arahan bagi mahasiswa dalam pencapaian kompetensi dalam
menyelesaikan mata ajar keperawatan Medical Bedah II.
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
Panduan Praktek Klinik KMB II Akademi Keperawatan HKBP Balige Page iii
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
Mata kuliah ini diarahkan untuk memberikan kesempatan kepada para mahasiswa
mempraktekkan teori dan konsep yang telah dipelajari di kelas dan telah di uji coba di
laboratorium dibawah pengawasan instruktur laboratorium. Pembelajaran di klinik difokuskan
pada pengalaman belajar dalam memberikan asuhan keperawatan pada pasien dengan gangguan
sistem pernapasan, kardiovaskuler , pencernaan dan penginderaan. Selain metoda bedside
teaching, brifing (Pre and post conference)
untuk memberi kesempatan kepada para mahasiswa mempresentasikan kasus per kasus pasien
yang dirawatnya melalui metoda nursing round . Evaluasi terhadap pencapaian kompetensi
melalui ujian setiap kompetensi dengan berbagai kasus dapat dilakukan secara bertahap atau di
akhir pembelajaran di klinik.
Waktu Pelaksanaan di RSU HKBP setiap hari Senin s/d Rabu ( 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
BAB 3
A.STRATEGI PEMBELAJARAN
Kegiatan praktik keperawatan medical bedah II 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 pernafasan, cardiovaskuler, pencernaan dan penginderaan
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
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
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
( )
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)
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
(Ka.Ruangan) (Ka.Ruangan)
NIM : .................................................
Ruangan : ……………………………….
Patofisiologi
1. Keluhan
2. Fisik
3. Studi Diagnostik
4. Laboratorium
1.
2.
3.
4.
5.
7.
8.
9.
10.
Kab.Tobasa – Sumut
FORMAT PENGKAJIAN
I. BIODATA
A.IDENTITAS PASIEN
Nama : ..................................................
No.Register : ..................................................
Umur : ..................................................
Agama : ..................................................
Pendidikan : ..................................................
Pekerjaan : ..................................................
Alamat : ..................................................
B.PENANGGUNG JAWAB
Nama : ..................................................................
Pekerjaan : ..................................................................
Alamat : ..................................................................
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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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E. Alergi : ..........................................................................................
F. Immunisasi : ..........................................................................................
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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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 : …………………………………………………………………………………………
Reflek cahaya : …………………………………………………………………………………………
Muka : …………………………………………………………………………………………
Pemakaian alat bantu : …………………………………………………………………………………………
Bibir : …………………………………………………………………………………………
Mukosa gusi : …………………………………………………………………………………………
Lidah : …………………………………………………………………………………………
Tonsil / faring : …………………………………………………………………………………………
Peradangan : …………………………………………………………………………………………
Perdarahan : …………………………………………………………………………………………
Kebersihan : …………………………………………………………………………………………
Bau : …………………………………………………………………………………………
Fungsi pengecapan : …………………………………………………………………………………………
Kemampuan berbicara : …………………………………………………………………………………………
Kemampuan menelan : …………………………………………………………………………………………
6.Integumen ( Kulit )
Warna : …………………………………………………………………………………………
Turgor : ………………………………………………………………………………………
Kebersihan : …………………………………………………………………………………………
Kelainan pada kulit : …………………………………………………………………………………………
7.Leher
Auskultasi : ……………..…………………………………………………………………………
Palpasi : ……………..…………………………………………………………………………
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Perkusi : ……………..…………………………………………………………………………
……………..…………………………………………………………………………
Nyeri dada : ……………..…………………………………………………………………………
Produksi sputum : ……………..…………………………………………………………………………
Irama Pernafasan : ……………..…………………………………………………………………………
Inspeksi jantung : ……………..…………………………………………………………………………
Palpasi : …………………………………………………………………………………………
Ictus cordis ……………..…………………………………………………………………………
Perkusi : …………………………………………………………………………………………
Batas Jantung ……………..…………………………………………………………………………
Auscultasi : …………………………………………………………………………………………
a.Irama denyut jantung
8.Abdoment
Inspeksi : …………………………………………………………………………………………
Auskultasi : …………………………………………………………………………………………
Perkusi : …………………………………………………………………………………………
Palpasi : …………………………………………………………………………………………
- Tanda – tanda nyeri tekan : …………………………………………………………………………………………
- Benjolan /massa : …………………………………………………………………………………………
- Tanda – tanda ascites : …………………………………………………………………………………………
- Hepar : …………………………………………………………………………………………
- Lien : …………………………………………………………………………………………
- Titik Mc.Burney : …………………………………………………………………………………………
Massa /cairan : …………………………………………………………………………………………
Hepar : …………………………………………………………………………………………
Lien : …………………………………………………………………………………………
Ginjal : …………………………………………………………………………………………
Lain – lain : …………………………………………………………………………………………
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Nervus Olfaktorius ( NI )
…………………………………………………………………………………………………………………………………………….
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Nervus Optikus ( NII )
…………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………….
Nervus Occulomotorius , trochlear , dan abdusen ( NII , N IV , N VI )
…………………………………………………………………………………………………………………………………………….
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Nervus Trigeminus ( NV )
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c.Fungsi motorik :
d.Fungsi sensorik :
Graphesthesia Test
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Test membedakan dua titik
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Topognosis test
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e.Refleks
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1 a.Makan :
Diet
Komposisi
Frequensi
Makanan yang disukai
Selera makan
Makanan pantangan
b.Minum :
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
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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Balige , 20
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DIAGNOSA KEPERAWATAN :
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