FORMAT PENGKAJIAN KMB

PROGRAM STUDI S1 KEPERAWATAN DENGAN PENDEKATAN POLA

FAKULTAS ILMU-ILMU KESEHATAN FUNGSI KESEHATAN MENURUT GORDON
UNIVERSITAS NUSA NIPA
MAUMERE ( GORDON’S FUNCTIONAL HEALTH PATTERNS)

Tanggal masuk :……………………………. Tanggal Pengkajian :………………………….

Ruangan/Kelas :……………………………. Waktu Pengkajian :………………………….

No. Kamar :…………………………… Auto Anamese :………………………….

No Registrasi : Allo Anamese :…………………………

I. IDENTITAS
1. Nama :……………………………………………………………….
2. Umur :………………………………………………………………
3. Jenis kelamin :……………………………………………………………….
4. Agama :………………………………………………………………
5. Suku / bangsa :………………………………………………………………
6. Pendidikan :………………………………………………………………
7. Pekerjaan :………………………………………………………………
8. Alamat :………………………………………………………………
9. Penanggung jawab :………………………………………………………………

II. DATA MEDIK

1. Dikirim Oleh : UGD Dokter Praktik
2. Diagnosa Medik :
- Saat Masuk :………………………………………………………………
- Saat Pengkajian :………………………………………………………………

III. KEADAAN UMUM

1. Keadaan Sakit ; Klien tampak sakit ringan/sedang/berat
Dengan alasan : Tak bereaksi/ baring lemah/ duduk/ aktif/ gelisah/ posisi
tubuh……………..................…/ pucat/ cyanosis/ sesak nafas/ penggunaan alat
medis………………............... lain –lain……………………………………………….
2. Tanda – Tanda Vital :
 Kesadaran : ........................................................................................................
 Skala Coma Glasgow : Respon Motorik :
Respon Bicara :
Respon Membuka Mata :
Kesimpulan : .....................................................................................................
 Tekanan Darah :……………………………..mmHg
MAP :…………………………….mmHg
Kesimpulan : .............................................................................................

Asuhan Keperawatan Medikal Bedah |1

  Suhu :………............ Nadi :……………...
 Pernapasan : frekuensi……………….x/mnt
Irama : teratur / Kusmaul / cheysnes – strokes
Jenis : dada / perut
3. Antropometri :
 Lingkar lengan Atas :………………cm
 Tinggi Badan :………………cm
 Berat Badan :………………kg
 IMT ( Indeks Masa Tubuh ) :……………......................................…kg/m2
 Kesimpulan :……………………......................................
4. Genogram (min 3 generasi ke atas)

IV. RIWAYAT SAKIT DAN KESEHATAN

1. Keluhan Utama
:………………………………………………………………………………....
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2. Riwayat Penyakit Sekarang
:…………………………………………………………………………………
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Asuhan Keperawatan Medikal Bedah |2

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3. Riwayat Penyakit Dahulu :

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4. Riwayat Alergi :
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5. Riwayat Kesehatan Keluarga :…………………………………………………

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V. POLA FUNGSI KESEHATAN ( Gordon’s functional health )

1. Pola Persepsi/penatalaksanaan kesehatan :
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2. Pola Nutrisi Metabolik;
a. Keadaan sebelum sakit
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b. Keadaan saat sakit
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3. Pola Eliminasi :
a. Keadaan sebelum sakit
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b. Keadaan saat sakit
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4. Pola Aktivitas dan Latihan :

a. Keadaan sebelum sakit
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b. Keadaan saat sakit
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5. Pola Persepsi dan Kognitif :

a. Keadaan sebelum sakit
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b. Keadaan saat sakit
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6. Pola Persepsi dan Konsep Diri :
a. Keadaan sebelum sakit
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Asuhan Keperawatan Medikal Bedah |4

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b. Keadaan saat sakit
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7. Pola Reproduksi – Seksualitas :
a. Keadaan sebelum sakit
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b. Keadaan saat sakit
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8. Pola Mekanisme koping dan Toleransi terhadap Sters
a. Keadaan sebelum sakit
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b. Keadaan saat sakit
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9. Pola Nilai Kepercayaan :

a. Keadaan sebelum sakit
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b. Keadaan saat sakit
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Asuhan Keperawatan Medikal Bedah |5

VI. PENGKAJIAN FISIK
1. Rambut dan kulit kepala:………………………………………………………………….
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2. Hidrasi kulit:……………………………………………………………………………...
3. Mata:
a. Palpebral:…………………………………………………..........................................
b. Conjungtiva:………………………………………………………………………...
c. Kornea:……………………………………………………………………………….
d. Sklera:………………………………………………………………………………...
e. TIO:…………………………………………………………………………………..
f. Pupil:………………………………………………………………………………….
g. Refleks cahaya:……………………………………………………………………….
h. Visus:…………………………………………………………………………………
4. Hidung:…………………………………………………………………………………...
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5. Rongga mulut:……………………………………………………………………………
a. Gigi geligi:……………………………………………………………………………
b. Lidah:…………………………………………………………………………………
c. Tonsil:………………………………………………………………………………...
6. Telinga:
a. Pina:…………………………………………………………………………………..
b. Canalis:……………………………………………………………………………….
c. Membrane timpani: …………………………………………………………………
d. Tes pendengaran:
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7. Leher: …………………………………………………………………………………..
JVP:…….…………………………………………………………………………………
Kesimpulan:…..…………………………………………………………………………..

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 8. Kelenjar getah bening: ……………………………………………………………………
Tiroid:…………………………………………………………………………………….
9. Kaku kuduk: ……………………………………………………………………………..
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10. Thorak:
a. Inspeksi: ……………………………………………………………………………..
b. Palpasi: ………………………………………………………………………………
c. Perkusi: ………………………………………………………………………………
d. Batas paru: …………………………………………………………………………..
Kesimpulan: ……………………………………………………………………………..
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11. Jantung:
a. Inspeksi: ……………………………………………………………………………..
b. Palpasi: ………………………………………………………………………………
c. Perkusi: ………………………………………………………………………………
d. Auskultasi:BJ II.A:………………………..BJ II-P:………………………………....
BJ I-T:…………………………………..BJ I-M:……………………………………
12. Abdomen:
a. Inspeksi: ……………………………………………………………………………..
b. Auskultasi: …………………………………………………………………………...
c. Palpasi: ………………………………………………………………………………
d. Perkusi: ………………………………………………………………………………
13. Ginjal: nyeri ketuk………………………………………………………………………..
14. Kelenjar linfe, inguinal, genital, anus:……………………………………………………
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15. Lengan dan tungkai: ……………………………………………………………………..
a. Inspeksi: ……………………………………………………………………………...
b. Rentang gerak: ……………………………………………………………………….
c. Kekuatan otot; ………………………………………………………………………..
d. Refleks fisiologi: ……………………………………………………………………..
e. Refleks patologi: ……………………………………………………………………..
16. Payudara: …………………………………………………………………………………
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17. Cullumna vertebralis: ……………………………………………………………………
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 18. Uji saraf cranialis:
a. NI: ……………………………………………………………………………………
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b. NII: …………………………………………………………………………………..
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c. NIII, IV,VI: …………………………………………………………………………..
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d. NV: Sensorik: ………………………………………………………………………..
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Motorik: ………………………………………………………………………...
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e. NVII: Sensorik: ………………………………………………………………………
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Motorik: ………………………………………………………………………...
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f. NVIII: ………………………………………………………………………………..
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g. NIX: …………………………………………………………………………………
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h. NX: …………………………………………………………………………………..
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i. NXI: ………………………………………………………………………………….
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j. NXII:…………………………………………………………………………………
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 19. Sistem Reproduksi
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VII. Pemeriksaan Penunjang

Hasil
Tanggal Pemeriksaan No Kriteria Nilai Normal Satuan
Pemeriksaan

Asuhan Keperawatan Medikal Bedah |9

VIII. TERAPI

Dosis Cara Kontra

TgL No Terapi Indikasi
(Kandungan Obat) Pemberian Indikasi

......................., ………………… 2017 Mengetahui,

Pengkaji, Preseptor ...................................

(______________________________) ( ___________________________ )

Asuhan Keperawatan Medikal Bedah | 10

 B. KLASIFIKASI DATA :

Hari / Tanggal : ……………………………...........................................................................

Nama Klien/ Usia : …………………………....... / .....................................................................
Diagnosa Medis : ……………………………...........................................................................

DATA SUBYEKTIF :
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DATA OBYEKTIF : (Termasuk Hasil Pemeriksaan Fisik, Monitoring, dan Pemeriksaan Penunjang)
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Asuhan Keperawatan Medikal Bedah | 11

 C. ANALISA DATA :

Hari / Tanggal : ……………………………...........................................................................

Nama Klien/ Usia : …………………………....... / .....................................................................
Diagnosa Medis : ……………………………...........................................................................
(minimal 3 diagnosa)
No Data Etiologi Problem (NANDA)

Asuhan Keperawatan Medikal Bedah | 12

 D. DIAGNOSA KEPERAWATAN :

Hari / Tanggal : ……………………………...........................................................................

Nama Klien/ Usia : …………………………....... / .....................................................................
Diagnosa Medis : ……………………………...........................................................................

PRIORITAS MASALAH KEPERAWATAN :

1. .............................................................................................................................................

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2. .............................................................................................................................................

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3. .............................................................................................................................................

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4. .............................................................................................................................................

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5. .............................................................................................................................................

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6. .............................................................................................................................................

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7. .............................................................................................................................................

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8. .............................................................................................................................................

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 E. PATOFLOWDIAGRAM KASUS :

Asuhan Keperawatan Medikal Bedah | 14

 Contoh Format
F. RENCANA KEPERAWATAN SALIN di lembar bagian tengah
DEPARTEMEN ........................................................... Double Folio Bergaris

NAMA KLIEN : .................................................................................................................................... NAMA MAHASISWA : ......................................................

NIRM : .................................................................................................................................... PROGRAM : ...........................................................
DIAGNOSA MEDIS : .................................................................................................................................... INSITITUSI : .......................................................
BANGSAL / TEMPAT : ....................................................................................................................................

TUJUAN DAN KRITERIA HASIL RENCANA KEPERAWATAN (NIC)

DIAGNOSA AKTUAL / RESIKO / PK /
No TGL
KEPERAWATAN (NANDA) WELLNESS
(NOC) DAN RASIONAL

1 ....

R/ ....

2. ...

R/ ....

Dst..

(Berdasarkan ONEC, yaitu :

 Observation (Observasi)
 Nursing (Tindakan Mandiri Perawat)
 Education (Pendidikan Kesehatan)
 Collaboration (Kolaborasi Medis, Paramedis, dan
Keluarga)

Asuhan Keperawatan Medikal Bedah 15 NERS-FIKES-UNIPA

Asuhan Keperawatan Medikal Bedah 16 NERS-FIKES-UNIPA
 IMPLEMENTASI
Nama Klien :
Usia : Diagnosa Medis :

No Hari/Tgl/Jam Implementasi Paraf

Asuhan Keperawatan Medikal Bedah 17

NERS-FIKES-UNIPA
Asuhan Keperawatan Medikal Bedah 18

NERS-FIKES-UNIPA
 EVALUASI
Nama Klien :
Usia : Diagnosa Medis :

No Hari/Tgl/Jam EVALUASI Paraf

Asuhan Keperawatan Medikal Bedah 19

NERS-FIKES-UNIPA
Asuhan Keperawatan Medikal Bedah 20

NERS-FIKES-UNIPA