Lampiran 1

JADWAL PENYUSUNAN KTI

NO KEGIATAN WAKTU
1 Sosialisai Buku Pedoman UAP 3 Mei 2016
2 Pendaftaran sebagai peserta UAP dan pengajuan 3-6 Mei 2016
judul
3 Penyusunan 9-21 Mei 2016
4 Seminar Validasi Proposal 22-28 Mei 2016
5 Studi Lapangan/pengambilan data lapangan : 30 Mei -4 Juni 2016
- Lama perawatan klien (Responden) minimal 3
hari
6 Penyusunan Laporan Akhir KTI 6-18 Juni 2016
7 Ujian Akhir KTI 20-25 Juni 2016
8 Perbaikan Laporan Akhir dan Penyerahan 27-29 Juni 2016

Lampiran 2
Lampiran 3

SURAT PERMOHONAN MENJADI RESPONDEN

Kepada

Yth.Bapak/ Ibu

Di tempat

Yuliani Eka Putri, mahasiswa Program Studi D III Ilmu Keperawatan

Akper Dharma Husada Kediri Angkatan XX. Saya akan melakukan penelitian

tentang “Asuhan Keperawatan Dengan Masalah Kerusakan Integrita Jaringan

pada kasus diabetic foot”. Hasil pengambilan kasus ini akan sangat bermanfaat

dalam pedoman asuhan keperawatan medikal bedah.

Untuk itu saya mohon kesediaan kepada keluarga untuk memberikan

informasi secara jujur tentang keadaan klien. Semua data yang dikumpulkan akan

dirahasiakan dan tanpa nama. Data disajikan untuk kepentingan pengembangan

Ilmu Keperawatan.

Atas partisipasi saudara, saya sampaikan terima kasih.

Hormat Saya,

(YULIANI EKA PUTRI)

Lampiran 4
Lampiran 5
Lampiran 6

AKADEMI KEPERAWATAN DHARMA HUSADA

KEDIRI
JL. PENANGGUNGAN 41 A KEDIRI TELP../FAX : (0358) 772628

FORMAT PENGKAJIAN
KEPERAWATAN MEDIKAL BEDAH

NAMA MAHASISWA : _______________________________________

RUANG : _______________________________________
TANGGAL PENGKAJIAN : _______________________________________

1. BIODATA
Nama Pasien :
_____________________________________________
Nama Panggilan :
_____________________________________________
Umur :
_____________________________________________
Jenis Kelamin :
_____________________________________________
Pendidikan :
_____________________________________________
Diagnosis Medis :
_____________________________________________
Tanggal MRS :
_____________________________________________
Tanggal Pengkajian :
_____________________________________________
Alamat :
_____________________________________________
_____________________________________________
Pekerjaan :
_____________________________________________

2. KELUHAN UTAMA

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. RIWAYAT PENYAKIT SEKARANG

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

4. RIWAYAT PENYAKIT MASA LALU

______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

5. RIWAYAT KESEHATAN KELUARGA

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

GENOGRAM
6. DATA PSIKO SOSIAL SPIRITUAL
_______________________________________________________________\
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
7. POLA SEHARI-HARI (RUMAH DAN RUMAH SAKIT)
a. NUTRISI

Di Rumah Di Rumah Sakit

b. ISTIRAHAT TIDUR

Di Rumah Di Rumah Sakit

c. ELIMINASI
 BAB

Di Rumah Di Rumah Sakit

 BAK
 Di Rumah Di Rumah Sakit

d. KEBERSIHAN DIRI DAN SEKSUAL

Di Rumah Di Rumah Sakit

e. LAIN-LAIN
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

8. KEADAAN / PENAMPILAN UMUM PASIEN

______________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

9. TANDA-TANDA VITAL
Suhu Tubuh : …………………………………
Denyut Nadi : …………………………………
 Tekana Darah : …………………………………
Pernafasan : …………………………………
TB/BB : …………………………………

10. PEMERIKSAAN FISIK

a. Pemeriksaan Kepala Dan Leher

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
b. Pemeriksaan Integumen/Kulit dan Kuku

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

c. Pemeriksaan Payudara dan Ketiak (bila diperlukan)

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
d. Pemeriksaan Thorak/dada

 THORAK
 _________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

 PARU

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

 JANTUNG

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
e. Pemeriksaan Abdomen
____________________________________________________________
____________________________________________________________
____________________________________________________________
 ____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

f. Pemeriksaan kelamin dan Sekitarnya (bila diperlukan)

 GENETALIA
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

 ANUS
_________________________________________________________
_________________________________________________________
_________________________________________________________

g. Pemeriksaan Musculoskeletal
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
_______________________________________________________

h. Pemeriksaan Neurologi
____________________________________________________________
____________________________________________________________
____________________________________________________________
 ____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

i. Pemeriksaan Status Mental

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

11. PEMERIKSAAN PENUNJANG MEDIS

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

12. PENATALAKSANAAN DAN TERAPI

______________________________________________________________
______________________________________________________________
 ______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

13. HARAPAN PASIEN/KELUARGA SEHUBUNGAN DENGAN

MASALAH

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

14. DISCHARGE PLANNING

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Kediri………………..20…

MENGETAHUI PEMBIMBING TANDA TANGAN MAHASISWA

RUANGAN

(………………………………….……) (……………..........………………….)
 ANALISA DATA
NAMA PASIEN : _____________________________
DIAGNOSA MEDIS : _____________________________

NO KELOMPOK DATA KEMUNGKINAN MASALAH

PENYEBAB
 DAFTAR PRIORITAS MASALAH

NAMA PASIEN : ______________________________

DIAGNOSA MEDIS : ______________________________
NO DIAGNOSA TANGGAL TANGGAL TANDA
URUT KEPERAWATAN MUNCUL TERATASI TANGAN
 CATATAN TINDAKAN KEPERAWATAN
NAMA PASIEN : ____________________________
DIAGNOSA MEDIS : ____________________________
NO TGL TANDA
NO JENIS TINDAKAN
DIAGNOSA PELAKSANAAN TANGAN
 CATATAN PERKEMBANGAN
NAMA PASIEN : ____________________________
DIAGNOSA MEDIS : ____________________________
NO TGL TANDA
NO CATATAN PERKEMBANGAN
DIAG. /JAM TANGAN
Lampiran 7

LEMBAR KONSULTASI BIMBINGAN I

Nama : YULIANI EKA PUTRI

NIM : 2013.49.128
Pembimbing I : Dwi Rahayu, S.Kep.Ns., M.Kep
Judul : “Asuhan Keperawatan Dengan Masalah Kerusakan Integritas
Jaringan Pada Kasus Diabetic foot Di Ruang Melati RSUD
Kabupaten Kediri”

No Hari / Tanggal Konsultasi Bimbingan Tanda tangan

1 Kamis, Judul KTI
12-05-2016 BAB I latar belakang
- introduction
- justifikasi
- dampak
- solusi

2 Jum’at Hasil Revisi - justifikasi

13-05-2016 - dampak

3 Rabu Hasil Revisi - rencana keperawatan

18-05-2016 - intervensi dan

- rasional
- metodologi
- etika pengambilan
- Data

4 Kamis Hasil Revisi - metode penulisan

19-05-2016 - -rumusan masalah

- Diagnosa keperawatan

5 Sabtu - rencana keperawatan

 21-05-2016 Hasil Revisi
- Judul KTI
- Rumusan masalah
6 Selasa
24-05-2016 Hasil Revisi
- Metode penulisan
- Daftar pustaka
7 Kamis
26-05-2016 Hasil Revisi - Metode penulisan
- Lampiran depan
8 Senin
30-05-2016 Hasil Revisi - ACC Proposal

9 Kamis BAB IV, V - Askep kamis

28-07-2013 - Perbedaan data 28-07-2013
- Bab V Fakta
- Teori
- Opini

10 Rabu Hasil Revisi - Abstrak Rabu

30-07-2016 - Pembahasan 30-07-2016
- Gambar kaki pasien

11 Jum’at Hasil Revisi - ACC KTI Jum’at

03-08-2016 03-08-2016
Lampiran 8

LEMBAR KONSULTASI BIMBINGAN II

Nama : YULIANI EKA PUTRI

NIM : 2013.49.128
Pembimbing II : Heny Kristanto, S.Kp, M.Kes
Judul : “Asuhan Keperawatan Dengan Masalah Kerusakan Integritas
Jaringan Pada Kasus Diabetic foot Di Ruang Melati RSUD
Kabupaten Kediri ”

No Hari / Tanggal Konsultasi Bimbingan Tanda tangan

1 Senin BAB I, II, III - Metode penulisan
23-05-2013 - Font halaman
- Daftar pustaka
- Pengkajian
- Metodologi
- Subjek penelitian
- Jenis data
- Teknik pengambilan
data
- Analisa data

2 Rabu Hasil Revisi - Metodologi

25-05-2016 - Teknik pengambilan
data
- Wawancara

3 Jum’at Hasil Revisi - Metodologi

27-05-2016 - Teknik pengambilan
data
- Analisa data
4 Sabtu, Hasil revisi - Jenis data
 28-05-2016 - Data subjektif
- Data objektif

5 Senin, Hasil revisi - ACC Proposal

30 -05-2016

6 Selasa, Revisi - Bab IV

02-08-2016 - Bab V

7 Sabtu, Hasil revisi - ACC KTI

06-08-2016
Lampiran 9

Gambar kaki pasien kasus 1

Keterangan: Terdapat luka dengan kedalaman luka, luka dalam sampai menembus

tendon, atau tulang (derajat dua)., berdiameter ±10 cm, bau (+), pus

(+), terdapat jaringan nikrosis

Keterangan: Keadaan luka setelah intervensi hari ke tiga, bau (-), pus berkurang,

terdapat jaringan granulasi.

Lampiran 10

Gambar kaki pasien kasus 2

Keterangan : Luka berdiameter ±15 cm, kedalaman luka, luka dalam sampai

menembus tendon, atau tulang (derajat dua).,Keadaan luka setelah

intervensi hari ke tiga, bau (-), pus berkurang, terdapat jaringan

granulasi.