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Nama Mahasiswa : KELOMPOK I KMB Tempat Praktik :
NIM : Tgl. Praktik :

A. Identitas Klien
Nama :Tn.S............................................ No. RM : ............................................
Usia :68 tahun .. Tgl. Masuk :11-11-2019 ..........................
Jenis kelamin :Laki-laki ..................................... Tgl. Pengkajian :11-11-2019 ..........................
Alamat :jl.tlogo mas ................................ Sumber informasi :Ny.C ....................................
No. telepon :081353267893 ........................... Nama klg. dekat yg bisa dihubungi: .........................
Status pernikahan :menikah ..................................... .............................................
Agama :islam .......................................... Status :ISTRI ..................................
Suku :Jawa ........................................... Alamat :Jl.Tlogo Mas .......................
Pendidikan :SMA........................................... No. telepon :082565893212.....................
Pekerjaan : Pensiunan PNS .......................... Pendidikan :SMA ....................................
Lama berkerja :5 Tahun ...................................... Pekerjaan :IRT ......................................

B. Status kesehatan Saat Ini

1. Keluhan Utama
a. Saat MRS
klien mengatakan nyeri pada bagian persendian ibu jari kaki dan merasa keram
b. Saat Pengkajian
klien mengatakan nyeri telah dialami selama 3 hari sejak sebelum MRS sampai saat ini

2. Riwayat Kesehatan Saat ini

Klien mengatakan pada tgl.10-11-2019, pukul 17.00 WIB kakinya terasa keram dan nyeri hebat, badannya
terasa lemah, kepalanya terasa sakit, dan berkeringat dingin.Kemudian keluarga memutuskan agar klien
dibawa ke RS

C. Riwayat Kesehatan Terdahulu

1. Penyakit yg pernah dialami:
a. Kecelakaan (jenis & waktu) :Tidak ada ....................................................................................................
b. Operasi (jenis & waktu) :Tidak ada ....................................................................................................
c. Penyakit:
 Kronis :Tidak ada ...................................................................................................................................
 Akut :Tidak ada ...................................................................................................................................
d. Terakhir masuki RS :1 tahun lalu .................................................................................................
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2. Alergi (obat, makanan, plester, dll):

Tipe Reaksi Tindakan
............................................................... ........................................................ ...................................................
Tidak ada ............................................... tidak ada .......................................... tidak ada ....................................
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 cukup baik .................................................. cukup baik .......................................
 Bahaya kecelakaan tidak ........................................................... tidak ..................................................
 Polusi baik ............................................................ cukup baik ........................................
 Ventilasi baik ............................................................ baik ...................................................
 Pencahayaan baik ............................................................ baik ...................................................
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F. Pola Aktifitas-Latihan
Rumah Rumah Sakit
 Makan/minum 1 ............................................................. 2 ....................................................
 Mandi 1 ............................................................. 2 ....................................................
 Berpakaian/berdandan 1 ............................................................. 2 ....................................................
 Toileting 1 ............................................................. 2 ....................................................
 Mobilitas di tempat tidur 1 ............................................................. 2 ....................................................
 Berpindah 1 ............................................................. 2 ....................................................
 Berjalan 1 ............................................................. 2 ....................................................
 Naik tangga 1 ............................................................. 2 ....................................................
Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain (1 orang) , 3 = dibantu orang lain
(min. 2 orang), 4 = tidak mampu

G. Pola Nutrisi Metabolik

Rumah Rumah Sakit
 Jenis diit/makanan ........................................................ ...................................................
 Frekuensi/pola 3 kali ............................................... ...................................................
 Porsi yg dihabiskan 3 ...................................................... ...................................................
 Komposisi menu ikan,tempe ....................................... ...................................................
 Pantangan tidak ada .......................................... ...................................................
 Napsu makan stabil ................................................ ...................................................
 Fluktuasi BB 6 bln. terakhir ........................................................ ...................................................
 Jenis minuman kopi ................................................. ...................................................
 Frekuensi/pola minum 3 kali ............................................... ...................................................
 Gelas yg dihabiskan 1 gelas ............................................. ...................................................
 Sukar menelan (padat/cair) ........................................................ ...................................................
 Pemakaian gigi palsu (area) tidak ada .......................................... ...................................................
 Riw. masalah penyembuhan luka tidak ada .......................................... ...................................................

H. Pola Eliminasi
Rumah Rumah Sakit
 BAB:
- Frekuensi/pola ............................................................... ....................................................
- Konsistensi ............................................................... ....................................................
- Warna & bau kuning .................................................... ....................................................
- Kesulitan tidak ....................................................... ....................................................
- Upaya mengatasi ............................................................... ....................................................
 BAK:
- Frekuensi/pola ............................................................... ....................................................
- Warna & bau kuning .................................................... ....................................................
- Kesulitan ............................................................... ....................................................
- Upaya mengatasi ............................................................... ....................................................
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I. Pola Tidur-Istirahat
Rumah Rumah Sakit
 Tidur siang:Lamanya ........................................................ ......................................................
- Jam …s/d… 13.00-15.00 .................................... .....................................................
- Kenyamanan stlh. tidur ....................................................... .....................................................
 Tidur malam: Lamanya ........................................................ ......................................................
- Jam …s/d… 20.00-23.00 .................................... .....................................................
- Kenyamanan stlh. tidur tidak nyaman .................................. .....................................................
- Kebiasaan sblm. tidur pijat kaki......................................... .....................................................
- Kesulitan ....................................................... .....................................................
- Upaya mengatasi ....................................................... .....................................................

J. Pola Kebersihan Diri

Rumah Rumah Sakit
 Mandi:Frekuensi ............................................................ ...................................................
- Penggunaan sabun 1 ........................................................ ..................................................
 Keramas: Frekuensi ............................................................ ...................................................
- Penggunaan shampoo 1 ........................................................ ..................................................
 Gosok gigi: Frekuensi ............................................................ ...................................................
- Penggunaan pasta gigi 2 ........................................................ ..................................................
 Ganti baju:Frekuensi 2 .......................................................... ...................................................
 Memotong kuku: Frekuensi 1 .......................................................... ...................................................
 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

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1. Peran dalam keluarga kepala rumah tanggah .............................................................................................................

2. Sistem pendukung:suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain, sebutkan:suami ............................
......................................................................................................................................................
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:keluarga ...................................................................................
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: ........................................................................................................................................................

...................................................................................................................................................................................
. ..................................................................................................................................................................................
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 Kesadaran: ............................................................................................................................................................
 Tanda-tanda vital: - Tekanan darah :150/90 mmHg - Suhu :37,5………oC
- Nadi :85 x/menit - RR :20……… x/menit
 Tinggi badan: ................................................. cm Berat Badan: ...................................kg
2. Kepala & Leher
a. Kepala:
Tidak ada masalah ...............................................................................................................................
b. Mata:
Tidak ada masalah ...............................................................................................................................
c. Hidung:
Tidak ada masalah ...............................................................................................................................
d. Mulut & tenggorokan:
Tidak ada masalah ...............................................................................................................................
e. Telinga:
Tidak ada masalah ...............................................................................................................................
f. Leher:
Tidak ada masalah ................................................................................................................................................
3. Thorak & Dada:
 Jantung
- Inspeksi:..........................................................................................................................................................
- Palpasi: ...........................................................................................................................................................
- Perkusi: ...........................................................................................................................................................
- Auskultasi: ......................................................................................................................................................
 Paru
- Inspeksi:..........................................................................................................................................................
- Palpasi: ...........................................................................................................................................................
- Perkusi: ...........................................................................................................................................................
- Auskultasi: ......................................................................................................................................................
4. Payudara & Ketiak
Tidak ada masalah ...........................................................................................................................................

5. Punggung & Tulang Belakang

.........................................................................................................................................................................
6. Abdomen
 Inspeksi: ...............................................................................................................................................................
.............................................................................................................................................................................
 Palpasi: .................................................................................................................................................................
.............................................................................................................................................................................
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 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. Terapi
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Persepsi Klien Terhadap Penyakitnya
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A. ANALISA DATA
Nama Pasien : Tn.S
Umur : 68 Tahun
No. Register :
DATA PENUNJANG ETIOLOGI MASALAH
KEPERAWATAN
Sirkulasi darah daerah Nyeri akut
DS: Klien mengatakan radang (+)
nyeri
pada bagian kaki kanan
kiri,
tepatnya pada ibu jari.
DO: kekakuan pada kaki Vasodilatasi dari
dan kapiler
terdapat edema pada ibu
jari
kaki.
TTV :
T.D = 150/90 mmHg
RR = 20x/menit Eritema, Panas
Nadi= 85x/menit

Nyeri akut

DS : Pasien mengatakan Akumulasi cairan

gelisah bila bergerak. eksudat pd jaringan
DO : intertisial
Hambatan mobilitas
Pa Pasien terlihat lemas
Sianosis (+) fisik
Berkeringat dingin bila
merubah posisi dari tidur
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langsung duduk Oedema jaringan

Penekanan pada
jaringan sendi

DS : AMI Hipertensi
Klien mengeluh pusing ↓
DO : Vasokontriksi oleh
TD pasien mencapai saraf
150/90 simpatis
mmHg ↓
Peningkatann tekanan
darah
lebih dari 140/mmHg
↓
Hipertensi

B. DIAGNOSA KEPERAWATAN

DAFTAR DIAGNOSA KEPERAWATAN

BERDASARKAN PRIORITAS

No Diagnosa Keperawatan Tanggal Ditemukan Tanggal Teratasi

1. Nyeri akut b.d

2. Hambatan mobilitas fisik b.d gangguan perfusi

jaringan
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C. PERENCANAAN
RENCANA ASUHAN KEPERAWATAN

Diagnosa Keperawatan No. 1.Nyeri akut

2. Hambatan mobilitas fisik b.d gangguan perfusi jaringan

Tujuan

Kriteria Hasil

NOC
No. Indikator 1 2 3 4 5
1.

Keterangan Penilaian :
1 : idak sesuai
2 : g tidak sesuai
3 : adang tidak sesuai
4 : ang tidak sesuai
5 : esuai

Intervensi NIC
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2. Tujuan, Kriteria Standar, Interensi, Rasional

IMPLEMENTASI
Nama Klien : Tanggal Pengkajian :
No Reg : Diagnosa Medis :
No. Dx. TTD & Nama
Tgl Jam Tindakan Keperawatan Respon Klien
Kep. Terang
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D. PELAKSANAAN
CATATAN PERKEMBANGAN (PROGRESS NOTE)

Diagnosa Keperawatan No.

NOC :
Tanggal Observasi dan Hasil
No. Indikator
1 2 3 4 S 1 2 3 4 S 1 2 3 4 S

Keterangan Penilaian :
- : tidak sesuai
+ : sesuai yang diharapkan
S : Skoring
Keterangan Skoring :
1:-
2 : 1+
3 : 2+
4 : 3+
5 : 4+
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E. EVALUASI
EVALUASI

Hari/Tanggal
No. Dx Kep Evaluasi TTD
Jam
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RESUME KEPERAWATAN

NAMA KLIEN : TANGGAL :

NO. REG : DX. MEDIS :

S O A P I E
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FORMAT PENILAIAN
LAPORAN PENDAHULUAN DAN RENCANA KEPERAWATAN

Nama : Kelompok :
Tgl evaluasi : Ruang :
No Aspek yang dinilai Skore
1 Konsep dasar 30
1. Pengertian
2. Patofisiologi dan pohon masalah
3. Tanda dan gejala
4. Terapi
2 Konsep Asuhan Keperawatan 40
1. Pengkajian
2. Diagnosa keperawatan
3. Intervensi keperawatan
3 Referensi : minimal 3 buku keperawatan edisi 5 th terakhir 10
4 Responsi tepat waktu (sebelum pengkajian askep/paling 10
lambat hari ke-2 praktik di ruangan)
5 Pengumpulan tepat waktu (setelah responsi institusi, 10
maksimal hari ke-2 praktik di setiap ruangan)
Nilai Total 100

FORMAT PENILAIAN ASUHAN KEPERAWATAN DAN RESUME

Nama : Kelompok :
Tgl evaluasi : Ruang :

No Aspek yang dinilai Skore

1 Pengkajian : (pengumpulan data, analisa data, diagnosa

25
keperawatan)
2 Perencanaan : (prioritas masalah, tujuan, rencana
25
keperawatan, rasional )
3 Implementasi : (spesifikasi tindakan, obyektif, tepat) 25
4 Evaluasi : (re assesment, interpreting, planning) 25
5 Responsi tepat waktu (maksimal hari ke-3 setelah
pengkajian)
6 Pengumpulan tepat waktu (setelah revisi, maksimal hari
ke 5 praktik di setiap ruangan)
Nilai Total 100
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FORMAT PENILAIAN RESPONSI

LAPORAN PENDAHULUAN DAN ASUHAN KEPERAWATAN

No. Aspek Yang Dinilai Skore

1. Mampu menghubungkan tanda-tanda klinis dengan 10
patofisiologis yang terjadi
2. Mampu menganalisa data-data penunjang dengan benar 10
3. Mempu menjelaskan alas an prioritas masalah keperawatan 10
4. Mempu menjelaskan rasional dari tindakan keperawatan 15
5. Mempu menjelaskan tujuan tindakan kolaburasi 15
6. Mempu menjelaskan hasil evaluasi dari tindakan yang 10
dilakukan
7. Mampu menjelaskan kekurangan (penilaian diri) yang telah 10
dilakukan
8. Responsi tepat waktu (sesuai ruangan tempat dinas) 10
9. Pengumpulan tepat waktu (setelah responsi instirusi, 10
maksimal hari-6 praktik di setiap ruangan)
Total 100

FORMAT UJIAN AKHIR KEPERAWATAN MEDIKAL

No Aspek yang dinilai Skore

Pengkajian : (pengumpulan data, analisa data, diagnosa

1 25
keperawatan)
Perencanaan : (prioritas masalah, tujuan, rencana keperawatan,
2 25
rasional)
3 Implementasi : (spesifikasi tindakan, obyektif, tepat) 25
4 Evaluasi : (re assesment, interpreting, planning) 25
Total 100