Format Askep KMB
Format Askep KMB
SOEPRAOEN
PROGRAM STUDI KEPERAWATAN
A. Identitas Klien
Nama : No. RM :
Usia : Tanggal Masuk :
Jenis kelamin : Tanggal Pengkajian :
Alamat : Sumber Informasi :
No. Telepon : Nama klg. dekat yang bisa dihubungi:
Status pernikahan :
Agama : Status :
Suku : Alamat :
Pendidikan : No. telepon :
Pekerjaan : Pendidikan :
Lama bekerja : Pekerjaan :
Diagnosa Medis:
F. Genogram
G. Riwayat Lingkungan
Jenis Rumah Pekerjaan
Kebersihan
Bahaya Kecelakaan
Polusi
Ventilasi
Pencahayaan
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Palpasi :..................................................................................................................................
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- Perkusi :...................................................................................................................................
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- Auskultasi : .............................................................................................................................
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Paru
- Inspeksi ..................................................................................................................................
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- Palpasi : ..................................................................................................................................
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- Perkusi : ..................................................................................................................................
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- Auskultasi : .............................................................................................................................
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4. Payudara & Ketiak
Benjolan/massa : ..........................................................................................................................
Bengkak : ......................................................................................................................................
Nyeri : ...........................................................................................................................................
Nyeri tekan : ................................................................................................................................
Kesimetrisan : ...............................................................................................................................
5. Punggung & Tulang Belakang
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6. Abdomen
Inspeksi ............................................................................................................................................
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Palpasi...............................................................................................................................................
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Perkusi..............................................................................................................................................
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Auskultasi..........................................................................................................................................
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V. Persepsi Klien Terhadap Penyakitnya
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W. Kesimpulan
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X. Perencanaan Pulang
Tujuan Pulang......................................................................................................................................
Transportasi pulang.............................................................................................................................
Dukungan keluarga..............................................................................................................................
Antisipasi bantuan biaya setelah pulang..............................................................................................
Antisipasi masalah perawatan diri setelah pulang...............................................................................
Pengobatan..........................................................................................................................................
Rawat jalan ke......................................................................................................................................
Hal hal yang perlu diperhatikan di rumah............................................................................................
Keterangan lain....................................................................................................................................
Malang,
Pengkaji
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ANALISA DATA
NAMA KLIEN :
NO.REG :
No. Tanggal/
IMPLEMENTASI KEPERAWATAN EVALUASI
Dx Jam
CATATAN PERKEMBANGAN
Tgl No.Dx S O A P I E