FORMAT PENGKAJIAN KMB

A. Format Pengkajian
Nama Mahasiswa :
Nomor NPM :
Tempat Praktek :
Tanggal Praktek :

1. Data Biografi
Identitas Klien :
Nama : ........................................ No Register :
Umur : ........................................
Suku\Bangsa : ........................................
Status perkawinan : ........................................
Agama : ........................................
Pendidikan : ........................................
Pekerjaan : ........................................
Alamat : ........................................
Tanggal Masuk RS : ........................................
Tanggal Pengkajian : ........................................
Catatan Kedatangan : Kursi Roda ( ), Ambulans ( ), Barankar ( )

Keluarga Terdekat Yang Dapat Dihubungi :

Nama/Umur : ........................................ No Telpon : ......................................
Pendidikan : ........................................
Pekerjaan : ........................................
Alamat : ........................................
Sumber Informasi : ........................................

2. Riwayat Kesehatan/Keperawatan
1) Keluhan Utama / Alasan Masuk RS :
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2) Riwayat Kesehatan Sekarang :
Faktor Pencetus :.................................................................................................
.............................................................................................................................
 Sifat Keluhan ( Mendadak/ Perlahan-lahan /Terus Menerus/ Hilang Timbul
Atau Berhubungan Dengan Waktu ) : .................................................................
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.............................................................................................................................
Lokalisasi Dan Sifatnya ( Menjalar/Menyebar/Berpindah Pindah/ Menetap ) :
.............................................................................................................................
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Lamanya Keluhan :..............................................................................................
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Upaya Yang Telah Dilakukan Untuk Mengatasi :
.............................................................................................................................
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Keluhan Saat Pengkajian :...................................................................................
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Diagnosa Medik :
..................................................................Tanggal..............................................
..................................................................Tanggal..............................................

3. Riwayat Kesehatan Dahulu

Penyakit Yang Telah Dialami ( Jenis Penyakit, Lama Dan Upaya Untuk Mengatasi,
Riwayat Masuk RS ) :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Alergi : .........................................................................................................................
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Obat-Obatan Yang Pernah Digunakan :
Obat-Obatan Dosis Dosis Terakhir Frekunsi
(Resep/ObatBebas)
4. Riwayat Kesehatan Keluarga :
Penyakit Menular Atau Keturunan Dalam Keluarga : .....................................................
.........................................................................................................................................
.........................................................................................................................................

5. Pola Fungsi Kesehatan (Gordon)

1) Pola Persepsi Dan Pemeliharaan Kesehatan
Persepsi Terhadap Penyakit :..............................................................................
.............................................................................................................................
Penggunaan :
Tembakau ( Bungkus / Hari, Pipa, Cerutu, Berapa Lama, Kapan Berhenti ) :
.............................................................................................................................
.............................................................................................................................
Alkohol ( Jenis, Jumlah/ Hari/ Minggu/ Bulan) : .................................................
.............................................................................................................................
Alergi ( Obat-Obatan, Makanan, Plester, Dll ) : ..................................................
Reaksi Alergi .......................................................................................................

2) Pola Nutrisi Dan Metabolisme

Diet / Suplement Khusus : .................................................................................
Intruksi Diet Sebelumnya : ..................................................................................
Nafsu Makan ( Normal, Meningkat, Menurun ) : ...............................................
Penurunan Sensasi Kecap, Mual-Muntah, Stomatitis : ......................................
Fluktuasi BB 6 Bulan Terakhir (Naik/Turun) : ......................................................
Kesulitan Menelan (Disfagia) : ..........................................................................
Gigi (Lengkap/Tidak, Gigi Palsu) : ......................................................................
Riwayat Masalah Kulit/Penyembuhan/ (Ruam, Kering, Keringat Berlebihan,
Penyembuhan Abnormal) : .................................................................................
Jumlah Minum/ 24 Jam Dan Jenis (Kehausan Yang Sangat) : .............................
.............................................................................................................................
Frekuensi Makan : .....................................................................................
Jenis Makan : .....................................................................................
Pantangan Atau Alergi : .....................................................................................
Lain-Lain : .....................................................................................

3) Pola Eliminasi
Buang Air Besar (BAB)
Frekunsi : ................................................ Waktu : ....................................
Warna : ..........................................Konstitensi : ...................................
Kesulitan (Diare, Konstipasi, Inkontinesia) : .......................................................
Buang Air Kecil (BAK) :
Frekuensi : ................................................ Waktu : ....................................
Warna : ..........................................Konstitensi : ...................................
Kesulitan (Disuria, Noktiria, Hematuria, Retensi, Inkontinesia) : .......................
 Lain-Lain : ..........................................................................................................

4) Aktivitas Latihan
Kemampuan Perawatan Diri :
0 = Mandiri 3 = Dibantu Orang Lain Dan Peralatan
1 = Dengan Alat Bantu 4 = Ketergantingan / Ketidak Mampuan
2 = Dibantu Orang Lain
Kegiatan / Aktivitas 0 1 2 3 4
Makan Dan Minum
Mandi
Berpakaian/Berdandan
Toileting
Mobilisasi Ditempat Tidur
Berpindah
Berjalan
Menaiki Tangga
Berbelanja
Memasak
Pemeliharaan Rumah

Alat Bantu (Kruk, Pispot, Tongkat, Kursi Roda) :

Kekuatan Otot : ...........................................................................
Kemampuan ROM : ...........................................................................
Keluhan Saat Beraktivitas : ...........................................................................

5) Pola Istirahat Dan Tidur

Lama Tidur : ..........Jam/Malam..........Tidur Siang..........Tidur Sore....................
Waktu : .......................................................................................................
Kebiasaan Menjelang Tidur : ............................................................................
Masalah Tidur (Insomnia, Terbangun Dini, Mimpi Buruk) : ................................
.............................................................................................................................
Lain-Lain ( Merasa Segar / Tidak Setelah Tidur ) : ..............................................
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6) Pola Kognitif Dan Persepsi

Status Mental (Sadar / Tidak, Orientasi Baik Atau Tidak ) : ................................
.............................................................................................................................
Bicara : Normal ( ) Gagap ( ) Aphasia Ekspresif ( )
Kemampuan Berkomunikasi : Ya ( ) Tidak ( )
Kemampuan Memahami : Ya ( ) Tidak ( )
Tingkat Ansiestes : Ringan ( ) Sedang ( ) Berat ( ) Panik ( )
Pendengeran : DBN ( ) Tuli ( ) Kanan/Kiri, Tinitis ( ) Alat
Bantu Dengar ( )
Penglihatan (DBN, Buta, Katarak, Kacamata, Lensakontak, Dll) : .......................
 .............................................................................................................................
Vertigo : ..............................................................................................................
Ketidak Nyamanan/ Nyeri (Akut/Kronis) : ..........................................................
.............................................................................................................................
Penatalaksanaan Nyeri : .....................................................................................
Lain-Lain : ...........................................................................................................

7) Persepsi Diri Dan Konsep Diri

Perasaan Klien Tentang Masalah Kesehatan : ....................................................
.............................................................................................................................
Lain-Lain : ...........................................................................................................

8) Pola Peran Hubungan

Pekerjaan :
Sistem Pendukung : Pasangan ( ), Tetangga ( ), Tidak Ada ( ), Keluarga
Serumah ( ), Keluarga Tinggal Berjauhan ( ).
Masalah Keluarga Berkenan Dengan Perawatan RS : .........................................
.............................................................................................................................
.............................................................................................................................
Kegiatan Sosial : .......................................................................................
Lain-Lain : .......................................................................................

9) Pola Seksual Dan Reproduksi

Tanggal Menstruasi Terakhir (TMA) : ...............................................................
Masalah Menstruasi : ...............................................................
Pap Smear Terakhir : ...............................................................
Masalah Seksual B.D Penyakit : ...............................................................
Lain-Lain : ...............................................................

10) Pola Koping Dan Toleransi Stress :

Perhatian Utama Tentang Perawatan di RS Atau Penyakit (Finansial,
Perawatan Diri : ..................................................................................................
.............................................................................................................................
.............................................................................................................................
Kehilangan / Perubahan Besar Dimasa Lalu : .....................................................
Hal Yang Dilakukan Saat Ada Masalah (Sumber Koping) : ..................................
Penggunaan Obat Untuk Menghilangkan Stress : ..............................................
Keadaan Emosi Dalam Sehari-Hari (Santal/Tegang) : .........................................
Lain-Lain : ...........................................................................................................

11) Kenyakinan Dan Kepercayaan

Agama : ...............................................................................................................
Pengaruh Agama Dalam Kehidupan : .................................................................
B. Pemeriksaan Fisik
1. Keadaan Umum :
Kesadaran : ......................................... GCS : ...................................................
Klien Tampat Sehat/Sakit/Sakit Berat : ....................................................................
BB : ....................................................
TB : ....................................................
2. Tanda-Tanda Vital :
TD : .............................................
ND : .............................................
RR : .............................................
S : .............................................
3. Kulit
Warna Kulit ( Sianosis, Ikterus, Pucat Eritema, Dll ) : ...............................................
Kelembaban : .....................................................................................
Tugor kulit : .....................................................................................
Ada atau Tidaknya Odema : ......................................................................................
4. Kepala / Rambut
Inspeksi : ......................................................................................
Palpasi : ......................................................................................
5. Mata
Fungsi Penglihatan : Palpebra :
Ukuran Pupil :
Konjungtiva : Sklera :
Lensa / Iris :
Odema Palpebra :
6. Telinga
Fungsi Peendengaran : Fungsi Keseimbangan :
Kebersihan : Sekret :
Daun Telinga : Mastoid :
7. Hidung Dan Sinus
Inspeksi :
Fungsi Penciuman :
Pembekakan : Pendarahan :
Kebersihan : Sekret :
8. Mulut Dan Tenggorokan
Membran Mukosa : Kebersihan Mulut :
Keadaan Gigi :
Tanda Radang ( Bibir, Gusi, Lidah ) :
Trismus :
Kesulitan Menelan :
9. Leher
Trakea ( Simetris Atau Tidak ) :
Kartoid Bruid :
 JVP :
Kelenjar Limfe :
Kelenjar Tiroid :
Kuku Kuduk :
10. Thorak Atau Paru
Inspeksi :
Palpasi :
Perkusi :
Auskultasi :
11. Jantung
Inspeksi :
Palpasi :
Perkusi :
Auskultasi :
12. Abdomen
Inspeksi :
Palpasi :
Perkusi :
Auskultasi :
13. Genetalia :
14. Rektal :
15. Ekstermitas :
16. Vaskuler Perifer
Capilary Refille :
Clubbing :
Perubahan Warna :
17. Neurologis
Status Mental / GCS :
Motorik :
Sensorik :
Tanda Rangsangan Meninggal :
Saraf Kranial :
Reflek Pisiologis :
Reflek Ptologis :

C. Pemeriksaan Penunjang (Diagnostik dan Laoratorium)

( Dibuat Setiap Dilakukan Pemeriksaan Berdasarkan Tanggal Dilakukan)
No Hari / Tgl Jenis Hasil Nilai Normal interprestasi
Pemeriksaan
D. Penatalaksanaan Pengobatan
No Tgl Dan Waktu Jenis (Oral/Iv/Im/Topikal) Dosis Indikasi