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

3. Riwayat Kesehatan Dahulu

Penyakit Yang Telah Dialami ( Jenis Penyakit, Lama Dan Upaya Untuk Mengatasi,
Riwayat Masuk RS ) :
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Alergi :
..........................................................................................................................................
………………………………………………………………………………………….
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 :
1 = Mandiri 3 = Dibantu Orang Lain Dan Peralatan
2 = Dengan Alat Bantu 4 = Ketergantingan / Ketidak Mampuan
3 = 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 ) : ...........................................

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 Bnatu 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 Pendengaran : 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 Jenis (Oral/Iv/Im/Topikal) Dosis Indikasi
Waktu