Nama : ...................................................

NIM : ...................................................

DEPARTEMEN KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI PROFESI NERS
STIKES BHAKTI AL-QODIRI

FORMAT PENGKAJIAN KMB

Tgl / jam MRS : ……………………………….

Ruang : ……………………………….
No. Register : ……………………………….
Dx. Medis : ……………………………….
Tgl. Pengkajian :……………………………….

A. IDENTITAS KLIEN
Nama : ………………………………... Suami / Istri / Orang tua :
Umur : ………………………………... Nama :.…………………..
Jenis Kelamin : ………………………………… Pekerjaan :…………………..
Agama : ………………………………… Alamat :…………………...
Suku / Bangsa : …………………………………
Bahasa :………………………. ……….. Penanggung jawab :
Pendidikan : ……………………………....... Nama :…………………..
Pekerjaan : ………………………………… Alamat :…………………..
Status : ………………………………… …………………..
Alamat : ………………………………… …………………..
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B. KELUHAN UTAMA
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C. RIWAYAT PENYAKIT SEKARANG

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Upaya yang telah dilakukan

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Terapi yang telah diberikan
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 D. RIWAYAT KESEHATAN DAHULU
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E. RIWAYAT KESEHATAN KELUARGA
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Genogram : Keterangan:

RIWAYAT POLA PEMELIHARAAN KESEHATAN KLIEN

1. Tabel pengkajian nutrisi dan metabolisme
KETERANGAN SEBELUM SAKIT SAAT SAKIT
Frekuensi
Jenis
Porsi
Total konsumsi
Keluhan

2. Tabel pengkajian pola eliminasi

Eliminasi uri BAK
KETERANGAN SEBELUM SAKIT SAAT SAKIT
Frekuensi
Pancaran
Jumlah
Bau
Warna
Perasaan setelah BAK
Total produksi urin
Keluhan
Eliminasi alvi BAB
KETERANGAN SEBELUM SAKIT SAAT SAKIT
Frekuensi
Konsistensi
Bau
Warna
Keluhan

3. Tabel pengkajian pola aktivtas dan kebersihan diri

KETERANGAN SEBELUM SAKIT SAAT SAKIT
Mobilitas rutin
Waktu senggang
Mandi
Berpakaian
Berhias
Toileting
Makan minum
Tingkat ketergantungan

4. Pengkajian pola istirahat tidur

KETERANGAN SEBELUM SAKIT SAAT SAKIT
Jumlah jam tidur siang
Jumlah jam tidur malam
Pengantar tidur
Gangguan tidur
Perasaan waktu bangun

F. Keadaan Lingkungan Yang Mempengaruhi Timbulnya Penyakit

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1. Pola kognitif dan persepsi sensori

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2. Pola konsep diri
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3. Pola hubungan – peran
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4. Pola fungsi seksual – seksualitas

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5. Pola mekanisme koping
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6. Pola nilai dan kepercayaan
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G. STATUS MENTAL ( PSIKOLOGIS)

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H. RIWAYAT SOSIAL
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I. RIWAYAT SPIRITUAL
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J. KONSEP DIRI
1. Gambaran diri
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 2. Harga diri
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3. Ideal diri
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4. Identitas diri
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5. Peran diri
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K. PEMERIKSAAN FISIK
1. Status kesehatan umum
Keadaan / penampilan umum :
Kesadaran :…………………………. GCS :
BB sebelum sakit :…………………………. TB : ..…………………….
BB saat ini :………………………….
BB ideal :………………………….
Perkembangan BB :…………………………..
Tanda - tanda Vital :
TD : ……………………… mmHg Suhu :……………….. C
N : ……………………… x/mnt RR : ……………... x/mnt

2. Kepala
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3. Leher
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4. Thorax dan Kardiovaskuler
Thorax Kardiovaskuler
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5. Abdomen
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6. Tulang belakang
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7. Ekstermitas
Atas Kanan:………………………………………………………………………….
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Atas Kiri:.....………………………………………………………………………….
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Bawah Kanan:.……………………………………………………………………….
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Bawah Kiri:.………………………………………………………………………….
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8. Genetalia dan anus

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9. Pemeriksaan neurologis
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M. PEMERIKSAAN DIAGNOSTIK
a. Laboratorium
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 DARAH LENGKAP
Leukosit: ( N : 3.500 – 10.000 / µL )
Eritrosit: ( N : 1.2 juta – 1.5 juta µL )
Trombosit: ( N : 150.000 – 450.000 / µL )
Haemoglobin: ( N : 11.0 – 16.3 gr/dl )
Haematokrit: ( N : 35.0 – 50 gr / dl )
KIMIA DARAH
Ureum: ( N : 10 – 50 mg / dl )
Creatinin: ( N : 07 – 1.5 mg / dl )
SGOT: ( N : 2 – 17 )
SGPT: ( N : 3 – 19 )
BUN: ( N : 20 – 40 / 10 – 20 mg / dl )
Bilirubin: ( N : 1,0 mg / dl )
Total Protein: ( N : 6.7 – 8.7 mg /dl )
GD puas : ( N : 100 mg/dl )
GD 2 jpp: ( N : 140 – 180 mg / dl )
ANALISA ELEKTROLIT
Natrium: ( N : 136 – 145 mmol / l )
Kalium: ( N ; 3,5 – 5,0 mmol / l )
Clorida: ( N : 98 – 106 mmol / l )
Calsium: ( N : 7.6 – 11.0 mg / dl )
Phospor: ( N : 2.5 – 7.07 mg / dl )

b. Radiologi
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N. TERAPI
a. Oral
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b. Parenteral (melalui pembuluh darah)

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c. Lain-lain
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Jember, .............................. 2021

Mahasiswa,

NIM : ……………………........
F. Analisa Data (1)
Data Masalah Keperawatan Etiologi

DS:

DO:

DS:

DO:

DS:

DO:
G. Analisa Data (2)
Data Masalah Keperawatan Etiologi

DS:

DO:

DS:

DO:

DS:

DO:
 H. Daftar Prioritas Diagnosa Keperawatan

Tanggal Tanda
No. Diagnosa Keperawatan
Muncul Tangan

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5. ................................................................................................
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 I. Rencana Asuhan Keperawatan (1)
TGL NO. DX. TUJUAN INTERVENSI RASIONAL

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 J. Rencana Asuhan Keperawatan (2)
TGL NO. DX. TUJUAN INTERVENSI RASIONAL

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 K. Rencana Asuhan Keperawatan (3)
TGL NO. DX. TUJUAN INTERVENSI RASIONAL

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 L. Rencana Asuhan Keperawatan (4)
TGL NO. DX. TUJUAN INTERVENSI RASIONAL

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 M. Implementasi Keperawatan (1)
NO.
TGL IMPLEMENTASI WAKTU
DX.

1................................................................................................. ...........................
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 N. Implementasi Keperawatan (2)
NO.
TGL IMPLEMENTASI WAKTU
DX.

1................................................................................................. ...........................
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 O. Implementasi Keperawatan (3)
NO.
TGL IMPLEMENTASI WAKTU
DX.

1................................................................................................. ...........................
2................................................................................................. ...........................
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 P. Evaluasi 1 (SOAPIE)
Nama :............... Usia :.................
Kasus :.........................................................................................................

Masalah
Tanggal Jam Catatan Perkembangan TTD
Keperawatan

1.

2.

3.
 Q. Evaluasi 2 (SOAPIE)
Nama :............... Usia :.................
Kasus :.........................................................................................................

Masalah
Tanggal Jam Catatan Perkembangan TTD
Keperawatan

4.

5.

6.
 R. Evaluasi 3 (SOAPIE)
Nama :............... Usia :.................
Kasus :.........................................................................................................

Masalah
Tanggal Jam Catatan Perkembangan TTD
Keperawatan

7.

8.

9.
 S. Evaluasi 4 (SOAPIE)
Nama :............... Usia :.................
Kasus :.........................................................................................................

Masalah
Tanggal Jam Catatan Perkembangan TTD
Keperawatan

10.

11.

12.