Format Pengkajian KDM s1 2021

LAPORAN ASUHAN KEPERAWATAN
PRAKTIK KLINIK KEPERAWATAN DASAR
JUDUL:
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NAMA :..............................................................
TK/SMT :..............................................................
NIM :..............................................................
PROGRAM STUDI S1 KEPERAWATAN

STIKes BINA SEHAT PPNI KAB. MOJOKERTO
TA 2021/2022
Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

HALAMAN PENGESAHAN
Laporan asuhan keperawatan ini diajukan oleh :

Nama : ………………………………………………………………..
NIM : ………………………………………………………………..
Tingkat/ smt : ………………………………………………………………..
Program studi : ………………………………………………………………..
Judul asuhan keperawatan : ……………………………………………………………………..
…………………………………………………………………………………………………….
Telah diperiksa dan disetujui sebagai bagian dari persyaratan yang diperlukan untuk memenuhi
capaian pembelajaran Praktik Klinik Keperawatan Dasar pada Program Studi S1 Keperawatan STIKes
Bina Sehat PPNI Kab. Mojokerto
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Pembimbing ruangan, Pembimbing pendidikan,
(..........................................................) (........................................................)
Mengetahui,
Kepala ruangan
(..............................................................)

PENGKAJIAN KEPERAWATAN DASAR
PENDEKATAN 11 POLA GORDON
Rumah Sakit :.......................................

Ruang :.......................................
I. BIODATA
Nama :....................................... Status :.......................................

perkawinan
Register :....................................... Pendidikan :.......................................
Jenis Kelamin :....................................... Agama :.......................................
Pekerjaan :....................................... MRS tanggal :.......................................
Alamat :....................................... Diagnosa masuk :.......................................
Tanggal pengkajian :....................................... Oleh :.......................................
II. POLA KESEHATAN FUNGSIONAL

1. Pola persepsi kesehatan / penanganan kesehatan
a. Keluhan Utama
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b. Riwayat Penyakit Sekarang (RPS)
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c. Riwayat Penyakit Dahulu (RPD)
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d. Riwayat Penyakit Keluarga (RPK)
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2. Pola Nutrisi/ Metabolisme
a. Data Subyektif:
Intake nutrisi ( frekuensi, jumlah& komposisi)
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Intake cairan ( frekuensi,jumlah & jenis )
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Nafsu makan :........................................................................................
Masalah dengan makan :…………………………………………………………
Makanan kesukaan :........................................................................................
Alergi makanan :........................................................................................
b. Data Obyektif:
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3. Pola Eliminasi
Eliminasi Uri
a. Data Subyektif:
Pola BAK ( frekuensi, waktu, jumlah ) :................................................................
Karakteristik ( warna, kejernihan, bau, endapan ) :................................................................
Faktor yg mempengaruhi BAK :................................................................
Masalah eliminasi uri :................................................................
b. Data Obyektif:
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Eliminasi alvi
a. Data Subyektif:
Pola BAB ( frekuensi,waktu ) :................................................................
Karakteristik keluaran feses (bau , jumlah ) :................................................................
Masalah dengan BAB :................................................................
Faktor yang mempengaruhi BAB :................................................................
Penggunaan laksantif :................................................................
b. Data Obyektif:
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4. Pola Aktivitas – Latihan

Mobilitas/aktivitas
a. Data Subyektif
Pola aktivitas yg dilakukan :………………………………………………………....
Aktivitas diwaktu luang :……………………………………………………........
Masalah dalam aktivitas :……………………………………………………........
Penggunaan alat bantu :………………………………………............................
Aktivitas sejak sakit :........................................................................................
b. Data Obyektif:
Kemampuan perawatan diri
Jenis kemampuan 0 1 2 3 4
Makan / minum
Berpakaian
Mandi
Toileting
Mobilisasi di tempat tidur
Berjalan
0 : Mandiri 3 : Bantuan peralatan dan orang lain
1 : Dengan bantuan orang lain 4 : Tidak mampu
2 : Menggunakan alat bantu
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Respirasi
a. Data Subyektif
Masalah dalam pernafasan :……………………………………………………........
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Adakah keluhan batuk :………………………………………............................
Keluhan lainnya :........................................................................................
c. Data Obyektif:
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Sirkulasi
a. Data Subyektif
Masalah dalam sirkulasi :……………………………………………………........
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b. Data Obyektif:
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5. Pola Istirahat Tidur
a. Data Subyektif
Kebiasaan pola tidur ( waktu, jumlah, kualitas ) :................................................................
Dampak pola istitrahat tidur terhadap aktivitas sehari – hari :....................................................
Kesulitan tidur :........................................................................................
Alat bantu tidur :........................................................................................
b. Data Obyektif:
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6. Pola Kognitif Perseptual

a. Data Subyektif
Kemampuan panca indra (pendengaran, penglihatan, penghidu/penciuman)
.....................................................................................................................................................
Pemakaian alat bantu pendengaran, penglihatan :................................................................
Masalah sensori perseptual :........................................................................................
Perubahan memori :........................................................................................
Presepsi Nyeri & penanganan nyeri ( P, Q, R, S, T ) :................................................................
b. Data Obyektif:
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7. Pola Presepsi – Diri / Konsep Diri
a. Data Subyektif
Konsep diri
a. Body Image :........................................................................................
b. Self Ideal :........................................................................................
c. Self esteem :.......................................................................................
d. Role :.......................................................................................
e. Identitas :.......................................................................................
b. Data Obyektif:
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8. Pola Peran – hubungan

a. Data Subyektif
Keefektifan peran :........................................................................................
Hubungan dengan orang terdekat :........................................................................................
Efek perubahan peran terhadap hubungan :............................................................................
b. Data Obyektif:
.....................................................................................................................................................
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9. Pola Seksualitas – Reproduksi

a. Data subyektif
Dampak sakit terhadap seksualitas :.......................................................................................

Riwayat haid :.......................................................................................
Tindakan pengendalian kelahiran :.......................................................................................
Riwayat penyakit hubungan seksual :.......................................................................................
b. Data Obyektif:
.....................................................................................................................................................
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10. Pola Koping – Toleransi Stress

a. Data Subyektif
Penggunaan sistem pendukung :...........................................................................
Stressor sebelum sakit :...........................................................................
Metode koping yg biasa digunakan :...........................................................................
Faktor – faktor yg mempengaruhi koping :...........................................................................
Efek penyakit terhadap tingkat stress :...........................................................................
Penggunaan alkohol& obat lain untuk mengatasi stres :...................................................
b. Data Obyektif:
.....................................................................................................................................................
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11. Pola Nilai – Kepercayaan
a. Data subyektif
Agama: spiritualitas :...........................................................................
Kegiatan keagamaan & budaya :...........................................................................
b. Data Obyektif:
.....................................................................................................................................................
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III. Therapy medik
Mojokerto, .................
( ......................................)
CTT:
- Data subyektif : diperoleh melalui wawncara
- Data obyektif diperoleh dari pemeriksaan fisik, penunjang: hasil lab, foto thorak (dll)
- Data obyektif terintegrasi pada masing-masing pola

B. ANALISA DATA
Nama pasien :............................................................

Ruang :............................................................ No Register :..........................................
NO/TGL DATA ETIOLOGI MASALAH TTD
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DIAGNOSA KEPERAWATAN
TANGGAL NO DIAGNOSA KEPERAWATAN TANDA TANGAN
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C. RENCANA ASUHAN KEPERAWATAN
Nama pasien :..................................................
Ruang :.......................................................... No Register :...................................................
TGL NO DX TUJUAN/KRITERIA HASIL INTERVENSI RASIONAL
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D. IMPLEMENTASI
Nama pasien :..................................................

Ruang :................................................. No Register :........................................
NO TGL/
TINDAKAN TTD
DX WAKTU
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E. CATATAN PERKEMBANGAN
Nama pasien :..............................................

Ruang :.............................................. No Register :....................................
NO TGL/
EVALUASI TTD
DX WAKTU
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Format Pengkajian KDM s1 2021

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

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Bagikan atau Tanam Dokumen

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Hak Cipta:

Format Tersedia

Format Pengkajian KDM s1 2021

Diunggah oleh

Hak Cipta:

Format Tersedia

LAPORAN ASUHAN KEPERAWATAN

PRAKTIK KLINIK KEPERAWATAN DASAR

PROGRAM STUDI S1 KEPERAWATAN

Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

Laporan asuhan keperawatan ini diajukan oleh :

Pembimbing ruangan, Pembimbing pendidikan,

Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

Rumah Sakit :.......................................

Nama :....................................... Status :.......................................

II. POLA KESEHATAN FUNGSIONAL

Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

4. Pola Aktivitas – Latihan

Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

6. Pola Kognitif Perseptual

8. Pola Peran – hubungan

9. Pola Seksualitas – Reproduksi

Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

10. Pola Koping – Toleransi Stress

III. Therapy medik

Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

Nama pasien :............................................................

NO/TGL DATA ETIOLOGI MASALAH TTD

................................................ ............................................ ............................

Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

TANGGAL NO DIAGNOSA KEPERAWATAN TANDA TANGAN

Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

TGL NO DX TUJUAN/KRITERIA HASIL INTERVENSI RASIONAL

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Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

Nama pasien :..................................................

Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

Nama pasien :..............................................

Form Askep PK Dasar/ AZ S1 Keperawatan STIKes Bina Sehat PPNI Mojokerto

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