Format Pengkajian KMB
Format Pengkajian KMB
Nama Mahasiswa :
NIM :
IDENTITAS
1. Nama Pasien :
2. Umur :
3. Suku/ Bangsa :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :
8. Sumber Biaya :
KELUHAN UTAMA
1. Keluhan utama:………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………
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5. Lain-lain:
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Jenis................................................ Flow..............lpm
j. Penggunaan WSD:
- Jenis : .................................................................................................................................................................
- Jumlah cairan : ..................................................................................................................................................
- Undulasi :...................................................................................................................................................
- Tekanan : ..................................................................................................................................................
k. Tracheostomy: ya tidak
f. Kemampuan berkemih:
Spontan Alat bantu, sebutkan: .................................................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
g. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
h. Kandung kemih : Membesar ya tidak
i. Nyeri tekan ya tidak
j. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
k. Balance cairan:
..................................................................................................................................................................................
..................................................................................................................................................................................
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k. Lain-lain:
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6. Sistem pencernaan (B5)
a. TB :............... BB :................................
b. IMT :............... Interpretasi :................................
c. Mulut: bersih kotor berbau
d. Membran mukosa: lembab kering stomatitis
e. Tenggorokan:
sakit menelan kesulitan menelan
pembesaran tonsil nyeri tekan
f. Abdomen: tegang kembung ascites
g. Nyeri tekan: ya tidak
h. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
OD OS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO
8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
OD OS
Aurcicula
MAE
b. Tes Audiometri
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o. Lain-lain:
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..................................................................................................................................................................................
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b. Warna
c. Pitting edema: +/- grade:................
d. Ekskoriasis: ya tidak
e. Psoriasis: ya tidak
f. Pruritus: ya tidak
g. Urtikaria: ya tidak
h. Lain-lain:
..................................................................................................................................................................................
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PENGKAJIAN PSIKOSOSIAL
a. Persepsi klien terhadap penyakitnya:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah
TERAPI
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Kediri, ……………..20...
(……………………………)
ANALISIS DATA
Hari/
DATA ETIOLOGI MASALAH
Tgl/ Jam
TANGGAL: .................................
1.
2.
3.
4.
5.
6.
DIAGN
NOC
OSA
Hari/ Tgl/ (Nursing NIC
No. KEPER
Jam Outcome (Nursing Intervention C
AWATA
Classification)
N
Im
Hari/ ple
No. Par
Tgl/ Jam me Jam Evaluasi (SOAP)
Dx af
Shift nta
si