Lampiran (Format Pengkajian, Pedoman Tugas, Penilaian Dan Target Keterampilan)

Lampiran Buku Panduan
Program Pendidikan Profesi Ners

Stase Keperawatan Medikal Bedah
Untuk Mahasiswa S1 Keperawatan Program Pendidikan Profesi Ners dan

Pembimbing Klinik
Penyusun:
TIM Keperawatan Medikal Bedah

Profesi Ners ITKES Wiyata Husada Samarinda
PROGRAM STUDI PROFESI NERS

ITKES WIYATA HUSADA
SAMARINDA
2023
Identitas Mahasiswa
Paspoto
4x6
Nama :
NIM :
Jalur :
Kelompok :
Periode Praktik :
Alamat :
HP :
Panduan Penyusunan Laporan & Penilaian Kinerja 2

Lampiran-Lampiran
1. Format Pengkajian Keperawatan

2. Format Rencana Asuhan Keperawatan
3. Format Catatan Keperawatan
4. Format Subjektif, Objektif, Analisis, Planning (SOAP)
5. Format Penyusunan Laporan Resume Keperawatan di Ruang Operasi (IBS)
6. Format Penyusunan Laporan Resume Keperawatan di Ruang HD
7. Format Penyusunan Laporan Resume Keperawatan di Ruang Kemoterapi
8. Pedoman Laporan Studi Kasus Serta Presentasi/Seminar
9. Format Penilaian Proses Praktik Klinik/ Perilaku Profesional
10. Format Penilaian LP
11. Format Penilaian Laporan Kasus/Resume Keperawatan
12. Format Penilaian DOPS
13. Format Penilaian SOCA
14. Format Penilaian Ujian Praktik
15. Format Daftar Topik Diskusi
16. Format Penyusunan Activity Daily Living
17. Daftar Target Keterampilan Klinik KMB
18. Lembar Bukti Pengumpulan Tugas
19. Jadwal Praktik Stase KMB
FORMAT ASUHAN KEPERAWATAN KEPERAWATAN MEDIKAL BEDAH

PROFESI NERS ITKES WIYATA HUSADA SAMARINDA
Nama mahasiswa : .........................................................
Tempat praktek : ……………………………………

Tanggal : ……………………………………
I. Identitas diri klien
Nama : .......................................... Suku : …………………………………............
Umur : .......................................... Pendidikan :..........................................................

Jemis kelamin :........................................... Pekerjaan :..........................................................
Alamat :........................................... Lama bekerja :..........................................................

………………………………………………..........................
…………………………………………………....................... Tanggal masuk RS :........................................

Status perkawinan ........................................................... Tanggal Pengkajian : ……………………...........
Agama: .................................................................................. Sumber Informasi : ……………………….......
II. Riwayat penyakit

1. Keluhan utama saat masuk RS:
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
2. Riwayat penyakit sekarang:

..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
3. Riwayat Penyakit Dahulu

..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
Genogram:
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
4. Diagnosa medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah dilakukan:
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
III. Pengkajian saat ini (mulai hari pertama saudara merawat klien)

1. Persepsi dan pemeliharaan kesehatan
Pengetahuan tentang penyakit/perawatan
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
2. Pola nutrisi/metabolic
Program diit RS:
..........................................................................................................................................................................................
..........................................................................................................................................................................................
Intake makanan:
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
Intake cairan:
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
3. Pola eliminasi
a. Buang air besar
................................................................................................................................................................................
................................................................................................................................................................................
b. Buang air kecil
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
4. Pola aktifitas dan latihan:

Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi/ROM
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total
Oksigenasi:
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
5. Pola tidur dan istirahat
(lama tidur, gangguan tidur, perawasan saat bangun tidur)
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
6. Pola persepsual
(penglihatan, pendengaran, pengecap, sensasi):
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
7. Pola persepsi diri
(pandangan klien tentang sakitnya, kecemasan, konsep diri)

..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
8. Pola seksualitas dan reproduksi

(fertilitas, libido, menstuasi, kontrasepsi, dll.)
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
9. Pola peran hubungan
(komunikasi, hubungan dengan orang lain, kemampuan keuangan):
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
10. Pola managemen koping-stess

(perubahan terbesar dalam hidup pada akhir-akhir ini):
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
11. Sistem nilai dan keyakinan

(pandangan klien tentang agama, kegiatan keagamaan, dll)
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
IV. Pemeriksaan fisik
(cephalocaudal) yang meliputi : Inspeksi, Palpasi, Perkusi dan Auskultasi

keluhan yang dirasakan saat ini
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
TD: mm/H P: x/m N: x/m S: o
C
BB/TB…………………………………………
Kepala:

..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
Mata dan Telinga (Penglihatan dan pendengaran)
a. Penglihatan
 Berkurang  Ganda  Kabur  Buta/ gelap
..........................................................................................................................................................................................
..........................................................................................................................................................................................
▪ Visus: dioptri
▪ Sklera ikterik : (ya/tidak)
▪ Konjungtiva : (anemis/ tidak anemis)
▪ Nyeri : (ya/tidak), intensitas :
▪ Kornea : jernih/keruh/berbintik
▪ Alat bantu : tidak ada/lensa kontak/kaca mata
b. Pendengaran
 Normal  Berdengung  Berkurang  Alat bantu  Tuli
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
Keluhan lain:
..........................................................................................................................................................................................
..........................................................................................................................................................................................
..........................................................................................................................................................................................
Hidung:
..........................................................................................................................................................................................
..........................................................................................................................................................................................
Mulut/Gigi/Lidah:
..........................................................................................................................................................................................
..........................................................................................................................................................................................
Leher :
..........................................................................................................................................................................................
..........................................................................................................................................................................................
Respiratori

a. Dada :
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
b. Batuk : ya/tidak; produktif/tidak produktif
Karakteristik Sputum .........................................................................................................................................
c. Napas bunyi : vesikuler/lainnya, jelaskan
...................................................................................................................................................................................
...................................................................................................................................................................................
...................................................................................................................................................................................
▪ Sesak napas saat :
➢ Ekspirasi ➢ Inspirasi ➢ Istirahat ➢ Aktivitas
Tipe pernapasan :
 Perut  Dada  Biot
 Kussmaul  Cynestokes  Lainnya
........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
Frekuensi nafas : x/mnt

Penggunaan otot-otot asesori: (ya/tidak), Napas Cuping Hidung:......................................
Fremitus: ......................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
Sianosis : (ya/ tidak)
▪ Keluhan Lain:
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
Kardiovaskular
Riwayat Hipertensi: ............................................................... Masalah jantung……………..

Demam Rematik: ...................................................................
Bunyi Jantung: Frekuensi: ................................................. Irama………………….

Kualitas……………………………….. Murmur ………………………..
 Nyeri dada, Intensitas : Palpitasi
 Pusing  Cianosis
▪ Capillary refill :
 Riwayat Keluhan lainnya
................................................................................................................................................................................
.................................................................................................................................................................................
▪ Edema, lokasi : grade :

▪ Hematoma, lokasi :
...............................................................................................................................................................................
................................................................................................................................................................................
Neurologis
Rasa ingin pingsan/ pusing: ........................................................................................................................
Sakit Kepla: Lokasi nyeri ........................................................................Frekuensi ...................................
▪ GCS : Eye = Verbal = Motorik =
▪ Pupil : isokor/unisokor
▪ Reflek cahaya :
• Sinistra : +/- cepat/lambat

• Dextra : +/- cepat/lambat
▪ Bicara :
 Komunikatif  Aphasia  Pelo 
...................................................................................................................................................................
.....................................................................................................................................................................
.....................................................................................................................................................................
▪ Keluhan lain :
 Kesemutan  Bingung  Tremor  Gelisah  Kejang
...................................................................................................................................................................
.....................................................................................................................................................................
▪ Koordinasi ekastemitas
 Normal  Paralisis, Lokasi :  Plegia, Lokasi :

▪ Keluhan lain:
.....................................................................................................................................................................
.......................................................................................................................................................................
.......................................................................................................................................................................
.......................................................................................................................................................................
Integumen
▪ Warna kulit
 Kemerahan  Pucat  Sianosis  Jaundice  Normal
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
▪ Kelembaban :
 Lembab  Kering
▪ Turgor : elastis / tidak elastic
 > 2 detik  < 2 detik
Keluhan lain :
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
Abdomen
Nyeri Tekan: ..........................................................................................................................................................

Lunak/keras: ..........................................................................................................................................................
Massa:……………………………..ukuran/ Lingkar Perut: .................................................................................
Bising usus:............................................................................................................................................................
Asites : .....................................................................................................................................................................
...................................................................................................................................................................................
Keluhan lain: .........................................................................................................................................................

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

Muskuloskeletal
 Nyeri otot/tulang, lokasi : intensitas :
 Kaku sendi, lokasi :
 Bengkak sendi, lokasi :

 Fraktur (terbuka/tertutup), lokasi :
 Alat bantu, jelaskan :
 Pergerakan terbatas, jelaskan :
 Keluhan lain, jelaskan :
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
Seksualitas
Aktif melakukan hubungan seksual: ..................................................................................................................

..........................................................................................................................................................................................
Penggunaan alat kontrasepsi: ..............................................................................................................................

..........................................................................................................................................................................................
Masalah/kesulitan seksual: ....................................................................................................................................
..........................................................................................................................................................................................
Perubahan terakhir dalam frekuensi: ................................................................................................................
..........................................................................................................................................................................................
Wanita:
Usia Menarche :…………… lamanya siklus:……………..durasi:………………..
Periode menstruasi terakhir:……………………..Menopouse:……………………

Melakukan pemeriksaan payudara sendiri: ....................................................................................................
PAP smear terakhir: ..................................................................................................................................................
Pria
Rabas penis :……………………….Gangguan prostat:……………………………

Sirkumsisi :…………………………Vasektomi:…………………………………..
Impoten :…………………………….Ejakulasi dini:………………………………

V. Program terapi:
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
Hasil Pemeriksaan Penunjang dan Laboratorium

(dimulai saat anda mengambil sebagai kasus kelolaan, cantumkan tanggal pemeriksaan,
dan kesimpulan hasilnya)

................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
................................................................................................................................................................................................
Samarinda, ................... 2019
Perawat
(...............................................)

VI. Analisa Data
No Data Penunjang Kemungkinan Penyebab Masalah
1. Data Subjektif :
dst
Data Objektif :
VII. Diagnosa Keperawatan
1. …………………………………………………………………………………………………………………………………………………………
…………………………………………………….……………………………………………………………………………………………………
2. …………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………
3. …………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………...
4. …………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………
5. Dst….

RENCANA KEPERAWATAN
DIAGNOSA KEPERAWATAN
NO TUJUAN (NOC)/ (SLKI) INTERVENSI (NIC)/ (SIKI)
/MASALAH KOLABORASI
(NANDA/SDKI)
Dst

Catatan Perkembangan
Nama Klien : Umur :

No RM : Ruang :
Hari/Tgl No. Dx Implementasi Evaluasi (SOAP) Paraf
..................... .............. ..................................................................................... ......................................................................

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

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

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

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

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

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

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

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

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

FORMAT PENGKAJIAN KEPERAWATAN RUANG OPERASI
PROGRAM STUDI PROFESI NERS
ITKES WHS
ASUHAN KEPERAWATAN INSTALASI KAMAR OPERASI
Nama : Umur :
No RM : Tgl Lahir :
Jenis kelamin : Laki-laki Perempuan
Diagnosis Pre Op :
Jenis Tindakan Operasi :
Tangggal Operasi :
PENGKAJIAN
Ringkasan Pasien
Alasan Tindakan Operasi dilakukan
(ceritakan perjalanan pernyakit pasien hingga di putuskan untuk menjalani tindakan operasi)
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................

...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
Pengkajian Psikologis secara Naratif pasien Peri Operatif
(Jelaskan kondisi pasien sejak pre-op hingga post-op terkait kondisi psikologis)
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
Pengkajian Intra Operastif
(Jelaskan tindakan operasi yang dilakukan, bila ada tindakan eksisi/pengangkatan, sertakan
foto/gambar bentuk kista/tumor, bentuk batu dll)
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................

...................................................................................................................................................................
A. PRE OPERASI
1. Keadaan Umum :
Compos Mentis Somnolen GCS: E ....... V....... M ...........
Apatis Soporo Reaksi pupil: ................. / .............
Delirium Coma
2. Tanda – Tanda Vital :

- TD : ………….mmHg - Nadi : ………..x/menit - Suhu : …………
- RR : ………….x/menit - TB/BB : …………………
3. Pernafasan
Spontan Cemas
Tenang Canula O2 : …………. 1/menit
Tidak Ada Respon
4. Penilaian Nyeri
Lokasi
Derajat
0 1 2 3 4 5 6 7 8 9 10
Keterangan :
0 : Tidak Nyeri 4-7 : Nyeri Sedang
1-3 : Nyeri Ringan 8-10 : Nyeri Berat
5. Integritas Kulit
Tidak Utuh
6. Sign In
Tidak Ya

7. Marker Area Operasi
Tidak
Ya
Nama : Umur :
No RM : Tgl Lahir :
PENGKAJIAN
B. INTRA OPERASI
Anastesi Mulai : …….....S/D……. Pembedahan : …..….S/D……...
Jenis Pembiusan Spinal / Regional Ga/Umum Lokal
Tanda-Tanda Vital TD : ……. MmHg RR : ……. X/Menit N : ……. X/Menit
S : ……. Oc BB : ……. Kg
Pernafasan Spontan Ventilator
Canula O2 : …….. x/ Menit
Posisi canul infuse Tangan Kaki Arteri Line
Posisi Operasi Supinasi Pronasi Miring Lithotomi
Jenis Operasi Steril Bersih Kotor
Catheter Urine Ya Tidak Nomor : Ket :
Cairan Infuse Jenis ……. Jumlah ……. cc
Transfuse Golongan darah : ……Jumlah ……. cc
IWL (insensible water loos) Jumlah …….
Antiseptic Kulit Betadine 7,5% Betadine 10% Alkohol Microsil
Time Out Ya Tidak
Insisi Kulit Mediana Pranmedial
Electrosurgical Ya Tidak Bipolar Monopolar

Volume :………
Pemeriksaan Kulit Sebelum Operasi Bersih Kotor
(Sudah Tercukur) (Belum Tercukur)
Pemeriksaan Kulit Sesudah Operasi Utuh Menggelembung / Bengkak
Monitor Anastesi Ya Tidak Stand By
Mesin Anastesi Ya Tidak Stand By
Thorniquet Ya Tidak
Lokasi Thorniquet Tangan Kaki
Pemakaian Implant Ya Tidak Lokasi ………. Jenis ……..
Irigasi Luka Ya Tidak
Cairan NaCl H2O2
Penilaian Nyeri P :
Q :
R :
S :
T :
0 1 2 3 4 5 6 7
8 9 10
Keterangan :
0 : Tidak Nyeri
1-3 : Nyeri Ringan
4-7 :Nyeri Sedang
8-10 :Nyeri Berat

Tampon
Jumlah kasa yang dipakai sebelum operasi:.........................................
Jumlah kassa yang dipakai setelah operasi: .........................................
Jumlah jarum sebelum operasi: .........................................
Jumlah jarum sesudah operasi: .........................................
Bisturi sebelum operasi:.................................................Ukuran............................
Bisturi sesudah operasi...................................................Ukuran...........................
Roll kassa sebelum operasi.....................
Roll kassa sesudah operasi......................
Jumlah depper sebelum operasi:.......................
Jumlah depper sesudah operasi..........................
Diperiksa oleh.....................
Instrumen lengkap: ya tidak
Sign out: ya tidak
Indikator alat yang disterilkan
Internal: Bagus
Tidak
External: Bagus
Tidak
Nama : Umur :
No RM : Tgl Lahir :
PENGKAJIAN
C. POST OPERASI

1. Kesadaran CM Delirium Apatis
Somnolen Soporo Coma Coma
2. Pernafasan Spontan Canula tenang Cemas
3. Tanda-tanda Vital TD :…….. mmHg, N : ….. x/menit S : ……˚C
RR :……..x/menit, BB/TB :……… SpO2 :……..
4. Penilaian Nyeri Lokasi Derajat
5. 0 1 2 3 4 5 6 7 8 9 10
Keterangan : 0 : tidak nyeri
2-3 : nyeri ringan
4-7 : nyeri sedang
8-10 : nyeri hebat
6. Perdarahan Jumlah………. CC
7. Transfusi Gol Darah….. Jumlah…….
8. Cairan infuse Jenis…….. Jumlah…….
9. Ekstermitas Hangat Dingin
10. Mukosa Mulut Lembab Dingin
11. Turgor Kulit Elastis Tidak Elastis
12. Sirkulasi Merah muda Sianosi
13. Urine jumlah……….
14. Catheter Urine Ya Tidak
15. Obat-obatan yang diberikan :

Catatan:
Mahasiswa diwajibkan menetapkan Masalah Keperawatan Saat Pre, Intra dan Post Operasi, serta
Menyusun Rencana Asuhan dan Implementasi da Evaluasi mengacu pada Format pengkajian Pasien
Secara Umum (yang terdapat pada bagian sebelumnya)

FORMAT PENGKAJIAN KEPERAWATAN PENYUSUNAN
RESUME KEPERAWATAN DI RUANG
HEMODIALISA
Nama Mahasiswa :
NIM :
Tempat Pengkajian :
Tanggal :
IDENTITAS KLIEN
Nama : No. RM :
Umur : Pekerjaan :
Jenis Kelamin : Status Perkawinan :
Agama : Tanggal MRS :
Pendidikan : Tanggal Pengkajian :
Alamat : Sumber Informasi :
Diagnosa :
Medis
PROSES KEPERAWATAN
Perjalan Penyakit Pasien
(Awal Pasien terdiagnosis CKD hingga pasien di instruksikan hemodialisis)
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................

PRE HEMODIALISA
1) Data Fokus
Data Subjektif:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Data Objektif:
BB Pre HD : Kg
BB post HD sebelumnya : Kg
Peningkatan BB interdialisis : Kg
Tanda vital :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
2) Diagnosa Keperawatan
...........................................................................................................................................
...........................................................................................................................................
3) Intervensi Keperawatan
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
4) Implementasi Keperawatan
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
5) Evaluasi Keperawatan (SOAP)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
INTRA HEMODIALISA
1) Data Fokus
Data Subjektif:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Data Objektif:
UF Goal :
Cairan dialisat :
TMP :
Qd :
Qb :
Dosis Heparin :
Tanda vital :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
POST HEMODIALISA
1) Data Fokus
Data Subjektif:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Data Objektif :
BB Post HD :
Tanda vital :
Pengkajian Akses HD :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
..................., ..............................
(..............................)

FORMAT PENGKAJIAN KEPERAWATAN PENYUSUNAN
RESUME KEPERAWATAN DI RUANG
KEMOTERAPI
NAMA MAHASISWA :
NIM :
TANGGAL PRAKTEK :
A. ASUHAN KEPERAWATAN PRE-KEMOTERAPI

1. Identitas
Nama :
Umur :
No RM :
Diagnosa Medis :
Status :
Agama :
Tanggal Masuk :
Tanggal pengkajian :
Sumber informasi :
2. Pengkajian
a. Riwayat Kesehatan
Keluhan utama :
Riwayat Penyakit Sekarang:

Riwayat Penyakit Dahulu
Riwayat Pengobatan Sebelumnya
b. Pola kebiasaan
1) Pemeliharaan dan persepsi terhadap kesehatan
2) Nutrisi/ metabolik
3) Pola eliminasi
4) Pola aktivitas dan latihan

Kemampuan Perawatan Diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur

Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain & alat,
4: tergantung total
Oksigenasi:
5) Pola tidur dan istirahat
6) Pola persepsi, sensori kognitif
7) Pola persepsi diri
8) Pola seksual dan reproduksi
9) Pola peran-hubungan
10) Pola manajemen koping stress
11) Sistem nilai dan keyakinan
c. Pengkajian Fisik;
1) Keadaan umum
2) Pemeriksaan Fisik (Head to Toe)
(Fokus pada masalah yang terjadi pada pasien)

d. Pemeriksaan Laboratorium
e. Persiapan Kemoterapi:
3. Analisa Data
Diagnosa Keperawatan Tujuan Intervensi

4. Implementasi dan Evaluasi
Diagnosa Keperawatan
Implementasi Evaluasi

B. ASUHAN KEPERAWATAN INTRA-KEMOTERAPI
1. Pengkajian
a. Persiapan

b. Pelaksanaan:
2. Analisa Data


C. ASUHAN KEPERAWATAN POST-KEMOTERAPI
1. Pengkajian
2. Analisa Data


PEDOMAN LAPORAN STUDI KASUS SERTA PRESENTASI/SEMINAR
1. Pemilihan Pasien Kelolaan Kelompok dilaksanakan di Hari Pertama dinas diruang

tersebut. Ketentuan pemilihan topik studi kasus ditentukan oleh Preseptor ruangan
dengan memperhatikan lama rawat inap dan feasibility kelompok dalam
melaksanakan asuhan keperawatan sepanjang sepekan
2. Format Pelaksanaan Asuhan Keperawatan Mengacu pada Format Pengkajian,
Intervensi dan Implementasi yang terdapat pada buku lampiran ini
3. Penyusunan Laporan disusun berdasarkan ketentuan sebagai berikut
a. Bab I: Latar Belakang, Tujuan dan Manfaat Penulisan
b. Bab II: Studi Literatur yang meliputi
1. Konsep Medik
a) Defenisi
b) Etilogi
c) Pathway (Konsep MAP)
d) Manifestasi Klinis
e) Pemeriksaan Penunjang dan
f) Penetalaksanaan Medik (Farmakologi)
2. Konsep Manajemen Asuhan
a) Pengkajian
b) Masalah Keperawatan (Minimal 3 masalah Keperawatan)
c) Intervensi
c. Bab III: Laporan Studi Kasus
Laporan disusun secara Naratif dengan Ketentuan sebagai berikut:
1) Pengkajian
2) Masalah Keperawatan
3) Intervensi
4) Implementasi
5) Evaluasi
d. Bab IV: Penutup (Kesimpulan dan Saran)

e. Referensi
4. Materi Presentasi diantaranya:

a) Cover → Judul Laporan Studi Kasus, Uraian Kelompok
b) Konsep Medik terdiri dari (defenisi dan Pathway)

c) Laporan Studi Kasus (Pengkajian, Masalah Keperawatan, Intervensi,
Implementasi dan Evaluasi)
d) Kesimpulan
e) Referensi

PENILAIAN PROSES PRAKTIK KLINIK/ PERILAKU PROFESIONAL
KEPERAWATAN MEDIKAL BEDAH TAHAP PROFESI NERS STASE KMB
Nama Mahasiswa/ NIM :……………………../……………………………

Ruangan :…………………………………………………...
Nilai
Komponen Penilaian
1 2 3 4 5
A. Proses Keperawatan (20%), mahasiswa mampu:
1. Melakukan pengkajian keperawatan secara Bio Psiko Sosio
Kultural Spiritual
2. Melakukan pengkajian secara akurat
3. Mengembangkan diagnose keperawatan dengan tepat dan
benar (PES sesuai dengan data penunjang)
4. Mengidentifikasi masalah keperawatan yang aktual dan
resiko
5. Menerapkan prioritas keperawatan
6. Menetapkan tujuan yang realistis
7. Mengidentifikasi tindakan keperawatan mandiri dan
kolaborasi
8. Melakukan evaluasi SOAP setiap hari
9. Memodifikasi recana sesuai evaluasi
10. Mendokumentasikan rencana keperawatan dengan benar
B. Komunikasi (15%), Mahasiswa mampu:
1. Menciptakan interaksi dengan klien dan keluarga dengan
percaya diri
2. Menggunakan komunikasi nonverbal dan verbal yang
efektif dalam merespon klien dan keluarga
3. Melakukan komunikasi yang efektif dengan tim kesehatan
lain
4. Menuliskan laporan dengan padat, tepat, ringkas dan
akurat
C. Perilaku Profesional (15%), mahasiswa mampu
1. Menampilkan sikap baik dan sopan
2. Mempertahankan privasi dan kerahasiaan klien
3. Mengambil inisiatif dalam situasi belajar
4. Memperlihatkan sikap selalu tepat waktu

5. Bekerjasama dengan berpartisipasi dalam kegiatan
ruangan
6. Memakai seragam sesuai dengan ketentuan
7. Mampu mengidentifikasi kekuatan dan kelemahan diri
8. Menerapkan teori dan konsep keperawatan dalam
memberikan asuhan keperawatan
D. Keterampilan dasar (20%), mahasiswa mampu:
1. Melakukan pengkajian (anamnesis dan pemeriksaan fisik)
2. Melakukan tindakan yang sudah direncanakan sesuai
dengan prosedur
3. Melakukan tindakan pencegahan terhadap infeksi
4. Menciptakan keamanan dan kenyamanan
5. Menggunakan alat secara tepat guna
6. Mengkaji dan memenuhi (jika diperlukan) kebutuhan
dasar klien
7. Membantu klien dalam proses duka cita dan berkabung
8. Memberikan pendidikan Kesehatan
E. Memenuhi objektif (15%), mahasiswa mampu:
memberikan asuhan keperawatan pada klien yang
mengalami gangguan sistem tertentu di ruang masing-
masing sesuai dengan objektif
1. Menghubungkan tanda-tanda klinis dengan patofisiologi
yang terjadi
2. Menganalisis data-data penunjang sesuai dengan kasus
3. Menjelaskan rasional tindakan keperawatan
4. Menjelaskan tujuan kolaborasi
G. Analisa data dan pemecahan masalah selama diskusi,
mahasiswa mampu:
1. Memperlihatkan kesiapan diri untuk melakukan praktek
klinik dengan menyampaikan hasil bacaan materi kasus
yang terkait
2. Menyampaikan ide yang bermanfaat
3. Mempresentasikan masalah secara sistematis
4. Merespon pertanyaan dari pembimbing dengan tepat
5. Merujuk pada referensi dalam menyampaikan ide
JUMLAH

Penilaian = jumlah total nilai yang diperoleh
2
Pengesahan Penilai: ______________________________________________________________________
Komentar mahasiswa : ___________________________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Samarinda, …………………………… 2023

Preceptor
(……………………………………………)

Format Penilaian Laporan Pendahuluan
NAMA MAHASISWA :
TEMPAT PRAKTEK :
TANGGAL :
NO ASPEK NILAI
MAKS SKOR
1 Teori tentang penyakit (definisi,
patofisiologi, tanda dan gejala,
20
pemeriksaan penunjang,
komplikasi)
2 Ketepatan rumusan diagnosa
20
keperawatan
3 Prioritas diagnosa keperawatan 5
4 Ketepatan rumusan tujuan 10
5 Perencanaan tindakan
20
keperawatan
6 Rasionalisasi tindakan
10
keperawatan
7 Daftar Pustaka 5
8 Penampilan laporan 10
TOTAL NILAI
Keterangan :
Nilai :
A = > 81
B = 70 – 80
Penilai, C = 60 – 69,9
Samarinda, …………………………… 2023

Preceptor
(……………………………………………)

Format Penilaian Kasus kelolaan
NAMA MAHASISWA :
TEMPAT PRAKTEK :
TANGGAL :
NO ASPEK NILAI
MAKS SKOR
1 Ketepatan pengumpulan data 20
2 Kelengkapan data / pengkajian 20
3 Identifikasi diagnosa
keperawatan/ masalah 5
kolaborasi
4 Ketepatan rumusan diagnosa
15
keperawatan
5 Ketepatan rumusan tujuan 10
6 Ketepatan tindakan
15
keperawatan
7 Evaluasi 10
8 Penampilan laporan 5
TOTAL NILAI
Keterangan :
Nilai :
A = > 81
B = 70 – 80
Penilai, C = 60 – 69,9
Samarinda, …………………………… 2023

Preceptor
(……………………………………………)

Penilaian Direct Observasional of Preocedure Skill (DOPS)
Nama Mahasiswa : ……………………………………………. NIM : …………………………………………….

Inisial Pasien : ……………………………………………. Dx Medis : …………………………………………….
Usia : ……………………………………………. Jenis Kelamin : …………………………………………….
Ketergantungan : ……………………………………………. Dx : …………………………………………….
Keperawatan
Tempat : ……………………………………………. Tanggal : …………………………………………….
Jenis : …………………………………………….
Keterampilan
No Komponen Bobot Nilai

1 Indikasi, kontraindikasi prosedur 10
2 Kemampuan anatomi dan fisiologi yang sesuai dengan 10
prosedur
3 Inform consent 5
4 Persiapan sebelum prosedur 10
5 Keterampilan prosedur 25
6 Universal precaution, teknik aseptik 10
7 Keterampilan komunikasi 10
8 Pencegahan dan manajemen komplikasi 10
9 Manajemen setelah prosedur 10
Total Nilai 100
Komentar: Evaluator
__

Penilaian Case Test atau Student Oral Case Analysis (SOCA)
Nama Mahasiswa : ……………………………………………. NIM : …………………………………………….

Inisial Pasien : ……………………………………………. Dx Medis : …………………………………………….
Usia : ……………………………………………. Jenis Kelamin : …………………………………………….
Ketergantungan : ……………………………………………. Dx : …………………………………………….
Keperawatan
Tempat : ……………………………………………. Tanggal : …………………………………………….
No Aspek Penilaian Bobot Nilai

1 Review kasus secara umum: fokus penilaian 10
kemampuan mahasiswa dalam menyusun peta konsep
dan menjelaskan hubungan antara diagnosis dengan
kondisi lainnya seperti etiologi, faktor risiko dan faktor
predisposisi)
2 Keterlibatan ilmu-ilmu dasar: menggambarkan 20
keterkaitan ilmu-ilmu dasar dalam patofisiologi dan
pathogenesis terjadinya suatu penyakit/gangguan.
3 Patogenesis: menjelaskan mekanisme terjadinya suatu 20
penyakit dan perubahan berbagai struktur tubuh yang
ditunjukkan dengan berbagai pemeriksaan penunjang.
4 Patofisiologi: menjelaskan setiap mekanisme terjadinya 20
suatu penyakit yang ditandari dengan timbulnya
berbagai gejala dan tanda penyakit.
5 Manajemen atau penatalaksanaan: menjelaskan 10
berbagai jenis intervensi keperawatan berdasarkan pada
diagnosa keperawatan dan perencanaan keperawatan.
6 Komplikasi 5
7 Prognosis 5
8 Penampilan mahasiswa 10
Total Nilai 100
Komentar: Evaluator
__

FORMAT PENILAIAN UJIAN PRAKTEK KLINIK
PRAKTEK PROFESI KEPERAWATAN STASE KMB
Nama Mahasiswa : …………………………………………………………………………………………………….

Nim : …………………………………………………………………………………………………….
Diagnosa Medis : …………………………………………………………………………………………………….
Diagnosa keperawatan : ............................................................................................................................................
Ruangan : …………………………………………………………………………………………………….
A. Dokumentasi
Keperawatan (40%)
Skore
No Kriteria Bobot Bobot x nilai
1 2 3 4
1 Pengkajian 20
a. Identitas klien
b. Riwayat Keperawatan
c. Tanda vital dan keadaan umum
d. Pengkajian data fokus
e. Pemeriksaan Penunjang
f. Validasi data
2 Diagnosa Keperawatan 20
a. Mencakup komponen PES/PE
b. Relevan dengan data
c. Memberi arah intervensi
keperawatan
d. Bersifat spesifik sesuai kasus
3 Perencanaan 20
a. Prioritas
b. Tujuan
Spesifik
Dapatdiukur/simpel
Dapat dicapai
Realistis
Batasan waktu tepat
c. Tindakan
Spesifik sesuai tujuan
Pencatatan sesuai prioritas
Menggunakan kalimat perintah
Dapat dilaksanakan
4 Pelaksanaan 20
a. Sesuai rencana tindakan
b. Menggunakan kalimat kerja
operasional
c. Tercantum waktu dan tanda tangan
5 Evaluasi 20
a. Respon klien
b. Terdapat waktu dan tanda tangan
Total Skor 100

B. Keterampilan Klinik (20%)
Skor Bobot x
No Aspek Yang dinilai Bobot
1 2 3 4 skore
1 Persiapan : 20
a. Klien diberi informasi tentang
prosedur yang akan dilakukan
b. Melakukan pengkajian yang
berkaitan dengan tindakan yang
akan dilakukan
c. Lingkungan yang nyaman dan
bersih bagi klien
d. Jenis alat yang disediakan sesuai
kebutuhan
2 Pelaksanaan : 50
a. Komunikasi dengan klien
b. Memperhatikan privacy klien
c. Kualitas alat (sterilisasi)
d. Penggunaan alat
e. Tindakan sesuai dengan prosedur
f. Tindakan sesuai dengan prinsip
g. Memperhatikan respon klien
h. Membereskan alat
3 Evaluasi 30
a. Melakukan evaluasi tindakan
keperawatan
b. Mendokumentasikan tindakan
Jumlah Skor 100
C. Responsi (40%)
Skore
No Aspek yang dinilai Bobot Bobot x Skore
1 2 3 4
1 Mampu menjawab dan 30
berargumentasi dengan benar
2 Menggunakan landasan teori 30
3 Efektifitas waktu dalam 20
menjawab
4 Bersikap profesional 20
Total 100
Nilai = Jumlah (bobot x skore) : 4 Balikpapan,…………....................................

Evaluator
(…………………………………………………)

DAFTAR TOPIK DISKUSI
Ruangan: __________________________________
NO Topik Diskusi Tanggal & paraf pembimbing
Ruangan: __________________________________
Ruangan: __________________________________
Ruangan: __________________________________

DAFTAR TARGET KETERAMPILAN KLINIK KMB
Nama mahasiswa :
NIM :
1. Mahasiswa mampu memperlihatkan keterampilan prosedur dasar di bagian keperawatan dewasa
No Prosedur Tanggal/tempat Paraf pembimbing target

1 Memberikan transfusi darah 5
2 Mempertahankan teknik aseptic pada setiap tindakan 5
3 Mengangkat jahitan luka operasi 3
4 Memberikan pendidikan kesehatan 5
5 Memberikan obat melalui SC, IM, IV 5
6 Melakukan pemasangan infuse 5
7 Melakukan skin test 5
8 Menghitung balans cairan 5
9 Memberikan kompres 5
10 Melatih ROM 5
2. Mahasiswa mampu memperlihatkan keterampilan melakukan prosedur pada klien dengan masalah pada sistem
pernapasan

1 Melakukan pengkajian fisik 5
2 Memberikan latihan napas dalam dan batuk efektif 5
3 Mengambil spesimen untuk pemeriksaan BTA 5
4 Melakukan fisoterapi dada (perkusi, vibrasi, postural 5
drainage)
5 Memberikan oksigen melalui nasal kanul 5
6 Memberikan oksigen melalui masker 5
7 Memberikan inhalasi 5
3. Mahasiswa mampu memperlihatkan keterampilan prosedur pada klien dengan masalah pada sistem gastrointestinal

2 Memberikan makan/ minum melalui oral 5
3 Memberi makan melalui NGT 5
4 Melakukan huknah 3
5 Melakukan perawatan kolostomi/ileostomy 3
6 Melakukan irigasi kolostomi/ ileostomy 3
4. Mahasiswa mampu memperlhatkan keterampilan prosedur pada klien dengan masalah pada sistem perkemihan

2 Melakukan kateterisasi urin pada wanita 3
3 Melakukan kateterisasi urin pada pria 3
4 Melakukan irigasi kateter 5
5 Melakukan pemasangan kateter kondom 3
6 Melakukan perawatan kateter 5
5. Mahasiswa mampu memperlihatkan keterampilan prosedur pada klien dengan masalah pada sistem persyarafan

2 Memberikan posisi side lying 3

3 Memberikan posisi dengan teknik log roll 4
4 Melakukan perhitungan GCS 5
6. Mahasiswa mampu memperlihatkan keterampilan prosedur pada klien dengan masalah pada sistem muskuloskeletal

1 Melakukan pemeriksaan fisik 5
2 Merawat klien yang menggunakan traksi 3
3 Merawat klien yang menggunakan gips 3
4 Melatih menggunakan crutch dan walker 3
5 Memindahlan klien dari tempat tidur ke kursi dan 4
sebaliknya
6 Menggunakan kursi roda 5
7 Mengganti balutan 5
8 Mencegah deformitas pada klien dengan imobilisasi 5
9 Merawat luka Bakar 3

Lembar Bukti Pengumpulan Tugas
Nama Mahasiswa : ______________________________
NIM : ____________________________
Hari/ Tanggal Topik Asuhan Keperawatan Tanda Tangan Tanda Tangan Keterangan
Preseptor PA

Lampiran (Format Pengkajian, Pedoman Tugas, Penilaian Dan Target Keterampilan)

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Lampiran (Format Pengkajian, Pedoman Tugas, Penilaian Dan Target Keterampilan)

Diunggah oleh

Hak Cipta:

Format Tersedia

Lampiran Buku Panduan

Program Pendidikan Profesi Ners

Untuk Mahasiswa S1 Keperawatan Program Pendidikan Profesi Ners dan

TIM Keperawatan Medikal Bedah

PROGRAM STUDI PROFESI NERS

Panduan Penyusunan Laporan & Penilaian Kinerja 2

1. Format Pengkajian Keperawatan

FORMAT ASUHAN KEPERAWATAN KEPERAWATAN MEDIKAL BEDAH

Nama mahasiswa : .........................................................

Tempat praktek : ……………………………………

I. Identitas diri klien

Nama : .......................................... Suku : …………………………………............

Umur : .......................................... Pendidikan :..........................................................

Alamat :........................................... Lama bekerja :..........................................................

…………………………………………………....................... Tanggal masuk RS :........................................

Agama: .................................................................................. Sumber Informasi : ……………………….......

II. Riwayat penyakit

2. Riwayat penyakit sekarang:

3. Riwayat Penyakit Dahulu

Panduan Penyusunan Laporan & Penilaian Kinerja 4

Panduan Penyusunan Laporan & Penilaian Kinerja 5

Pengetahuan tentang penyakit/perawatan

Program diit RS:

4. Pola aktifitas dan latihan:

Panduan Penyusunan Laporan & Penilaian Kinerja 6

Mobilitas di tempat tidur

5. Pola tidur dan istirahat

(lama tidur, gangguan tidur, perawasan saat bangun tidur)

(penglihatan, pendengaran, pengecap, sensasi):

7. Pola persepsi diri

(pandangan klien tentang sakitnya, kecemasan, konsep diri)

Panduan Penyusunan Laporan & Penilaian Kinerja 7

(komunikasi, hubungan dengan orang lain, kemampuan keuangan):

10. Pola managemen koping-stess

11. Sistem nilai dan keyakinan

IV. Pemeriksaan fisik

(cephalocaudal) yang meliputi : Inspeksi, Palpasi, Perkusi dan Auskultasi

Panduan Penyusunan Laporan & Penilaian Kinerja 8

 Berkurang  Ganda  Kabur  Buta/ gelap

▪ Nyeri : (ya/tidak), intensitas :

▪ Alat bantu : tidak ada/lensa kontak/kaca mata

 Normal  Berdengung  Berkurang  Alat bantu  Tuli

Panduan Penyusunan Laporan & Penilaian Kinerja 9

c. Napas bunyi : vesikuler/lainnya, jelaskan

▪ Sesak napas saat :

➢ Ekspirasi ➢ Inspirasi ➢ Istirahat ➢ Aktivitas

 Perut  Dada  Biot

 Kussmaul  Cynestokes  Lainnya

Frekuensi nafas : x/mnt

Sianosis : (ya/ tidak)

Riwayat Hipertensi: ............................................................... Masalah jantung……………..

Bunyi Jantung: Frekuensi: ................................................. Irama………………….

Panduan Penyusunan Laporan & Penilaian Kinerja 10

 Nyeri dada, Intensitas : Palpitasi

 Riwayat Keluhan lainnya

▪ Edema, lokasi : grade :

Rasa ingin pingsan/ pusing: ........................................................................................................................

Sakit Kepla: Lokasi nyeri ........................................................................Frekuensi ...................................

▪ GCS : Eye = Verbal = Motorik =

• Sinistra : +/- cepat/lambat

 Komunikatif  Aphasia  Pelo 

 Kesemutan  Bingung  Tremor  Gelisah  Kejang

 Normal  Paralisis, Lokasi :  Plegia, Lokasi :