format askep kmb
DESCRIPTION
berisi mengenai format pengkajian kmbTRANSCRIPT
![Page 1: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/1.jpg)
ASUHAN KEPERAWATAN MEDIKAL BEDAH
Nama Mahasiswa :
Nim :
Tempat Praktik :
Tanggal :
PENGKAJIAN
Identitas
1. Identitas Klien
Nama :...........................................................................L/P Usia (......)
Tempat & tgl Lahir :.....................................................................................................
Golongan Darah : O/ A/ B/ AB
Agama : Islam/ Protestan/ Katolik/ Hindu/ Budha/ Konghuchu
Suku :.....................................................................................................
Status Perkawinan : Kawin/ Belum kawin/ Janda/ Duda (Cerai: Hidup/ Mati)
Pendidikan Terakhir : .....................................................................................................
Pekerjaan :.....................................................................................................
TB/ BB :..........................Cm ..............................Kg..................................
Alamat :.....................................................................................................
.......................................................................................................
Telp. ................................/.....................................
2. Identitas Penanggungjawab
Nama : .....................................................................................................
Umur : .....................................................................................................
Jenis Kelamin : P/L
Agama : Islam/ Protestan/ Katolik/ Hindu/ Budha/ Konghuchu
Suku : .....................................................................................................
Hubungan dg Pasien : .....................................................................................................
Pendidikan Terakhir : .....................................................................................................
Pekerjaan : .....................................................................................................
Alamat :.....................................................................................................
.......................................................................................................
Telp. ................................/.....................................
![Page 2: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/2.jpg)
RIWAYAT KELUARGA
Genogram
Keterangan:
RIWAYAT LINGKUNGAN HIDUPTipe Tempat tinggal : .....................................................................................................Jumlah Kamar : .....................................................................................................Kondisi Tempat Tinggal :......................................................................................................Jumlah Orang Yang Tinggal Di Rumah: Laki-Laki :............orang Perempuan :......... orang
STATUS KESEHATAN Status Kesehatan Saat Ini Alasan Masuk Rumah Sakit/ Keluhan Utama :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Faktor Pencetus:........................................................................................................................... ......................................................................................................................................................Timbulnya Keluhan : ( ) Bertahap ( ) MendadakFaktor yang memperberat: .................................................................................................................................................................................................................................................................Pemahaman & Penatalaksanaan Masalah KesehatanUpaya Yang Dilakukan Untuk Mengatasinya:Diagnosa Medik :Tanggal :
![Page 3: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/3.jpg)
Tanggal :Tanggal :Status Kesehatan Masa LaluPenyakit yang Pernah Dialami : ..................................................................................................Kecelakaan :Pernah Dirawat :Penyakit :Waktu :Operasi : Alergi : Agen:
Reaksi Spesifik:Obat-obatan :Makanan :Faktor Lingkungan :Satus Imunisasi :Tetanus, Desentri : influinza:Pnemovaks :Kebiasaan : Merokok/ kopi/ obat/ alkohol, lain-lain yang merugikan
kesehatan:.................................................................................Obat-Obatan
No Nama Dosis Keterangan
TINJAUAN SISTEMKeadaan Umum :..................................................................................................
...................................................................................................Tingkat kesadaran :Composmentis, Apatis, Somnolen, Suporus, ComaSkala GCS : Eye .................. Verbal .............. Motorik................Tanda- Tanda Vital : TD:................. N:............... RR:................. S:.......................
1. Sistem Pernafasan Gejala (Subjektif):a. Dispnea:b. Riwayat Penyakit Sistem pernafasan : ( ) Bronkhitis
( ) Asma ( ) TBC ( )Emfisema ( ) Pneumonia ( ) Lain-lain..................
c. Perokok : ..................... Pak/ Hari Lama: .................. (Bulan/ Tahun)
d. Penggunaan Alat bantu :.........................................................................................
Tanda (Objektif) a. Pernafasan : 1) Frekwensi:............. 2) Kedalaman: ............... 3) Simetris :.................b. Penggunaan Otot bantu nafas: ..................................... Cuping Hidung:......................c. Batuk :.................. Sputum (Karakteristik Sputum):.....................................................
![Page 4: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/4.jpg)
d. Bunyi Nafas :................................................................................................................e. Sianosis:........................................................................................................................f. Gelisah :.......................................................................................................................
..2. Sistem Kardiovaskuler
a. Tekanan Darah (TD) b. Nadi Palpasi :c. Bunyi jantung :................Irama:....................... Kualiltas...................... Murmur............d. Ekstrimitas: Akral:.................... Warna................ CRT.................... Plebitis.................e. Warna: Membran Mukosa:..................... Bibir................. Konjungtiva..................
Punggung kuku........................... Skela................................3. Sistem Integumen
Gejala ( Subjektif)a. Riwayat gangguan kulit:b. Keluhan klien:
Tanda (Objektif)a. Lesi kulit:b. Jumlah lesi:c. Penyebaran lesi:d. Abnormalitas kuku:e. abnormalitas
4. Sistem Perkemihan
Gejala Subjektif a. Riwayat penyakit ginjal/ kandung kemih: .................................................................b. Riwayat penggunaan deuritik:....................................................................................c. Rasa nyeri/ rasa terbakar saat kencing:......................................................................d. Konsultasi BAK:........................................................................................................Tanda (objektif)a. Pola BAK: .............................. Frekuensi:.............................Retensi.....................b. Perubahan kandung kemih:.......................... Distensi Kandung Kemih:...................c. Karakteristik urine: Warna...................... Jumlah.................... Bau...........................
5. Sistem GastrointestinalGejala (subjektif)
a. Diit biasa (tipe):.......................................... Jumlah makan per hari:.......................b. Pola diit:....................................................... Makan terakhir:...................................c. Nafsu/ selera makan:...................................Mual/ Muntah:.....................................d. Nyeri Ulu Hati:............................................................................................................e. Alergi Makanan:...........................................................................................................f. Masalah mengunyah/ menelan:....................................................................................Tanda (objektif)
a. BB:.................................................TB:.....................................b. Turgor kulit:............................................. Tonus Otot:...............................................c. Edema:....................................................... Acites:.......................................................
![Page 5: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/5.jpg)
d. Kondisi Mulut: Gigi.................. Mukosa Mulut: ............................Lidah:..................e. Bising Usus:.................................................................................................................
6. Sistem Eliminasi Gejala (subjektif) a. Pola BAB:..................................................................................................................b. Kesulitan BAB: Konstipasi:................................. Diare:...........................................c. Penggunaan Laksantif:...............................................................................................d. BAB terakhir:.............................................................................................................e. Riwayat perdarahan:...................................................................................................f. Riwayat inkontinensia alvi:........................................................................................
Tanda (objektif) a. Abdomen : Nyeri tekan:................................... Lunak/ Keras:.............................
Massa:............................. Lingkar Abdomen: ............... Bising Usus:.................Integritas kulit perut:.............................................................................................
b. Hemoroid:
7. Sistem Endokrin Gejala (subjektif) .................................................................................................................................................................................................................................................................................................................................................................................................................................Tanda (objektif) .................................................................................................................................................................................................................................................................................................................................................................................................................................
8. Sistem ImuneGejala (subjektif).................................................................................................................................................................................................................................................................................................................................................................................................................................Tanda (objektif) .................................................................................................................................................................................................................................................................................................................................................................................................................................
9. Sistem MuskuloskeletalGejala (subjektif) Keluhan:......................................................................................................................................................................................................................................................................
Tanda (objektif)
![Page 6: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/6.jpg)
Kekuatan otot :Tonus otot :Kemampuan aktifitas :Deformitas :
10. Sistem Reproduksi Gejala (subjektif)
Tanda (objektif)
11. Sistem PersyarafanGejala (subjektif)
Tanda (objektif) GCS : Nervous Cranial 1-12 :Reflek normal :Reflek Patologis :
12. Sistem PenglihatanGejala (subjektif)
Tanda (objektif) Konjungtiva :Pupil :Sklera :Penampilan Bola Mata :Pergerakan bola Mata :
13. Sistem Pendengaran Gejala (subjektif)
Tanda (objektif) Daun Telinga : Liang telinga :Fungsi Pendengaran :
14. Sistem PengecapanGejala (subjektif)
Tanda (objektif) Membedakan rasa:Warna lidah:
15. Sistem Penciuman
![Page 7: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/7.jpg)
Gejala (subjektif)
Tanda (objektif) Membedakan Bau:
DATA TAMBAHAN POLA SEBELUM DI RS SESUDAH DI RS
Pola istirahat tidur WaktuLama TidurKebiasaan Pengantar TidurKesulitan Tidur Pola Aktifitas Dan Latihan Kegiatan Sehari-hariOlah ragaKegiatan waktu luangPola Bekerja Jenis PekerjaanJumlah Jam KerjaJadwal Kerja
ASPEK PSIKOSOSIALPola Pikir dan Persepsi:Konsep Diri:Komunikasi/ hubungan:Mekanisme koping:Sistem dan nilai kepercayaan:
![Page 8: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/8.jpg)
PERSEPSI KLIEN TENTANG PENYAKIT
A. Harapan Klien:
B. Analisa Data No Data Etiologi Problem
![Page 9: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/9.jpg)
C. RENCANA KEPERAWATANNo RM: Nama: Usia:No. Dx
Kep
Hari& Tanggal Pukul
Tujuan Tindakan Rasional
![Page 10: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/10.jpg)
![Page 11: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/11.jpg)
D. IMPLEMENTASI DAN EVALUASI No RM: Nama: Usia:No. Dx
Kep
Hari& Tanggal Pukul
TindakanTanda Tangan
Hari& Tanggal Pukul
EvaluasiTanda Tangan
![Page 12: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/12.jpg)
![Page 13: Format Askep KMB](https://reader036.vdocuments.net/reader036/viewer/2022071709/55cf921c550346f57b93ae3c/html5/thumbnails/13.jpg)