format askep kmb
DESCRIPTION
Jooss ikiiTRANSCRIPT
ASUHAN KEPERAWATAN MEDIKAL BEDAH
PADA ............... DENGAN .......................................................
DI RUANG .........................................................................................
I. PENGKAJIAN
Tanggal Pengkajian : ...................................
Tanggal Masuk Ruangan : ...................................
Ruang : ...................................
A. IDENTITAS
1. Identitas Klien
Nama : ...................................
No. Rekam Medis : ...................................
Umur : ...................................
Jenis Kelamin : ...................................
Agama : ...................................
Pekerjaan : ...................................
Suku : ...................................
Bahasa : ...................................
Alamat : ...................................
Pembiayaan Kesehatan : ...................................
2. Identitas Penanggung Jawab
Nama : ...................................
Umur : ...................................
Pekerjaan : ...................................
Suku : ...................................
Hubungan dg Klien : ...................................
Bahasa : ...................................
Alamat : ...................................
No.Telpon : ...................................
B. KELUHAN UTAMA
1. Pertama kali masuk RS (............................................................................)
Keluhan utama :
......................................................................................................................
Keluhan lainnya :
......................................................................................................................
2. Saat Pengkajian (Tanggal: ..............................., Pukul ..........................)
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
C. RIWAYAT PENYAKIT SEKARANG
1. Pertama kali masuk RS (............................................................................)
a. Keluhan : ..............................................................................................
b. Keadaan :
KU = ........................
Kesadaran = ........................
GCS = ........................
Tekanan Darah = ........................
RR = ........................
HR = ........................
Suhu = ........................
c. Terapi yang diberikan : ........................................................................
d. Follow up : ...........................................................................................
2. Ruang rawat inap (......................................................................................)
a. Dx. Medis
1) Primer : ........................
2) Sekunder : ........................
b. Keluhan :
...............................................................................................................
...............................................................................................................
c. Keadaan
KU = ........................
Kesadaran = ........................
GCS = ........................
Tekanan Darah = ........................
RR = ........................
HR = ........................
d. Terapi yang diberikan
Diit = .................................................................................
e. Support system
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
D. RIWAYAT PENYAKIT DAHULU
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
............................................................................................................................
E. RIWAYAT PENYAKIT KELUARGA
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
F. PEMERIKSAAN FISIK
Tanggal ...............................................
1. Keadaan Klien
a. Keadaan Umum : ........................
b. Kesadaran : ........................
c. GCS : ........................
d. TTV
TD = ........................
RR = ........................
HR = ........................
T = ........................
2. Pemeriksaan Fisik
a. Kepala
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
b. Mata
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
c. Leher
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
d. Hidung
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
e. Mulut
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
f. Telinga
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
g. Dada dan Paru
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
h. Payudara
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
i. Jantung
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
..............................................................................................................
j. Abdomen
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
k. Genitalia
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
l. Kulit dan Kuku
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
m. Ekstremitas atas dan ekstremitas bawah
Inspeksi : ......................................................................................
Kekuatan otot :
Kanan Kiri
..............................
..............................
Pergerakan
Kanan Kiri
................................
................................
ROM Ekstremitas atas
Kanan : ..................................................................................
Kiri : ..................................................................................
ROM Ekstremitas bawah
Kanan : ..................................................................................
Kiri : ..................................................................................
n. Pemeriksaan lain
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
G. PENGKAJIAN KEBUTUHAN DASAR
1. Kebutuhan Oksigenasi
Sebelum sakit :
a. A (Airway)
: ..........................................................................................................
...............................................................................................................
...............................................................................................................
.....
b. B (Breathing) :
...............................................................................................................
...............................................................................................................
...............................................................................................................
c. C (Circulation) :
...............................................................................................................
...............................................................................................................
...............................................................................................................
Selama sakit :
a. A (Airway)
: ............................................................................................................
................................................................................................................
................................................................................................................
. .............................................................................................................
b. B (Breathing) :
...............................................................................................................
...............................................................................................................
...............................................................................................................
.............................................................................................................
c. C (Circulation) :
................................................................................................................
................................................................................................................
............................................................................................................. ..
...........................................................................................................
2. Kebutuhan Nutrisi dan Cairan
Nutrisi
Indeks Sebelum sakit Selama sakit
A
(Antropometri)
B (Biokimia)
C (Clinis)
D (Diet)
Cairan
a. Sebelum sakit
Intake
Output
Balance cairan
Hematokrit
b. Selama sakit
Intake
Output
Balance cairan
Hematokrit
3. Kebutuhan Eliminasi
BAK
Kategori Sebelum Sakit Selama Sakit
Frekuensi
Jumlah
Warna
Bau
Konsistensi
BAB
Kategori Sebelum Sakit Selama Sakit
Frekuensi
Jumlah
Warna
Bau
Konsistensi
4. Kebutuhan Termoregulasi
Sebelum sakit Selama sakit
Suhu tubuh
Produksi keringat
Adaptasi suhu
lingkungan
5. Kebutuhan Aktivitas dan Latihan
Sebelum Sakit :
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
Indeks KATZ klien sebelum sakit
Kategori Mandiri Tergantung
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
Selama Sakit :
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
Indeks KATZ klien selama sakit
Kategori Mandiri Tergantung
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
6. Kebutuhan Seksualitas
Sebelum sakit Selama sakit
Kebutuhan dicintai
dan mencintai
Status pernikahan
Alat kontrasepsi
Kebutuhan akan seks
7. Kebutuhan Psikososial (stress, koping, dan konsep diri)
Sebelum sakit Selama sakit
Stress dan koping
Konsep diri :
1. Gambaran
diri
2. Identitas diri
3. Peran diri
4. Ideal diri
5. Harga diri
8. Kebutuhan aman dan nyaman
a. Kebutuhan rasa aman
Sebelum sakit Selama sakit
Keamanan
lingkungan
Lingkungan yang
aman
b. Kebutuhan rasa nyaman
Sebelum sakit Selama sakit
Rasa nyaman:
1. Nyeri
2. Mual dan
muntah
3. Gangguan
rasa
nyaman
lain :
pusing,
gatal,
dikubitus
9. Kebutuhan Spiritual
Sebelum sakit Selama sakit
Agama
Kegiatan
beribadah
10. Kebutuhan Hygiene
Kebiasaan hygiene Sebelum sakit Saat sakit
Mandi
Mencuci rambut
Menggososk gigi
Berganti pakaian
Berhias
Kebersihan kuku
tangan dan kaki
11. Kebutuhan Istirahat dan Tidur
Kategori Sebelum Sakit Selama Sakit
Jam tidur
Pola tidur
Posisi tidur yang
disukai
Lingkungan
12. Kebutuhan Rekreasi
Sebelum sakit Selama sakit
13. Kebutuhan Informasi dan Komunikasi
Sebelum sakit Selama sakit
Pengetahuan dan
informasi mengenai
penyakit
Pengetahuan dan
informasi mengenai
terapi/rencana terapi
yang diberikan
Minat belajar mengenai
suatu topik (penyakit
yang diderita)
14. Kebutuhan Aktualisasi Diri
Sebelum sakit Selama sakit
H. PEMERIKSAAN PENUNJANG
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
I. TERAPI
JenisTerapi
Dosis RuteIndikasi & Cara Kerja
Kontra Indikasi
Efek Samping
JenisTerapi
Dosis RuteIndikasi & Cara Kerja
Kontra Indikasi
Efek Samping
II. ANALISA DATA
No. Hari/tanggal Data fokus Masalah Etiologi
III. DIAGNOSA KEPERAWATAN
No.Tgl/jam
ditemukanDiagnosa Keperawatan Ttd
IV. RENCANA KEPERAWATAN
NoHari/
Tanggal
No.
DxTujuan dan Kriteria Hasil Intervensi Rasional
NoHari/
Tanggal
No.
DxTujuan dan Kriteria Hasil Intervensi Rasional
NoHari/
Tanggal
No.
DxTujuan dan Kriteria Hasil Intervensi Rasional
NoHari/
Tanggal
No.
DxTujuan dan Kriteria Hasil Intervensi Rasional
No Hari/ No. Tujuan dan Kriteria Hasil Intervensi Rasional
Tanggal Dx
V. IMPLEMENTASI
No Tanggal JamNo. Dx.
KeperawatanImplementasi Respon TTD
No Tanggal Jam No. Dx. Implementasi Respon TTD
Keperawatan
No Tanggal Jam No. Dx. Implementasi Respon TTD
Keperawatan
No Tanggal Jam No. Dx. Implementasi Respon TTD
Keperawatan
No Tanggal Jam No. Dx. Implementasi Respon TTD
Keperawatan
No Tanggal Jam No. Dx. Implementasi Respon TTD
Keperawatan
No Tanggal Jam No. Dx. Implementasi Respon TTD
Keperawatan
No Tanggal Jam No. Dx. Implementasi Respon TTD
Keperawatan
VI. EVALUASI
NoTanggal/
jamDiagnosa Keperawatan Evaluasi TTD
NoTanggal/
jamDiagnosa Keperawatan Evaluasi TTD
NoTanggal/
jamDiagnosa Keperawatan Evaluasi TTD