ASUHAN KEPERAWATAN STASE KEPERAWATAN MEDIKAL BEDAH (KMB)

TERHADAP Tn/Ny ............. DENGAN .................... DI RUANG ...................

RUMAH SAKIT DKT TK IV BANDAR LAMPUNG
TAHUN 2017

Ruang : .............................
No. MR / CM : .............................
Tanggal Pengkajian : .............................
Pukul : .............................

I. DATA DASAR
A. Identitas Pasien
1. Nama (Inisial Klien) : ................................................................................
2. Usia : ................................................................................
3. Status Perkawinan : ................................................................................
4. Pekerjaan : ................................................................................
5. Agama : ................................................................................
6. Pendidikan : ................................................................................
7. Suku : ................................................................................
8. Bahasa Yang Digunakan : ................................................................................
9. Alamat Rumah : ................................................................................
10. Sumber Biaya : ................................................................................
11. Tanggal Masuk RS : ................................................................................
12. Diagnosa Medis : ................................................................................

B. Sumber Informasi (penanggung jawab)

1. Nama : ................................................................................
2. Umur : ................................................................................
3. Hubungan dengan klien : ................................................................................
4. Pendidikan : ................................................................................
5. Pekerjaan : ................................................................................
6. Alamat : ................................................................................

II. RIWAYAT KESEHATAN

A. Riwayat Kesehatan Masuk Rs : ....................................................................................
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B. Riwayat Kesehatan Saat Pengkajian / Riwayat Penyakit Sekarang (PQRST) :
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1. Keluhan Utama
a. Penyebab : .................................................................................
b. Onse : .................................................................................
c. Lamanya : .................................................................................
d. Frekuensi : .................................................................................
e. Intensitas : .................................................................................
f. Faktor pencetus : .................................................................................
g. Lokasi : .................................................................................
h. Hal yang memberatkan : .................................................................................
i. Hal yang meringankan : .................................................................................
2. Keluhan Penyerta : .................................................................................

C. Riwayat Kesehatan Lalu

1. Riwayat Alergi : .................................................................................
2. Riwayat kecelakaan : .................................................................................
3. Riwayat perawatan RS : .................................................................................
4. Riwayat penyakit berat/kronis : ..............................................................................
5. Riwayat pengobatan : .................................................................................
D. Riwayat Genogram

Keterangan :
: Laki Laki : Klien

:Perempuan : Pernikahan / Keturunan

/ : meninggal ................. : Serumah

E. Riwayat Psikososial-Spiritual
1. Support System : .................................................................................
2. Komunikasi : .................................................................................
3. System nilai kepercayaan : .................................................................................

F. Lingkungan
1. Rumah
a. Bahaya : ...........................................................................................
b. Kebersihan : ...........................................................................................
c. Polusi : ...........................................................................................
2. Pekerjaan
a. Bahaya : ...........................................................................................
b. Kebersihan : ...........................................................................................
c. Polusi : ...........................................................................................

G. Pola Kebiasaan Sehari-Hari Sebelum Dan Saat Sakit

1. Pola Nutrisi Dan Cairan
a. Pola Nutrisi
1) Sebelum sakit : .................................................................................
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2) Saat sakit : .................................................................................
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b. Pola Cairan
1) Sebelum sakit : .................................................................................
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2) Saat sakit : .................................................................................
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2. Pola Eliminasi
a. BAK (Buang Air Kecil) :
1) Sebelum sakit : .................................................................................
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2) Saat sakit : .................................................................................
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 b. BAB (Buang Air Besar) :
1) Sebelum sakit : .................................................................................
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2) Saat sakit : .................................................................................
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c. IWL (Insensible Water Lose) : ....................................cc / hari

3. Pola Personal Hygiene

a. Sebelum sakit : .............................................................................................
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b. Saat sakit : ............................................................................................
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4. Pola Istirahat Dan Tidur

a. Sebelum sakit : .............................................................................. .............
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b. Saat sakit : ................................................................................ ..... ...
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5. Pola Aktivitas Dan Latihan

a. Sebelum sakit : .............................................................................. ... ........
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b. Saat sakit : ................................................................................ .........
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6. Pola Kebiasaan yang mempengaruhi kesehatan

a. Sebelum sakit : .............................................................................. ... ........
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b. Saat sakit : ................................................................................ ..........
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H. Pengkajian Fisik
1. Pemeriksaan umum
a. Kesadaran : ..................................................
b. Tekanan Darah : .................................................. mmHg
c. Nadi : .................................................. x / Menit
d. Pernafasan : .................................................. x / Menit
e. Suhu : .................................................. 0 C
f. TB / BB : .................................................. Cm / Kg

2. Pemeriksaan fisik per system

a. Sistem Penglihatan : .................................................................................
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b. Sistem Pendengaran : ................................................................................

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 c. Sistem Wicara : ................................................................................

d. Sistem Pernafasan : ................................................................................

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e. Sistem Kardiovaskuler : ................................................................................

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f. Sistem Neurologi : ................................................................................

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g. Sistem Pencernaan : ................................................................................

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h. Sistem Immunology : ................................................................................

i. Sistem Endokrin : ................................................................................

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j. Sistem Urogenital : ................................................................................

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k. Sistem Integumen : ................................................................................

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l. Sistem muskuloskeletal : ................................................................................

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I. Pemeriksaan Penunjang
1. Pemeriksaan diagnostik :
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 2. Pemeriksaan laboratorium :
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J. Penatalaksanaan
1. Penetalaksanaan Medis :
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2. Penatalaksanaan Keperawatan :
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K. Data Fokus
1. Data Subjektif :
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2. Data Objektif :
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III. ANALISA DATA
No. DATA Etiologi Masalah
(Pathway)

IV. PRIORITAS MASALAH

1.
2.
3.
V. RENCANA ASUHAN KEPERAWATAN

Nama Klien : .....................................................................

Dx. Medis : .....................................................................

Umur / Jenis Kelamin : .....................................................................

No. Diagnosa Keperawatan Tujuan Intervensi Rasional

VI. CATATAN PERKEMBANGAN

Nama Klien : ...............................................................

Dx. Medis : ...............................................................

Ruang : ...............................................................

No. MR : ...............................................................

No. Tanggal Diagnosa Keperawatan Implementasi Evaluasi Paraf

(Respon / Hasil)