Professional Documents
Culture Documents
Format Pengkajian KMB
Format Pengkajian KMB
Nama Mahahasiswa :
NIM :
I. PENGKAJIAN
B. RIWAYAT KESEHATAN
1. KELUHAN UTAMA :
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2. RIWAYAT PENYAKIT SEKARANG :
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3. RIWAYAT PENYAKIT MASA LALU :
a. Penyakit yang pernah dialami
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b. Pengobatan /tindakan yang dilakukan
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c. Pernah Operasi
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d. Riwayat alergi
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5. GENOGRAM ( 3 GENERASI)
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6. RIWAYAT PSIKOSOSIAL :
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Kemampuan 0 1 2 3 4 5
Perawatan diri
Mandi
Toileting
Berpakaian
Mobilitas di tempat
tidur
Berpindah
Ambulasi (ROM)
Interpretasi Hasil :
0 : mandiri
1 : alat Bantu
2 : dibantu olang lain
3 : tergantung total
8. PEMERIKSAAN FISIK :
a. Keadaam umum : .................................................................................................................
Kesadaran : .................................................................................................................
GCS : .................................................................................................................
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e. Payudara dan ketiak :
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g. Pemeriksaan Abdomen :
a) Inspeksi
a. Bentuk abdomen : .........................................................................
b. Benjolan / massa : .........................................................................
c. Bayangan pembuluh darah : .........................................................................
b) Auskultasi
a. Peristaltik usus : .........................................................................
c) Palpasi
a. Tanda nyeri tekan : .........................................................................
b. Benjolan / massa : .........................................................................
c. Tanda ascites : .........................................................................
d. Hepar : .........................................................................
e. Lien : .........................................................................
f. Titik Mc Burney : .........................................................................
d) Perkusi
a. Suara abdomen : .........................................................................
b. Pemeriksaan ascites : .........................................................................
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i. Ekstrimitas / Pemeriksaan muskuloskeletal
a) Kesimetrisan otot : .........................................................................
b) Edema : .........................................................................
c) Kekuatan otot : .........................................................................
d) Kelainan pada ekstrimitas dan kuku : .........................................................................
j. Pemeriksaan Integumen :
a.Kebersihan : .........................................................................
b. Kehangatan : .........................................................................
c.Warna : .........................................................................
d. Turgor : .........................................................................
e.Kelembapan : .........................................................................
f. Kelainan pada kulit : .........................................................................
9. SPIRITUAL :
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Nama Pasien : ………………………………. No. Register : ……………………
ANALISIS DATA
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RENCANA KEPERAWATAN
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Nama Pasien : ……………………………………… No. Register :………………………………………..
CATATAN PERKEMBANGAN