5/26/2018 Format Pengkajian Edit Print

1/22

FORMAT EVALUASI PENYULUHAN KEPERAWATAN

Nama Mahasiswa :

NIM :

No Aspek yang ditelitiNilai

MaksimalNilai

1 Penyajiana. Sesuai waktu yang di alokasikanb. Menggunakan bahasa yang bisa di mengertic. Kelancaran dan kejelasan penyajiand. Penampilan penyaji dalam penyuluhan

40

2 Isi Penyuluhan

a. Kesesuaian TIK dengan TIUb. Kesesuaian materi dengan TIKc. Kesesuaian kegiatan penyuluhand. Kesesuaian media/alat dan sumbere. Kesesuaian alat evaluasi

30

3 Tanya Jawaba. Ketepatan menjawabb. Kemampuan mengemukakan argumentc. Sikap penyuluh menanggapi pertanyaan

30

Total 100

Score Akhir : (Penyaji + Isi + Tanya Jawab) =

., 2014

Pembimbing,

______________________________

NIP.

5/26/2018 Format Pengkajian Edit Print

2/22

PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBERFORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :

NIM :

Tempat Pengkajian :

Tanggal :

I. Identitas Klien

Nama : No. RM :Umur : Pekerjaan :Jenis Kelamin : Status Perkawinan :Agama : Tanggal MRS :Pendidikan : Tanggal

Pengkajian:

Alamat : Sumber Informasi :

II. Riwayat Kesehatan

1. DiagnosaMedik:.................................

..

2. KeluhanUtama:........

3. Riwayat penyakit sekarang:

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

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

4. Riwayat kesehatan terdahulu:a. Penyakit yang pernah

dialami:.................................

..

.

.

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

5/26/2018 Format Pengkajian Edit Print

3/22

b. Alergi (obat, makanan, plester,

dll):.................................

..

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

c.Imunisasi:

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

d.Kebiasaan/pola hidup/life

style:.................................

..

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

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

e. Obat-obat yang

digunakan:.................................

..

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

..

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

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

5. Riwayat penyakit keluarga:...................................

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

Genogram:

5/26/2018 Format Pengkajian Edit Print

4/22

III. Pengkajian Keperawatan

1. Persepsi kesehatan & pemeliharaan kesehatan

Interpretasi :

.

2. Pola nutrisi/ metabolik (ABCD)- Antropometeri

Interpretasi :

- Biomedical sign :

Interpretasi :

- Clinical Sign :

Interpretasi :

- Diet Pattern :

5/26/2018 Format Pengkajian Edit Print

5/22

Interpretasi :

3. Pola eliminasi:BAK

- Frekuensi :..- Jumlah :..- Warna : ..- Bau : ..- Karakter : ..- BJ :..- Alat Bantu : ..- Kemandirian : mandiri/dibantu- Lain : ..

BAB

- Frekuensi :..- Jumlah :..- Konsistensi : ..- Warna : ..- Bau : ..- Karakter : ..- BJ :..- Alat Bantu : ..- Kemandirian : mandiri/dibantu- Lain : ..

Interpretasi :

4.

Pola aktivitas & latihan

c.1. Aktivitas harian (Activity Daily Living)

Kemampuan perawatan diri 0 1 2 3 4

Makan / minum

Toileting

Berpakaian

Mobilitas di tempat tidur

BerpindahAmbulasi / ROM

5/26/2018 Format Pengkajian Edit Print

6/22

Status Oksigenasi :

Fungsi kardiovaskuler :

Terapi oksigen :

Interpretasi :

.

5. Pola tidur & istirahatDurasi :

Gangguan tidur : .

Keadaan bangun tidur : ..

Lain-lain :

Interpretasi :

.

6. Pola kognitif & perceptualFungsi Kognitif dan Memori :

Fungsi dan keadaan indera :

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

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

Interpretasi :

.

7. Pola persepsi diriGambaran diri :

Identitas diri :

Harga diri :

Ideal Diri :

5/26/2018 Format Pengkajian Edit Print

7/22

Peran Diri :

Interpretasi :

.

8. Pola seksualitas & reproduksiPola seksualitas

Fungsi reproduksi

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

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

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

Interpretasi :

.

9. Pola peran & hubungan

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

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

..........................................................................................................................................................Interpretasi :

.

10.Pola manajemen koping-stress

Interpretasi :

.

11.System nilai & keyakinan

Interpretasi :

.

5/26/2018 Format Pengkajian Edit Print

8/22

IV. Pemeriksaan Fisik

Keadaan umum:

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

Tanda vital:

- Tekanan Darah : mm/Hg- Nadi : X/mnt- RR : X/mnt- Suhu : C

Interpretasi :

.

Pengkajian Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi)

1. Kepala

2. Mata

3. Telinga..........................................

4. Hidung

5. Mulut

6. Leher

5/26/2018 Format Pengkajian Edit Print

9/22

7. Dada........

8. Abdomen

9. Urogenital

10.Ekstremitas

11.Kulit dan kuku

12.Keadaan lokal

V. Terapi

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

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

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

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

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

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

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

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

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

5/26/2018 Format Pengkajian Edit Print

10/22

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

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

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

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

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

VI. Pemeriksaan Penunjang & Laboratorium

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jember, April 2014

Pengambil Data,

(_________________________________)

5/26/2018 Format Pengkajian Edit Print

11/22

ANALISA DATA

NO DATA PENUNJANG ETIOLOGI MASALAH

5/26/2018 Format Pengkajian Edit Print

12/22

5/26/2018 Format Pengkajian Edit Print

13/22

DAFTAR DIAGNOSA KEPERAWATAN

Tanggal No Dx Diagnosa Keperawatan Nama terang dan ttd

5/26/2018 Format Pengkajian Edit Print

14/22

RENCANA TINDAKAN KEPERAWATAN

Diagnosa Keperawatan Tujuan dan Kriteria hasil Rencana Tindakan Keperawatan Rasional

5/26/2018 Format Pengkajian Edit Print

15/22

5/26/2018 Format Pengkajian Edit Print

16/22

TINDAKAN KEPERAWATAN

Tanggal Jam Tindakan Keperawatan Nama dan TTD

5/26/2018 Format Pengkajian Edit Print

17/22

EVALUASI KEPERAWATAN

Tanggal No. Dx Evaluasi Keperawatan Nama dan TTD

5/26/2018 Format Pengkajian Edit Print

18/22

5/26/2018 Format Pengkajian Edit Print

19/22

CATATAN PERKEMBANGAN

DIAGNOSA:

WAKTU IMPLEMENTASI PARAF EVALUASIJAM:

5/26/2018 Format Pengkajian Edit Print

20/22

5/26/2018 Format Pengkajian Edit Print

21/22

FORMAT RESUME KASUS KELOLAAN HARIAN

S (Subjektif):...............................................................................................................................................................................

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

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

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

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

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

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

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

O (Objektif):

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

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

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

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

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

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

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

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

A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan DO):

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

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

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

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

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

P(Perencanaan):

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

5/26/2018 Format Pengkajian Edit Print

22/22

I (Implementasi):

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

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

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

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

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

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

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

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

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

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

E (Evaluasi):

S (Subjektif):

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

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

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

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

O(Objektif):

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

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

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

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

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

A(analisa):

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

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

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

P(Perencanaan:

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

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

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

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

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

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

Jember, April 2014

Petugas pelaksana,

(_________________________________)