FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa : ..............................................................................

Tempat praktik : ..............................................................................

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A. DATA DEMOGRAFI

1. Identitas diri klienNama : ...................................................................Usia : ...................................................................Jenis kelamin : ...................................................................Alamat : ...................................................................Suku bangsa : ...................................................................Status pernikahan : ...................................................................Agama / keyakinan : ...................................................................Pendidikan : ...................................................................Pekerjaan : ...................................................................Diagnosa medik : ...................................................................Tanggal masuk : ...................................................................Tanggal pengkajian : ...................................................................

2. Penanggung jawabNama : ...................................................................Usia : ...................................................................Jenis kelamin : ...................................................................Pekerjaan : ...................................................................Hubungan dengan klien : ...................................................................

B. KELUHAN UTAMA

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C. RIWAYAT KESEHATAN

1. Riwayat kesehatan sekarang

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2. Riwayat kesehatan lalu

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3. Riwayat kesehatan keluarga

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Genogram:

D. RIWAYAT PSIKOSOSIAL

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E. RIWAYAT SPIRITUAL

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F. PEMERIKSAAN FISIK

1. Keadaan umum klien

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2. Tanda-tanda vital

TD : mmHg, HR : x/menit,

RR : x/menit, Suhu : oC

3. Sistem Pernafasan

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4. Sistem Kardiovaskuler

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5. Sistem Pencernaan

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6. Sistem Pengindraan

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7. Sistem Saraf

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8. Sistem Muskoloskeletal

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9. Sistem Integumen

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10. Sistem Endokrin

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11. Sistem Perkemihan

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12. Sistem Reproduksi

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13. Sistem Imunitas

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G. AKTIFITAS SEHARI- HARI

1. Nutrisi

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2. Cairan

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3. Eliminasi

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4. Istirahat tidur

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5. Olahraga

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6. Rokok/ alkohol

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7. Personal Hygiene

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8. Aktivitas / mobilitas fisik

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9. Rekreasi

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H. TES DIAGNOSTIK

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I. TERAPI SAAT INI

Nama Obat Dosis Indikasi Kontraindikasi Efek samping

PENGELOMPOKKAN DATA

NAMA PASIEN :

RUANG RAWAT :

DATA SUBJEKTIF DATA OBJEKTIF

ANALISA DATA

NAMA PASIEN :

RUANG RAWAT :

NO DATA MASALAH ETIOLOGI

DIAGNOSA KEPERAWATAN

NAMA PASIEN :

RUANG RAWAT :

NO DIAGNOSA KEPERAWATANTGL

DITEMUKAN

TGL

TERATASI

RENCANA KEPERAWATAN

NAMA PASIEN : RUANG RAWAT : TGL/JAM NO. Dx TUJUAN RENCANA TINDAKAN RASIONAL

CATATAN TINDAKAN

NAMA PASIEN : RUANG RAWAT :

CATATAN PERKEMBANGAN

TGL/JAM NO. DX IMPLEMENTASI RESPON TTD

NAMA PASIEN : RUANG RAWAT : TANGGAL NO DX JAM EVALUASI HASIL/ SOAP