FORMAT PENGKAJIANKEPERAWATAN MEDIKAL BEDAHNama Mahasiswa: ..............................................................................

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

Waktu praktik: ..............................................................................

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 jawab

Nama

: ...................................................................Usia

: ...................................................................Jenis kelamin

: ...................................................................Pekerjaan

: ...................................................................Hubungan dengan klien: ...................................................................B. KELUHAN UTAMA

..............................................................................................................................................................................................................................................................................................................................................................................................................................C. RIWAYAT KESEHATAN

1. Riwayat kesehatan sekarang

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Riwayat kesehatan lalu

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................3. Riwayat kesehatan keluarga

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Genogram:

D. RIWAYAT PSIKOSOSIAL

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................E. RIWAYAT SPIRITUAL

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................F. PEMERIKSAAN FISIK

1. Keadaan umum klien

................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Tanda-tanda vital

TD : mmHg,

HR : x/menit, RR : x/menit,

Suhu : oC3. Sistem Pernafasan

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 4. Sistem Kardiovaskuler

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 5. Sistem Pencernaan

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 6. Sistem Pengindraan................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................7. Sistem Saraf

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 8. Sistem Muskoloskeletal

.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 9. Sistem Integumen

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 10. Sistem Endokrin

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 11. Sistem Perkemihan

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 12. Sistem Reproduksi

.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 13. Sistem Imunitas

.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... G. AKTIFITAS SEHARI- HARI

1. Nutrisi........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 2. Cairan

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 3. Eliminasi

........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ 4. Istirahat tidur................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................5. Olahraga................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................6. Rokok/ alkohol................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................7. Personal Hygiene

................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................8. Aktivitas / mobilitas fisik

................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ ........................................................................................................................................................................................................................................................................9. Rekreasi

........................................................................................................................................................................................................................................................................ ........................................................................................................................................................................................................................................................................H. TES DIAGNOSTIK

........................................................................................................................................................................................................................................................................ ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................I. TERAPI SAAT ININama ObatDosisIndikasiKontraindikasiEfek samping

PENGELOMPOKKAN DATANAMA PASIEN

:

RUANG RAWAT :

DATA SUBJEKTIFDATA OBJEKTIF

ANALISA DATANAMA PASIEN

:

RUANG RAWAT :

NODATAMASALAHETIOLOGI

DIAGNOSA KEPERAWATANNAMA PASIEN

:

RUANG RAWAT : NODIAGNOSA KEPERAWATANTGL

DITEMUKANTGL

TERATASI

RENCANA KEPERAWATAN

NAMA PASIEN

:

RUANG RAWAT : TGL/JAMNO. DxTUJUANRENCANA TINDAKANRASIONAL

CATATAN TINDAKAN

NAMA PASIEN

:

RUANG RAWAT : TGL/JAMNO. DXIMPLEMENTASIRESPONTTD

CATATAN PERKEMBANGAN

NAMA PASIEN

:

RUANG RAWAT : TANGGALNO DXJAMEVALUASI HASIL/ SOAP