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FORMAT DOKUMENTASI ASUHAN KEPERAWATAN MEDIKAL BEDAH PROGRAM STUDI ILMU KEPERAWATAN UNEJ A. PENGKAJIAN I. Identitas Klien: No. Rekam Medis (RM) Nama Klien Nama panggilan Tempat/tanggal lahir Umur Agama Jenis kelamin Alamat Pendidikan Pekerjaan Suku Bahasa yang dimengerti Diagnosa medis SMRS II.

: : : : : : : : : : : : :

Tanggal MRS : Tanggal pengkajian: Sumber informasi :

Riwayat Penyakit 1. Keluhan Utama: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 2. Riwayat Penyakit Sekarang: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 3. Riwayat Penyakit Dahulu: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 4. Riwayat Penyakit Keluarga: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 1

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

III. Pengkajian Saat Ini (Pola Fungsional Kesehatan): 1. Persepsi dan pemeliharaan kesehatan. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. ...... 2. Pola nutrisi/metabolik a.Program diit RS :......................................................................................................... b. Intake makanan : Sebelum masuk RS:.......................................................................................................... ........................................................................................................... Saat di RS :.......................................................................................................... ........................................................................................................... ........................................................................................................... c. Intake cairan : Sebelum masuk RS:.......................................................................................................... ........................................................................................................... Saat di RS :.......................................................................................................... ........................................................................................................... ........................................................................................................... d. Riwayat alergi makanan:.................................................................................................. 3. Pola eliminasi a. Buang Air besar (BAB):................................................................................................. .................................................................................................. b. Buang Air kecil (BAK):................................................................................................. ................................................................................................... 4. Pola aktivitas dan latihan Kemampuan perawatan diri 0 1 2 3 4 Ket. Makan/minum Mandi Toileting Berpakaian Mobilitas di tempat tidur Berpindah/berjalan Ambulasi/ROM 0: mandiri; 1: dengan alat bantu; 2: dibantu orang lain; 3: dibantu orang lain dan alat; 4: tergantung total 2

Oksigenasi:.......................................................................................................................... . 5. Pola tidur dan istirahat .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 6. Pola persepsi-kognisi Penglihatan :....................................................................................................................... Pendengaran :....................................................................................................................... Pengecapan :....................................................................................................................... Penciuman :....................................................................................................................... Perasa :....................................................................................................................... Sensasi :....................................................................................................................... Orientasi (OTW):.................................................................................................................. 7. Pola persepsi diri-konsep diri .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. ...