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ASUHAN KEPERAWATAN MEDIKAL BEDAH PADA ............... DENGAN ................................................ ....... DI RUANG ................................................. ........................................ I.PENGKAJIAN Tanggal Pengkajian : ................................... Tanggal Masuk Ruangan : ................................... Ruang : ................................... A. IDENTITAS 1. Identitas Klien Nama : ............................ ....... No. Rekam Medis : ................................... Umur : ............................ ....... Jenis Kelamin : ...................................

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ASUHAN KEPERAWATAN MEDIKAL BEDAH

PADA ............... DENGAN .......................................................

DI RUANG .........................................................................................

I. PENGKAJIAN

Tanggal Pengkajian : ...................................

Tanggal Masuk Ruangan : ...................................

Ruang : ...................................

A. IDENTITAS

1. Identitas Klien

Nama : ...................................

No. Rekam Medis : ...................................

Umur : ...................................

Jenis Kelamin : ...................................

Agama : ...................................

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

Suku : ...................................

Bahasa : ...................................

Alamat : ...................................

Pembiayaan Kesehatan : ...................................

2. Identitas Penanggung Jawab

Nama : ...................................

Umur : ...................................

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

Suku : ...................................

Hubungan dg Klien : ...................................

Bahasa : ...................................

Alamat : ...................................

No.Telpon : ...................................

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B. KELUHAN UTAMA

1. Pertama kali masuk RS (............................................................................)

Keluhan utama :

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Keluhan lainnya :

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2. Saat Pengkajian (Tanggal: ..............................., Pukul ..........................)

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C. RIWAYAT PENYAKIT SEKARANG

1. Pertama kali masuk RS (............................................................................)

a. Keluhan : ..............................................................................................

b. Keadaan :

KU = ........................

Kesadaran = ........................

GCS = ........................

Tekanan Darah = ........................

RR = ........................

HR = ........................

Suhu = ........................

c. Terapi yang diberikan : ........................................................................

d. Follow up : ...........................................................................................

2. Ruang rawat inap (......................................................................................)

a. Dx. Medis

1) Primer : ........................

2) Sekunder : ........................

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b. Keluhan :

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c. Keadaan

KU = ........................

Kesadaran = ........................

GCS = ........................

Tekanan Darah = ........................

RR = ........................

HR = ........................

d. Terapi yang diberikan

Diit = .................................................................................

e. Support system

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D. RIWAYAT PENYAKIT DAHULU

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E. RIWAYAT PENYAKIT KELUARGA

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F. PEMERIKSAAN FISIK

Tanggal ...............................................

1. Keadaan Klien

a. Keadaan Umum : ........................

b. Kesadaran : ........................

c. GCS : ........................

d. TTV

TD = ........................

RR = ........................

HR = ........................

T = ........................

2. Pemeriksaan Fisik

a. Kepala

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b. Mata

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c. Leher

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d. Hidung

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e. Mulut

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f. Telinga

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g. Dada dan Paru

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h. Payudara

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i. Jantung

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j. Abdomen

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k. Genitalia

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l. Kulit dan Kuku

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m. Ekstremitas atas dan ekstremitas bawah

Inspeksi : ......................................................................................

Kekuatan otot :

Kanan Kiri

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Pergerakan

Kanan Kiri

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ROM Ekstremitas atas

Kanan : ..................................................................................

Kiri : ..................................................................................

ROM Ekstremitas bawah

Kanan : ..................................................................................

Kiri : ..................................................................................

n. Pemeriksaan lain

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G. PENGKAJIAN KEBUTUHAN DASAR

1. Kebutuhan Oksigenasi

Sebelum sakit :

a. A (Airway)

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b. B (Breathing) :

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c. C (Circulation) :

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Selama sakit :

a. A (Airway)

: ............................................................................................................

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

b. B (Breathing) :

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c. C (Circulation) :

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2. Kebutuhan Nutrisi dan Cairan

Nutrisi

Indeks Sebelum sakit Selama sakit

A

(Antropometri)

B (Biokimia)

C (Clinis)

D (Diet)

Cairan

a. Sebelum sakit

Intake

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Output

Balance cairan

Hematokrit

b. Selama sakit

Intake

Output

Balance cairan

Hematokrit

3. Kebutuhan Eliminasi

BAK

Kategori Sebelum Sakit Selama Sakit

Frekuensi

Jumlah

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Warna

Bau

Konsistensi

BAB

Kategori Sebelum Sakit Selama Sakit

Frekuensi

Jumlah

Warna

Bau

Konsistensi

4. Kebutuhan Termoregulasi

Sebelum sakit Selama sakit

Suhu tubuh

Produksi keringat

Adaptasi suhu

lingkungan

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5. Kebutuhan Aktivitas dan Latihan

Sebelum Sakit :

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Indeks KATZ klien sebelum sakit

Kategori Mandiri Tergantung

Bathing

Dressing

Toileting

Transferring

Continence

Feeding

Selama Sakit :

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Indeks KATZ klien selama sakit

Kategori Mandiri Tergantung

Bathing

Dressing

Toileting

Transferring

Continence

Feeding

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6. Kebutuhan Seksualitas

Sebelum sakit Selama sakit

Kebutuhan dicintai

dan mencintai

Status pernikahan

Alat kontrasepsi

Kebutuhan akan seks

7. Kebutuhan Psikososial (stress, koping, dan konsep diri)

Sebelum sakit Selama sakit

Stress dan koping

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Konsep diri :

1. Gambaran

diri

2. Identitas diri

3. Peran diri

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4. Ideal diri

5. Harga diri

8. Kebutuhan aman dan nyaman

a. Kebutuhan rasa aman

Sebelum sakit Selama sakit

Keamanan

lingkungan

Lingkungan yang

aman

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b. Kebutuhan rasa nyaman

Sebelum sakit Selama sakit

Rasa nyaman:

1. Nyeri

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2. Mual dan

muntah

3. Gangguan

rasa

nyaman

lain :

pusing,

gatal,

dikubitus

9. Kebutuhan Spiritual

Sebelum sakit Selama sakit

Agama

Kegiatan

beribadah

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10. Kebutuhan Hygiene

Kebiasaan hygiene Sebelum sakit Saat sakit

Mandi

Mencuci rambut

Menggososk gigi

Berganti pakaian

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Berhias

Kebersihan kuku

tangan dan kaki

11. Kebutuhan Istirahat dan Tidur

Kategori Sebelum Sakit Selama Sakit

Jam tidur

Pola tidur

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Posisi tidur yang

disukai

Lingkungan

12. Kebutuhan Rekreasi

Sebelum sakit Selama sakit

13. Kebutuhan Informasi dan Komunikasi

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Sebelum sakit Selama sakit

Pengetahuan dan

informasi mengenai

penyakit

Pengetahuan dan

informasi mengenai

terapi/rencana terapi

yang diberikan

Minat belajar mengenai

suatu topik (penyakit

yang diderita)

14. Kebutuhan Aktualisasi Diri

Sebelum sakit Selama sakit

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H. PEMERIKSAAN PENUNJANG

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I. TERAPI

JenisTerapi

Dosis RuteIndikasi & Cara Kerja

Kontra Indikasi

Efek Samping

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JenisTerapi

Dosis RuteIndikasi & Cara Kerja

Kontra Indikasi

Efek Samping

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II. ANALISA DATA

No. Hari/tanggal Data fokus Masalah Etiologi

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III. DIAGNOSA KEPERAWATAN

No.Tgl/jam

ditemukanDiagnosa Keperawatan Ttd

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IV. RENCANA KEPERAWATAN

NoHari/

Tanggal

No.

DxTujuan dan Kriteria Hasil Intervensi Rasional

NoHari/

Tanggal

No.

DxTujuan dan Kriteria Hasil Intervensi Rasional

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NoHari/

Tanggal

No.

DxTujuan dan Kriteria Hasil Intervensi Rasional

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NoHari/

Tanggal

No.

DxTujuan dan Kriteria Hasil Intervensi Rasional

No Hari/ No. Tujuan dan Kriteria Hasil Intervensi Rasional

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Tanggal Dx

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V. IMPLEMENTASI

No Tanggal JamNo. Dx.

KeperawatanImplementasi Respon TTD

No Tanggal Jam No. Dx. Implementasi Respon TTD

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Keperawatan

No Tanggal Jam No. Dx. Implementasi Respon TTD

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Keperawatan

No Tanggal Jam No. Dx. Implementasi Respon TTD

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Keperawatan

No Tanggal Jam No. Dx. Implementasi Respon TTD

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Keperawatan

No Tanggal Jam No. Dx. Implementasi Respon TTD

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Keperawatan

No Tanggal Jam No. Dx. Implementasi Respon TTD

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Keperawatan

No Tanggal Jam No. Dx. Implementasi Respon TTD

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Keperawatan

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VI. EVALUASI

NoTanggal/

jamDiagnosa Keperawatan Evaluasi TTD

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NoTanggal/

jamDiagnosa Keperawatan Evaluasi TTD

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NoTanggal/

jamDiagnosa Keperawatan Evaluasi TTD

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