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ASUHAN KEPERAWATAN MEDIKEL BEDAH
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DI RUANG ……………… RSUD ……………………………………
Nama Mahasiswa : ……………………………………
NIM : ……………………………………
Tempat Praktik : Ruang ……………………………
RSUD ……………………………
Tanggal Pengkajian : ……………………………… 2014
A. PENGKAJIAN
Pengkajian dilakukan pada Hari ………… Tanggal ……………………… 2014 di
Ruang ………… RSUD ………………………………… secara alloanamnesa dan
autoanamnesa.
1. IDENTITAS
a. Identitas Klien
Nama : ………………………………………………
Jenis Kelamin : ………………………………………………
Umur : ………………………………………………
Pendidikan Terakhir : ………………………………………………
Agama : ………………………………………………
Suku : ………………………………………………
Status Perkawinan : ………………………………………………
Pekerjaan : ………………………………………………
Alamat : ………………………………………………
Diagnosa medis : ………………………………………………
No RM : ………………………………………………
Tanggal masuk : ………………………………………………
b. Identitas Penanggungjawab
Nama : ………………………………………………
Umur : ………………………………………………
Jenis Kelamin : ………………………………………………
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Agama : ………………………………………………
Suku : ………………………………………………
Hubungan dng pasien : ………………………………………………
Pekerjaan : ………………………………………………
2. RIWAYAT KESEHATAN
a. Keluhan Utama :
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b. Riwayat kesehatan sekarang :
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c. Riwayat kesehatan dahulu :
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d. Riwayat kesehatan keluarga :
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3. POLA PENGKAJIAN FUNGSIONAL
a. Pola persepsi-Management Kesehatan
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b. Pola nutrisi
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c. Pola Eliminasi
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d. Pola latihan – Aktivitas
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e. Pola kognitif perseptual
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f. Pola istirahat – tidur
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g. Pola Konsep Diri/Persepsi Diri
1) Gambaran diri (citra tubuh)
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2) Identitas
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3) Peran
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4) Ideal diri
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5) Harga diri
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h. Pola Peran dan Hubungan
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i. Pola Reproduksi / Seksual
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j. Pola Pertahanan Diri (Coping toleransi stress)
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k. Pola Keyakinan Dan Nilai
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4. PEMERIKSAAN FISIK
a. Tanda – tanda Vital
TANDA-TANDA VITAL
HARI & TANGGAL
Hari :Tgl :
Hari :Tgl :
Hari :Tgl :
Tekanan Darah ……… mmHg ……… mmHg ……… mmHg
Nadi ……… x/menit ……… x/menit ……… x/menit
Respiratory Rate ……… x/menit ……… x/menit ……… x/menit
Suhu ……… 0C ……… 0C ……… 0C
b. Pemeriksaan head to toe
1) Kepala : ………………………………………………
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2) Mata : ………………………………………………
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3) Hidung : ………………………………………………
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4) Mulut dan tenggorokan : ………………………………………………
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5) Telinga : ………………………………………………
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6) Dada :
Thorak
I : ………………………………………………………………………
P : ………………………………………………………………………
P : ………………………………………………………………………
A : ………………………………………………………………………
Jantung
I : ………………………………………………………………………
P : ………………………………………………………………………
P : ………………………………………………………………………
A : ………………………………………………………………………
7) Abdomen :
I : ………………………………………………………………………
P : ………………………………………………………………………
P : ………………………………………………………………………
A : ………………………………………………………………………
8) Genetalia : ………………………………………………
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9) Integumen : ………………………………………………
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10) Ekstremitas : ………………………………………………
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5. DATA PENUNJANG
a. Laboratorium
Hari / Tanggal : ………………………………………………
Jenis Pemeriksaan HasilSatuan
Nilai Normal Ket.
b. Radiologi
Hari / Tanggal : ………………………………………………
c. Terapi
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Hari / Tanggal : ………………………………………………
No. TANGGAL NAMA OBAT DOSISCARA
PEMBERIAN
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B. ANALISA DATA
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
No.HARI
TANGGALJAM
DATA FOKUS MASALAH ETIOLOGI
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No.HARI
TANGGALJAM
DATA FOKUS MASALAH ETIOLOGI
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C. PERIORITAS DIAGNOSA KEPERAWATAN
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D. RENCANA TINDAKAN KEPERAWATAN
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
HARITANGGAL
JAM
No. DP
TUJUAN & KRITERIA HASIL(NOC)
INTERVENSI (NIC) Ttd.
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HARITANGGAL
JAM
No. DP
TUJUAN & KRITERIA HASIL(NOC)
INTERVENSI (NIC) Ttd.
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E. TINDAKAN KEPERAWATAN
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
HARI & TANGGAL
PUKUL
No.DP
IMPLEMENTASI RESPON PASIEN Ttd.
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HARI & TANGGAL
PUKUL
No.DP
IMPLEMENTASI RESPON PASIEN Ttd.
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F. EVALUASI
Nama : …………………………………………… No. RM : ……………………………………………
Umur : …………………………………………… Ruang : ……………………………………………
No.HARI
TANGGALJAM
DIAGNOSA KEPERAWATAN EVALUASI TTD
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No.HARI
TANGGALJAM
DIAGNOSA KEPERAWATAN EVALUASI TTD