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FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH Nama Mahasiswa : .............................................................................. Tempat praktik



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



Waktu praktik



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



A. DATA DEMOGRAFI 1. Identitas diri klien Nama 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 :



RR :



x/menit,



Suhu :



x/menit, o



C



3. 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 INI Nama Obat



Dosis



Indikasi



Kontraindikasi



PENGELOMPOKKAN DATA NAMA PASIEN



:



RUANG RAWAT



:



DATA SUBJEKTIF



DATA OBJEKTIF



Efek samping



ANALISA DATA NAMA PASIEN



:



RUANG RAWAT



:



NO



DATA



MASALAH



ETIOLOGI



DIAGNOSA KEPERAWATAN NAMA PASIEN



:



RUANG RAWAT



:



NO



DIAGNOSA KEPERAWATAN



TGL



TGL



DITEMUKAN



TERATASI



RENCANA KEPERAWATAN NAMA PASIEN TGL/JAM



NO. Dx



:



RUANG RAWAT : TUJUAN



RENCANA TINDAKAN



CATATAN TINDAKAN



RASIONAL



NAMA PASIEN TGL/JAM



NO. DX



:



RUANG RAWAT : IMPLEMENTASI



RESPON



TTD



CATATAN PERKEMBANGAN NAMA PASIEN TANGGAL



: NO DX



RUANG RAWAT : JAM



EVALUASI HASIL/ SOAP