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 : ………………………………………………

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

Hari / Tanggal : ………………………………………………

No. TANGGAL NAMA OBAT DOSISCARA

PEMBERIAN

B. ANALISA DATA

Nama : …………………………………………… No. RM : ……………………………………………

Umur : …………………………………………… Ruang : ……………………………………………

No.HARI

TANGGALJAM

DATA FOKUS MASALAH ETIOLOGI

No.HARI

TANGGALJAM

DATA FOKUS MASALAH ETIOLOGI

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.

HARITANGGAL

JAM

No. DP

TUJUAN & KRITERIA HASIL(NOC)

INTERVENSI (NIC) Ttd.

E. TINDAKAN KEPERAWATAN

Nama : …………………………………………… No. RM : ……………………………………………

Umur : …………………………………………… Ruang : ……………………………………………

HARI & TANGGAL

PUKUL

No.DP

IMPLEMENTASI RESPON PASIEN Ttd.

HARI & TANGGAL

PUKUL

No.DP

IMPLEMENTASI RESPON PASIEN Ttd.

F. EVALUASI

Nama : …………………………………………… No. RM : ……………………………………………

Umur : …………………………………………… Ruang : ……………………………………………

No.HARI

TANGGALJAM

DIAGNOSA KEPERAWATAN EVALUASI TTD

No.HARI

TANGGALJAM

DIAGNOSA KEPERAWATAN EVALUASI TTD