STIKES HAFSHAWATY PESANTREN ZAINUL HASAN PROBOLINGGO

FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :…………………………………………………………………….

NIM :…………………………………………………………………….
Tempat Pengkajian :…………………………………………………………………….

PENGKAJIAN KEPERAWATAN

I. Identitas Klien
Nama : ……………………………………. No. RM : …………………………………..
Tanggal lahir : ……………………………………. Pekerjaan : …………………………………..
Jenis Kelamin : ……………………………………. Status Perkawinan : …………………………………..
Agama : ……………………………………. Tanggal MRS : ………………… Jam : ……….
Pendidikan : ……………………………………. Tanggal Pengkajian : ………………… Jam : ……….
Alamat : ……………………………………. Sumber Informasi : …………………………………..
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II. Riwayat Kesehatan

1. Diagnosa Medik:
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2. Keluhan Utama:
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3. Riwayat penyakit sekarang:

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 4. Riwayat kesehatan terdahulu:
a. Penyakit yang pernah dialami:
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b. Alergi (obat, makanan, plester, dll):

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c.Imunisasi:
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d.Kebiasaan/pola hidup/life style:

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e. Obat-obat yang digunakan:

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5. Riwayat penyakit keluarga:

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Genogram:
Keterangan :
: Laki-laki
: Perempuan
: Menikah
// : Cerai
: Anak kandung
: Anak angkat
: Anak kembar
: Pasien
: Meninggal
: Tinggal serumah

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo /

2020
III. Pengkajian Keperawatan
1. Persepsi kesehatan & pemeliharaan kesehatan
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Interpretasi :
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2. Pola nutrisi/ metabolik (ABCD) (saat sebelum sakit dan saat di rumah sakit)
Antropometry……………..………………………………………………………………………….………....………
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Interpretasi :
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Biomedical sign :
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Interpretasi :
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Clinical Sign :
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Interpretasi :
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Diet Pattern (intake makanan dan cairan):
Pola makan Sebelum sakit Saat di rumah sakit

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 Interpretasi :
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3. Pola eliminasi: (saat sebelum sakit dan saat di rumah sakit)

BAK Sebelum sakit Saat di rumah sakit
Frekuensi
Jumlah
Warna
Bau
Karakter
BJ
Alat bantu
Kemandirian
(mandiri/dibantu)
Lainnya
Interpretasi:
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BAB Sebelum sakit Saat di rumah sakit

Frekuensi
Jumlah
Warna
Bau
Karakter
Alat bantu
Kemandirian
(mandiri/dibantu)
Lainnya
Interpretasi:
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Balance cairan:
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Interpretasi:
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4. Pola aktivitas & latihan (saat sebelum sakit dan saat di rumah sakit)
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Aktivitas harian (Activity Daily Living)
Kemampuan perawatan diri 0 1 2 3 4
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi / ROM
Ket: 0: tergantung total, 1: dibantu petugas dan alat, 2: dibantu petugas, 3: dibantu alat,
4: mandiri
Status SkorADL : ……………………………………………………………………………………………………….
Status Oksigenasi :
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Fungsi kardiovaskuler :
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Terapi oksigen :
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Interpretasi :
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5. Pola tidur & istirahat (saat sebelum sakit dan saat di rumah sakit)
Istirahat dan Tidur Sebelum sakit Saat di rumah sakit
Durasi
Gangguan tidur
Keadaan bangun
tidur
Lain-lain
Interpretasi :
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6. Pola kognitif & perceptual

Fungsi Kognitif dan Memori :
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 Fungsi dan keadaan indera :
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Interpretasi :
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7. Pola persepsi diri

Gambaran diri :
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Ideal diri :
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Harga diri :
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Peran Diri :
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Identitas Diri :
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Interpretasi :
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8. Pola seksualitas & reproduksi

Pola seksualitas
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Fungsi reproduksi
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 Interpretasi :
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9. Pola peran & hubungan

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Interpretasi :
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10. Pola manajemen koping-stress

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Interpretasi :
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11. Sistem nilai & keyakinan

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Interpretasi :
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IV. Pemeriksaan Fisik

Keadaan umum:
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Tanda vital:
- Tekanan Darah : mm/Hg
- Nadi : X/mnt
- RR : X/mnt
- Suhu : C

Interpretasi :
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Pengkajian Fisik Head to toe (Inspeksi, Palpasi, Perkusi, Auskultasi)
1. Kepala
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2. Mata
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3. Telinga
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4. Hidung
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5. Mulut
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6. Leher
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7. Dada
Jantung
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Paru
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Payudara dan Ketiak
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Posterior
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8. Abdomen
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9. Genetalia dan Anus
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10. Ekstremitas
Ekstremitas atas
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Ekstremitas bawah
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11. Kulit dan kuku
Kulit
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Kuku
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12. Keadaan lokal
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V. Terapi

Farmako dinamik Indikasi dan Kontra Implikasi

No Jenis Terapi Dosis Rute Efek samping
dan farmako kinetik Indikasi keperawatan

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 10

VI. Pemeriksaan Penunjang & Laboratorium
Nilai normal Hasil(Tanggal/Jam)
No Jenis pemeriksaan Nilai Satuan

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 1

2020
Pemeriksaan Radiologi
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Pemeriksaan Penunjang Lainnya

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Pengambil Data,

( )
NIM.
 ANALISIS DATA

Tanggal/Jam :
Paraf &
NO DATA PENUNJANG ETIOLOGI MASALAH
Nama
 DIAGNOSA KEPERAWATAN

Tanggal Tanggal
No Diagnosis Keperawatan Keterangan
perumusan pencapaian
 PERENCANAAN KEPERAWATAN
Tanggal/Jam :
DIAGNOSIS PARAF &
NO TUJUAN DAN KRITERIA HASIL INTERVENSI
KEPERAWATAN NAMA

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 1

2020
 IMPLEMENTASI KEPERAWATAN
Diagnosa :
Tanggal Jam IMPLEMENTASI Paraf EVALUASI Paraf