FORMAT PENGKAJIAN
KEPERAWATAN MEDIKAL BEDAH
Nama Mahasiswa : ..............................................................................
Tempat praktik : ..............................................................................
Waktu praktik : ..............................................................................
A. DATA DEMOGRAFI
1. Identitas diri klienNama : ...................................................................Usia : ...................................................................Jenis kelamin : ...................................................................Alamat : ...................................................................Suku bangsa : ...................................................................Status pernikahan : ...................................................................Agama / keyakinan : ...................................................................Pendidikan : ...................................................................Pekerjaan : ...................................................................Diagnosa medik : ...................................................................Tanggal masuk : ...................................................................Tanggal pengkajian : ...................................................................
2. Penanggung jawabNama : ...................................................................Usia : ...................................................................Jenis kelamin : ...................................................................Pekerjaan : ...................................................................Hubungan dengan klien : ...................................................................
B. KELUHAN UTAMA
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C. RIWAYAT KESEHATAN
1. Riwayat kesehatan sekarang
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2. Riwayat kesehatan lalu
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3. Riwayat kesehatan keluarga
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Genogram:
D. RIWAYAT PSIKOSOSIAL
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E. RIWAYAT SPIRITUAL
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F. PEMERIKSAAN FISIK
1. Keadaan umum klien
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2. Tanda-tanda vital
TD : mmHg, HR : x/menit,
RR : x/menit, Suhu : oC
3. Sistem Pernafasan
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4. Sistem Kardiovaskuler
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5. Sistem Pencernaan
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6. Sistem Pengindraan
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7. Sistem Saraf
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8. Sistem Muskoloskeletal
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9. Sistem Integumen
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10. Sistem Endokrin
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11. Sistem Perkemihan
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12. Sistem Reproduksi
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13. Sistem Imunitas
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G. AKTIFITAS SEHARI- HARI
1. Nutrisi
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2. Cairan
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3. Eliminasi
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4. Istirahat tidur
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5. Olahraga
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6. Rokok/ alkohol
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7. Personal Hygiene
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8. Aktivitas / mobilitas fisik
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9. Rekreasi
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H. TES DIAGNOSTIK
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I. TERAPI SAAT INI
Nama Obat Dosis Indikasi Kontraindikasi Efek samping
PENGELOMPOKKAN DATA
NAMA PASIEN :
RUANG RAWAT :
DATA SUBJEKTIF DATA OBJEKTIF
ANALISA DATA
NAMA PASIEN :
RUANG RAWAT :
NO DATA MASALAH ETIOLOGI
DIAGNOSA KEPERAWATAN
NAMA PASIEN :
RUANG RAWAT :
NO DIAGNOSA KEPERAWATANTGL
DITEMUKAN
TGL
TERATASI
RENCANA KEPERAWATAN
NAMA PASIEN : RUANG RAWAT : TGL/JAM NO. Dx TUJUAN RENCANA TINDAKAN RASIONAL
CATATAN TINDAKAN
NAMA PASIEN : RUANG RAWAT :
CATATAN PERKEMBANGAN
TGL/JAM NO. DX IMPLEMENTASI RESPON TTD
NAMA PASIEN : RUANG RAWAT : TANGGAL NO DX JAM EVALUASI HASIL/ SOAP