FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa : ..............................................................................
Tempat praktik

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Waktu praktik

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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

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2. Penanggung jawab
Nama
Usia
Jenis kelamin
Pekerjaan
Hubungan dengan klien

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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 :

RR :

x/menit,

Suhu :

x/menit,
o

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

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