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
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 :

3. Sistem Pernafasan

x/menit,
o

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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 KEPERAWATAN

TGL
DITEMUKAN

TGL
TERATASI

RENCANA KEPERAWATAN
NAMA PASIEN
Diagnosa Keperawatan
TGL/JAM

:
:

NO. Dx

RUANG RAWAT :
TUJUAN

RENCANA TINDAKAN

RASIONAL

CATATAN TINDAKAN
NAMA PASIEN
TGL/JAM

RUANG RAWAT :

NO. DX

IMPLEMENTASI

RESPON

CATATAN PERKEMBANGAN
NAMA PASIEN
TANGGAL

:
NO DX

RUANG RAWAT :
JAM

EVALUASI HASIL/ SOAP

TTD