ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa:__________________________
NIM:_______________

A. PENGKAJIAN
Tanggal
: ________________________________________________________
Jam
: ________________________________________________________
1. Identitas klien
Nama
: ________________________________________________________
Umur
: ________________________________________________________
Jenis kelamin : Perempuan/ Laki-laki
Pendidikan
: ________________________________________________________
Pekerjaan
: ________________________________________________________
Alamat
: ________________________________________________________
Tgl. masuk RS: ______________________________________________________
No RM
: ________________________________________________________
Dx. Medis
: _______________________________________________________
2. Riwayat kesehatan
Keluhan utama:
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Riwayat penyakit sekarang:
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Riwayat penyakit dahulu:
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Riwayat penyakit keluarga:

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3. Pola Kesehatan Fungsional :

a. Pola persepsi kesehatan-manajemen kesehatan
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b. Pola nutrisi-metabolik
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c. Pola eliminasi
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d. Pola aktivitas latihan

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Kemampuan perawatan diri
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi / ROM

Keterangan: 0= mandiri; 1= dengan alat bantu; 2= dibantu orang lain; 3= dibantu

orang lain dan alat; 4= tergantung total

e. Pola istirahat tidur

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f. Pola persepsi kognitif
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g. Pola persepsi diri-konsep diri

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h. Pola peran hubungan
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i. Pola seksualitas reproduksi
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j. Pola koping-toleransi stres
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k. Pola nilai kepercayaan

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4. Pemeriksaan Fisik
a. Keadaan umum: ____________________________________________________
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b. Tanda Vital:________________________________________________________
c. TB/BB:____________________________________________________________
d. Kepala
Bentuk
: ________________________________________________________
Rambut
: ________________________________________________________
Wajah
: ________________________________________________________
Mata
: ________________________________________________________
Hidung
: ________________________________________________________
Mulut
: ________________________________________________________
Telinga
: ________________________________________________________
Leher
: ________________________________________________________
e. Thorak (Paru dan Jantung)
Inspeksi
1) Bentuk dada:_____________________________________________________
2) Denyut jantung: __________________________________________________
3) Ekspansi:________________________________________________________
4) Kecepatan pernapasan:_____________________________________________
5) Retraksi interkosta: _______________________________________________
6) Suara batuk: _____________________________________________________
Palpasi
1)
2)
3)
4)

Nyeri dada: ______________________________________________________

Kesimetrisan ekspansi: ____________________________________________
Taktil fremitus: __________________________________________________
Denyut apeks (letak dan kekuatan): ___________________________________

Perkusi
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Auskultasi

1) Suara paru: ______________________________________________________

2) Suara jantung: ___________________________________________________
f. Abdomen
Inspeksi
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Auskultasi
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Palpasi
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Perkusi
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g. Ekstremitas
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h. Kulit
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i. Genetalia
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5. Pemeriksaan Penunjang
a. Pemeriksaan Laboratorium
No

Parameter

Hasil

Satuan

Nilai Normal

b.

6. Terapi
Nama Obat

Sediaan

Dosis

Jalur Masuk

Fungsi

B. ANALISA DATA
DATA

ETIOLOGI

MASALAH

C. PRIORITAS DIAGNOSA KEPERAWATAN

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D. RENCANA KEPERAWATAN
E. N

o
.
D
x

F. Tujuan

G. Intervensi

H. Rasional

I.

J.

M. N
o

K.

N. Tujuan

L.

O. Intervensi

P.

Rasional

.
D
x

Q.

R.

U.

S.

T.

V. IMPLEMENTASI
W. Tgl X.
/Ja
m

o. Dx

Y. Implementasi

Z. Respon

AA.
Pa

AB.

AC.

AG.

AH.

Tgl/Ja
m

o. Dx

AD.

AE.

AI. Implementasi

AF.

AJ. Respon

AK.
Pa

AL.

AM.

AN.

AO.

AP.

AQ. EVALUASI
AS. N
o
AR.

Tgl/Jam
D
x

AU.
AT. Evaluasi (SOAP)

Par
a
f

AV.

AW.

AZ.

BA.

Tgl/Jam

No.
D

AY.

AX.

BB.Evaluasi (SOAP)

BC.
Par
a

x
BD.

BE.

BF.

BG.

BH.