ASUHAN KEPERAWATAN MEDIKEL BEDAH

DI RUANG RSUD

Nama Mahasiswa

NIM

Tempat Praktik

: Ruang
RSUD

Tanggal Pengkajian

: 2014

A. PENGKAJIAN
Pengkajian dilakukan pada Hari Tanggal 2014 di
Ruang RSUD secara alloanamnesa dan
autoanamnesa.
1. IDENTITAS
a. Identitas Klien
Nama
Jenis Kelamin
Umur
Pendidikan Terakhir
Agama
Suku
Status Perkawinan
Pekerjaan
Alamat
Diagnosa medis
No RM
Tanggal masuk
b. Identitas Penanggungjawab
Nama
Umur
Jenis Kelamin
Agama
Suku
Hubungan dng pasien
Pekerjaan

:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:

2. RIWAYAT KESEHATAN
a. Keluhan Utama
:
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b. Riwayat kesehatan sekarang :
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c. Riwayat kesehatan dahulu
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d. Riwayat kesehatan keluarga :
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3. POLA PENGKAJIAN FUNGSIONAL
a. Pola persepsi-Management Kesehatan
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b. Pola nutrisi
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c. Pola Eliminasi
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d. Pola latihan Aktivitas
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e. Pola kognitif perseptual
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f. Pola istirahat tidur
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g. Pola Konsep Diri/Persepsi Diri
1) Gambaran diri (citra tubuh)
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2) Identitas
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3) Peran
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4) Ideal diri
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5) Harga diri
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h. Pola Peran dan Hubungan
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i. Pola Reproduksi / Seksual
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j. Pola Pertahanan Diri (Coping toleransi stress)
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k. Pola Keyakinan Dan Nilai
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4. PEMERIKSAAN FISIK
a. Tanda tanda Vital
TANDA-TANDA
VITAL

HARI & TANGGAL

Hari :
Tgl :

Hari :
Tgl :

Hari :
Tgl :

Tekanan Darah

mmHg

mmHg

mmHg

Nadi

x/menit

x/menit

x/menit

Respiratory Rate

x/menit

x/menit

x/menit

Suhu

0C

0C

0C

b. Pemeriksaan head to toe

1) Kepala
2) Mata

3) Hidung
4) Mulut dan tenggorokan

5) Telinga

6) Dada
Thorak
I :
P :
P :
A :
Jantung
I :
P :
P :
A :
7) Abdomen
:
I :
P :
P :
A :
8) Genetalia
:

9) Integumen
:

10) Ekstremitas
:

5. DATA PENUNJANG
a. Laboratorium
Hari / Tanggal
Jenis Pemeriksaan

:
Hasil

Satuan

Nilai Normal

Ket.

b. Radiologi
Hari / Tanggal

c. Terapi
Hari / Tanggal

No. TANGGAL

NAMA OBAT

DOSIS

CARA
PEMBERIAN

B. ANALISA DATA
Nama
:
Umur
:

No. RM
Ruang

:
:

No.

HARI
TANGGAL
JAM

DATA FOKUS

MASALAH

ETIOLOGI

No.

HARI

DATA FOKUS

MASALAH

ETIOLOGI

TANGGAL
JAM

C. PERIORITAS DIAGNOSA KEPERAWATAN

1.

2.

3.

4.

5.

D. RENCANA TINDAKAN KEPERAWATAN

Nama
:
Umur
:
HARI
TANGGAL
JAM

No.
DP

TUJUAN & KRITERIA HASIL

(NOC)

No. RM
Ruang

:
:
INTERVENSI (NIC)

Ttd.

HARI
TANGGAL
JAM

No.
DP

TUJUAN & KRITERIA HASIL

(NOC)

INTERVENSI (NIC)

Ttd.

E. TINDAKAN KEPERAWATAN
Nama
:
Umur
:
HARI &
TANGGAL
PUKUL

No.
DP

IMPLEMENTASI

No. RM
Ruang

:
:
RESPON PASIEN

Ttd.

HARI &
TANGGAL
PUKUL

No.
DP

IMPLEMENTASI

RESPON PASIEN

Ttd.

F. EVALUASI
Nama
Umur
No.

:
:

HARI
TANGGAL
JAM

DIAGNOSA KEPERAWATAN

No. RM
Ruang

:
:
EVALUASI

TTD

No.

HARI
TANGGAL
JAM

DIAGNOSA KEPERAWATAN

EVALUASI

TTD