PENGKAJIAN

ASUHAN KEPERAWATAN MEDIKAL BEDAH STIKES

MUHAMMADIYA BANJARMASIN

NAMA MAHASISWA : MUHAMMAD HIPNI

NPM

PARAF CI

:-

TEMPAT PARAKTIK_: Ruang ICU RSUD Ulin

TANGGAL

: 23 s/d 25 Maret 2015

A. IDENTITAS KLIEN
1) Nama
2) Umur
3) Jenis kelamin
4) Alamat
5) Agama
6) Pekerjaan
7) Diagnosa medik
8) No. Medical Record
9) Tanggal masuk RS
10) Tanggal pengkajian

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Identitas Penanggung jawab

1) Nama
2) Umur
3) Hubungan dengan klien
B. KELUHAN UTAMA

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C. RIWAYAT PENYAKIT
1) Riwayat penyakit sekarang
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2) Kondisi saat dikaji (P Q R S T) :
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3) Riwayat penyakit dahulu
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4) Riwayat keluarga keluarga
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D. PEMERIKSAAN FISIK
1. Keadaan umum
a. Kesadaran
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b. GCS
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c. Tanda-Tanda vital :
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2. Pengkajian B1-B6
a. B1 (Breating)
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b. B2 (Blood)
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c. B3 (Brain)
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d. B4 (Bladder)
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e. B5 (Bowel)
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f. B6 (Bone)
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E. KEBUTUHAN FISIK, PSIKOSOSIAL DAN SPRITUAL
a. Aktifitas dan istirahat :
Di rumah
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Di RS
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b. Personal Hygine
Di rumah
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Di RS
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c. Nutrisi
Di rumah
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Di RS
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d. Eliminasi
Di rumah
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Di RS
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e. Seksualitas
Di rumah
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Di RS
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f. Psikososial
Di rumah
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Di RS
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g. Spritual
Di rumah
Di RS

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F. DATA PENUNJANG

G. THERAPHY
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