FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa : .................................................

NIM : .................................................
Tempat Praktek : .................................................
Tanggal : .................................................

I. PENGKAJIAN
A. No Registrasi pasien :
Identitas Pasien
Nama : .. L/P
Tempat & Tgl lahir : ....................................... Gol Darah : O / A / B / AB
Pendidikan Terakhir :
Agama : .............................................................................
Status perkawinan : .....................................................................................
Pekerjaan : .....................................................................................
TB/BB : .. cm/ kg
Alamat : .....................................................................................
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Tanggal Pengkajian : .....................................................................................
Tanggal MRS : ....................................................................................
DX Medis : .....................................................................................

B. STATUS KESEHATAN
1. KELUHAN UTAMA
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2. RIWAYAT PENYAKIT SEKARANG

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 3. RIWAYAT PENYAKIT DAHULU
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4. RIWAYAT PENYAKIT KELUARGA

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5. KEADAAN UMUM :

Tanda-tanda vital : Nadi : _____ Temp : _____ RR : _____ Tensi : ________

II. PENGKAJIAN SISTEM

1. B1 (BREATING)
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2. B2 (BLOOD)
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3. B3 (BRAIN)
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4. B4 (BLADDER)
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5. B5 (BOWEL)
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6. B6 (BONE)
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III. PEMERIKSAAN PENUNJANG
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IV. TERAPI
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V. ANALISA DATA
DATA INTERPRETASI
NO MASALAH (PROBLEM)
(SIGN/SYMPTOM) (ETIOLOGI)

1 2 3 4

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VI. DIAGNOSA KEPERAWATAN (PRIORITAS MASALAH)
1. ...........................................................................................................................
2. ...........................................................................................................................
3. ...........................................................................................................................
4. ...........................................................................................................................

VII. RENCANA KEPERAWATAN

NO TUJUAN
INTERVENSI RASIONAL
DX /KRITERIA HASIL

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VIII. IMPLEMENTASI

HARI &
NO
TANGGAL IMPLEMENTASI RESPON TTD
DX
PUKUL

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IX. CATATAN KEPERAWATAN
HARI &
NO
TANGGAL SOAPIE TTD
DX
PUKUL

1 2 3 4

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X. EVALUASI
HARI &
NO
TANGGAL SOAP TTD
DP
PUKUL

1 2 3 4