SEKOLAH TINGGI ILMU KEPERAWATAN

MUHAMMADIYAH PONTIANAK

PRAKTIK KLINIK KEPERAWATAN MEDIKAL BEDAH

I. IDENTITAS KLIEN
Inisial Klien : .................................................. No. Med. Reg : ..............................
Tempat, Tanggal Lahir : .................................................. Tgl. Masuk : ..................................
.................................................. Jam Masuk : ..................................
.................................................. Ruang : ..........................................
Jenis Kelamin : .................................................. Dr. yang Merawat : .......................
Status Perkawinan : .................................................. Dx. Medis : ...................................
Agama : ..................................................
Pendidikan : ..................................................
Pekerjaan : ..................................................
Alamat : .......................................................................................................
........................................................................................................
........................................................................................................
Keluarga yang mudah di hubungi :
Nama : .......................................................................................................
Jenis Kelamin : .......................................................................................................
Hub. dengan Klien : .......................................................................................................
No. Telp. : .......................................................................................................
Alamat : .......................................................................................................

II. RIWAYAT PENYAKIT SEKARANG

Sejak Kapan Serangan Datang :
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Lamanya :
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Gejala :
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Faktor Predisposisi :
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Tindakan Pengobatan :
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Harapan Klien Terhadap Pemberi Perawatan :

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

III. RIWAYAT KESEHATAN YANG LALU

A. Penyakit :
1. Kecelakaan dan Hospitalisasi :
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
 2. Operasi :
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
3. Penyakit yang paling sering diderita :
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

B. Alergi :
1. Tipe : ............................................................................................................
2. Reaksi : ............................................................................................................
3. Pengobatan : ............................................................................................................

C. Imunisasi :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

D. Kebiasaan :
1. Alkohol : Banyaknya : Lamanya :
2. Merokok : Banyaknya : Lamanya :

E. Pola Tidur :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

F. Pola Latihan :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
 G. Pola Nutrisi :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

H. Pola Kerja :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

IV. RIWAYAT KELUARGA

A. Kesehatan Anggota Keluarga :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
(Tampilkan Genogram)

B. Faktor Resiko Penyakit dalam Keluarga :

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
C. RIWAYAT LINGKUNGAN
A. Kebersihan :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

B. Bahaya Kesehatan :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

C. Polutan :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

D. RIWAYAT PSIKOSOSIAL
A. Bahasa yang Digunakan :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

B. Organisasi di Masyarakat :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

C. Sumber Dukungan di Masyarakat :

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
 D. Suasana Hati :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

E. Tingkat Perkembangan :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

E. PEMERIKSAAN FISIK (Data Fokus)

A. Kepala :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
B. Mata :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
C. Hidung :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
D. Telinga :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
E. Mulut dan Tenggorokan :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
F. Leher :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
G. Kelenjar Limfe :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
H. Paru – paru :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
I. Jantung :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
J. Abdomen/Perut :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
K. Eliminasi Bowel :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
L. Ekstrimitas Atas :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
M. Ekstrimitas Bawah :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
N. Kulit :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
O. Genitalia/Reproduksi :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
P. Eliminasi Urin :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
F. DATA PENUNJANG
A. Laboratorium :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
B. Rontgen :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
C. CT-Scan :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
D. Eco Cardiografi :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________