FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

I. PENGKAJIAN
A. IDENTITAS KLIEN
Nama Klien : ...................................................................................................................
No. RM : ...................................................................................................................
Usia : ...................................................................................................................
Jenis Kelamin : ...................................................................................................................
Tgl. MRS : ...................................................................................................................
Tgl. Pengkajian : ...................................................................................................................
Alamat : ...................................................................................................................
Status Pernikahan : ...................................................................................................................
Agama : ...................................................................................................................
Suku : ...................................................................................................................
Pendidikan Terakhir : ...................................................................................................................
Pekerjaan : ...................................................................................................................
Diagnosa medis : ....................................................................................................................
Dokter yang merawat : ....................................................................................................................

B. KELUHAN UTAMA
Saat MRS : .....................................................................................................................................
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Saat Pengkajian : ............................................................................................................................
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C. RIWAYAT PENYAKIT
1. Riwayat Penyakit Sekarang
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 2. Riwayat Penyakit Dahulu
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3. Riwayat Penyakit Keluarga

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Genogram :

Keterangan :
: Laki-laki : Garis perkawinan
: Perempuan : Tinggal serumah
/ : Sudah meninggal : Garis keturunan
: Klien

4. Riwayat Sosial
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D. KEADAAN UMUM
1. Kesadaran : ............................................................................................................
Scale Coma Glosgow : ............................................................................................................
 2. Tanda Vital
a. Tekanan darah : .......................
b. Nadi : .......................
c. Pernapasan : .......................
d. Suhu : .......................

E. PEMERIKSAAN FISIK
Area
No. Hasil Pemeriksaan
Pemeriksaan
1 Kulit dan Kepala
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2 Mata
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3 Hidung
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4 Bibir dan Mulut
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5 Telinga
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6 Leher
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7 Dada
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8 Axilla
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9 Abdomen
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10 Genetalia dan
Anus ......................................................................................................................
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11 Ektremitas atas
dan bawah ......................................................................................................................
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F. PENGKAJIAN 11 POLA KESEHATAN GORDON

1. Persepsi Terhadap Kesehatan – Manajemen Kesehatan
a. Keadaan Sebelum Sakit
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 b. Keadaan Saat Ini
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Masalah : .................................................................................................................................

2. Pola Aktivitas dan Latihan

NO AKTIVITAS SKOR
1 Makan/Minum
2 Mandi
3 Berpakaian/Berdandan
4 Toileting
5 Berpindah
6 Berjalan
7 Naik tangga
Keterangan :
0 = mandiri
1 = alat bantu
2 = dibantu orang lain/pengawasan
3 = dibantu orang lain, pengawasan, dan alat bantu
4 = tidak mampu
Alat bantu : tongkat/ splint/ brace/ kursi roda/ pispot/ walker/ kacamata/ dan lain-lain :
Masalah : ............................................................................................................................

3. Pola Istirahat dan Tidur

a. Keadaan Sebelum Sakit
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b. Keadaan Saat Ini
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Masalah : .................................................................................................................................
4. Pola Nutrisi
a. Keadaan Sebelum Sakit
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b. Keadaan Saat Ini
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Masalah : .................................................................................................................................

5. Pola Eliminasi
a. Keadaan Sebelum Sakit
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b. Keadaan Saat Ini
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Masalah : .................................................................................................................................

6. Pola Kognitif – Perceptual

a. Keadaan Sebelum Sakit
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b. Keadaan Saat Ini
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Masalah : .................................................................................................................................
7. Pola Konsep Diri
a. Keadaan Sebelum Sakit
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b. Keadaan Saat Ini
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Masalah : .................................................................................................................................

8. Pola Koping
a. Keadaan Sebelum Sakit
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b. Keadaan Saat Ini
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Masalah : .................................................................................................................................

9. Pola Seksualitas – Reproduksi

a. Keadaan Sebelum Sakit
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b. Keadaan Saat Ini
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Masalah : .................................................................................................................................
 10. Pola Peran – Hubungan
a. Keadaan Sebelum Sakit
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b. Keadaan Saat Ini
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Masalah : .................................................................................................................................

11. Pola Nilai dan Kepercayaan

a. Keadaan Sebelum Sakit
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b. Keadaan Saat Ini
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Masalah : .................................................................................................................................

G. PEMERIKSAAN SARAF
Meningeal sign
Kaku kuduk : ( - / + )
Kernig :(- / + )
Brudzinski I : ( - / + )
Brudzinski II : ( - / + )

Nervus Cranialis
Nervus I, Olfaktorius :
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Nervus II, Optikus:

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Nervus III, Oculomotorius, Nervus IV, Trokclearis dan Nervus VI, Abdusen:
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Nervus V, Trigeminus :
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Nervus VII, Facialis :

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Nevus VIII, Vestibulokokhlearis :

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Nervus IX, Glosoparingeal :

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Nervus X, Vagus :
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Nervus XI, Accessorius :

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Nervus XII, Hipoglosos :

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Reflek Fisiologis
Trisep :(- / + )
Bisep :(- / + )
Brakioradialis : ( - / + )
Patella :(- / + )
Acilles :(- / + )

Reflek Patologis
Babinski :(- / + )
Chaddok :(- / + )
Schaeffer :(- / + )
Oppenheim :(- / + )
Gordon :(- / + )
Gonda :(- / + )
II. PEMERIKSAAN PENUNJANG
Nama : Tanggal :

PEMERIKSAAN HASIL NILAI RUJUKAN SATUAN

HEMATOLOGI
Hemoglobin 14,0 – 18,0 g/dl
Eritrosit 4,0 – 10,5 ribu/µl
Leukosit 4,50 – 6,00 juta/µl
Hematokrit 42.00 – 52.00 vol%
Trombosit 150 – 450 ribu/µl
RDW-CV 11,5- 14,7 %
MCV, MCH, MCHC
MCV 80-97 Fl
MCH 27-32 Pg
MCHC 32-38 %
HITUNG JENIS
Basofil % 0,0-1,0 %
Eusinofil % 1,0-3,0 %
Gran % 50,0-70,0 %
Limfosit % 25,0-40,0 %
Monisit % 3,0-9,0 %
Basofil # <1 ribu/µl
Eusinofil # <3 ribu/µl
Gran # 2,50-7,00 ribu/µl
Limfosit # 1,25-4,0 ribu/µl
MID # 0,30-1.00 ribu/µl
PROTHROMBIN TIME
Hasil PT 9,9-13,5 detik
INR -
Control normal PT -
Hasil APTT 22,2-37,0 detik
Control normal APTT -
KIMIA
GULA DARAH
Gula darah sewaktu < 200 mg/dl
HATI
SGOT 0-46 U/l
SGPT 0-45 U/l
GINJAL
Ureum 10-50 mg/dl
Creatinin 0,7-14 mg/dl
ELEKTROLIT
Natrium 135-146 mmol/l
Kalium 3,4-5,4 mmol/l
Clorida 95-100 mmol/l
TERAPI SAAT INI
Nama Obat, Frekuensi
Pemberian, Dosis, Indikasi Kontraindikasi Efek Samping Cara Kerja Obat Konsiderasi Perawat
Cara Pemberian
Nama Obat, Frekuensi
Pemberian, Dosis, Indikasi Kontraindikasi Efek Samping Cara Kerja Obat Konsiderasi Perawat
Cara Pemberian
ANALISA DATA
NO. DATA PROBLEM ETIOLOGI
NO. DATA PROBLEM ETIOLOGI
PRIORITAS MASALAH KEPERAWATAN
RENCANA ASUHAN KEPERAWATAN
Diagnosa Keperawatan :
TUJUAN DAN
INTERVENSI RASIONAL IMPLEMENTASI EVALUASI
KRITERIA HASIL
Diagnosa Keperawatan :
TUJUAN DAN
INTERVENSI RASIONAL IMPLEMENTASI EVALUASI
KRITERIA HASIL
Diagnosa Keperawatan :
TUJUAN DAN
INTERVENSI RASIONAL IMPLEMENTASI EVALUASI
KRITERIA HASIL
CATATAN PERKEMBANGAN
HARI/TANGGAL/JAM DX. KEP. CATATAN PERKEMBANGAN (S.O.A.P.I.E) PARAF
HARI/TANGGAL/JAM DX. KEP. CATATAN PERKEMBANGAN (S.O.A.P.I.E) PARAF
HARI/TANGGAL/JAM DX. KEP. CATATAN PERKEMBANGAN (S.O.A.P.I.E) PARAF