FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH

Nama Preceptee :………………………………………..

NIM :………………………………………..
Ruangan :……………………………………….
Tanggal Pengkajian :…………………… Jam …………………

IDENTITAS

Nama Pasien :……………………..

Umur :……………………..
No. Register :……………………..
Jenis Kelamin :……………………..
Suku Bangsa :…………………….
Pekerjaan :…………………….
Pendidikan :…………………….
Alamat :……………………..
Tanggal MRS :…………………….
Diagnosa Medis :……………………..

STATUS KESEHATAN
Keluhan utama saat Masuk RS :
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Keluhan utama saat pengkajian :

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Riwayat kesehatan :
1. Riwayat Kesehatan/Penyakit sekarang :
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2. Riwayat Kesehatan/Penyakit dahulu :

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3. Riwayat Kesehatan/Penyakit keluarga :
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4. Genogram

5. Vital Signs:
Kesadaran /GCS :…………………………………..
Tekanan Darah : ................................................... ..
Frekuensi Pernapasan : ................................................... ..
Suhu : ................................................... ..
Nadi : ................................................... ..
Berat Badan : ................................................... ..
Tinggi Badan : ................................................... ..

POLA FUNGSI KESEHATAN :

1. Pola penatalaksanaan kesehatan / persepsi sehat
Data Subyektif:
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Data Obyektif:
Pemeriksaan fisik yang menunjang
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Masalah Keperawatan
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2. Pola Nutrisi– Metabolik
Data Subyektif:
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Data Obyektif:
Pemeriksaan fisik yang menunjang (IPPA)
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Masalah Keperawatan
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3. Pola Eliminasi Alvi &Uri

Data Subyektif:
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Data Obyektif:
Pemeriksaan fisik yang menunjang (IPPA)

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Masalah Keperawatan
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4. Pola Aktifitas
Data Subyektif:
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 Data Obyektif:
Pemeriksaan fisik yang menunjang (IPPA)

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5. Pola Istirahat Tidur

Data Subyektif:
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Data Obyektif:
Pemeriksaan fisik yang menunjang (IPPA)

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Masalah Keperawatan
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6. Pola Persepsi kognitif

Data Subyektif:
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Data Obyektif:
Pemeriksaan fisik yang menunjang (IPPA)

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Masalah Keperawatan
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7. Pola Konsep diri dan Persepsi diri

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Masalah Keperawatan
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8. Pola hubungan peran

Persepsi klien tantang pola hubungan

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Persepsi klien tentang peran dan tanggung jawab

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Masalah Keperawatan
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9. Pola Reproduksi Seksual

Data Subyektif:
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Data Obyektif:
Pemeriksaan fisik yang menunjang (IPPA)

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 Masalah Keperawatan
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10. Mekanisme Koping

Kemampuan mengendalian stress

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Sumber pendukung
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Masalah Keperawatan
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11. Pola tata nilai dan kepercayaan

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Masalah Keperawatan
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PEMERIKSAAN PENUNJANG

1. Pemeriksaan Laboratorium

Tanggal Pemeriksaan . Lab Hasil Nilai Normal

2. Pemeriksaan Radiologi
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3. Terapi dan Diet.

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DAFTAR MASALAH KEPERAWATAN

1……………………………………………………………………………………
2……………………………………………………………………………………
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6……………………………………………………………………………………
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Surabaya, ……………….…
Preceptee

(……………………….)
 ANALISA DATA

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

DATA ETIOLOGI PROBLEM

 DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

Nama Pasien : No. Register :

Umur : Diagnosa Medis :
NO DIAGNOSA KEPERAWATAN TTD
 INTERVENSI KEPERAWATAN

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

NO DIAGNOSA TUJUAN KRITERIA HASIL INTERVENSI RASIONAL

KEPERAWATAN
 IMPLEMENTASI

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

TANGGAL / JAM IMPLEMENTASI TTD

 EVALUASI

Nama Pasien : No. Register :

Umur : Diagnosa Medis :

TGL / DIAGNOSE EVALUASI

JAM KEPERAWATAN