FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :
NIM :
Tempat Praktek :
Tanggal :

I. PENGKAJIAN
A. Identitas
Identitas Klien
Nama : ………………………….. L/P
Tempat & Tgl lahir : ............................................... Gol Darah : O / A / B / AB
Pendidikan Terakhir : ………………………………………
Agama : .................................................................
Status perkawinan : .....................................................................
Pekerjaan : ...........................................................................................
TB/BB : ……….. cm/ …… kg
Alamat : ...........................................................................................
.......................................................................................................................................

Tanggal Pengkajian :......................................................................................

B. STATUS KESEHATAN
1. KELUHAN UTAMA

2. RIWAYAT PENYAKIT SEKARANG

3. KEADAAN UMUM : .......................................................................................

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

4. PENGKAJIAN SISTEM
1. B1 (BREATING)

2. B2 (BLOOD)

3. B3 (BRAIN)

1
 4. B4 (BOWEL)

5. B5 (BLADDER)

6. B6 (BONE)

I. ANALISA DATA

DATA INTERPRETASI
NO MASALAH (PROBLEM)
(SIGN/SYMPTOM) (ETIOLOGI)

1 2 3 4

II. DIAGNOSA KEPERAWATAN (PRIORITAS MASALAH)

1. ......................................................................................................................................
2. ......................................................................................................................................
3. ......................................................................................................................................

2
III. RENCANA KEPERAWATAN
TUJUAN
NO
/KRITERIA INTERVENSI
DX RASIONAL
HASIL

IV. IMPLEMENTASI

HARI &
NO
TANGGAL IMPLEMENTASI RESPON TTD
DX
PUKUL

3
IV. EVALUASI
HARI &
NO
TANGGAL TTD
DP SOAP
PUKUL

1 2 3 4