PEMERINTAH KABUPATEN KOTAWARINGIN TIMUR

AKADEMI KEPERAWATAN
TERAKREDITASI BAN-PT
SK AIPT NO: 3148/SK/BAN-PT/Akred/PT/XII/2016
SK AKREDITASI PRODI NO : 196/SK/BAN-PT/Ak-XIII/Dpl-III/IX/2013
Alamat: Jalan BatuBerlianNomor 11 Telp.(0531) 22960,Fax: (0531) 22940
e-mail :akper.kotim@yahoo.comSampitKode Pos : 74322

FORMAT ASUHAN KEPERAWATAN

KEPERAWATAN MEDIKAL BEDAH I

A. PENGKAJIAN
Nama Mahasiswa : ………………………
Tempat Prakterk : ………………………
Tanggal pengkajian : ………………………

1. Identitas Diri Klien

Nama : …………………… No. CM : ................
Tempat/tgl lahir : …………………… Tgl masuk RS : ………….
Umur : …………………… Sumber informasi : ………….
Jenis kelamin : …………………....
Alamat : ………...................
Status perkawinan : ……………………
Agama : ……………………
Suku : ……………………
Pendidikan : ……………………
Diagnosa Medis : ……………………

2. Keluhan Utama Saat Masuk Rumah Sakit

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3. Keluhan Utama Saat Pengkajian
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4. Riwayat Kesahatan Sekarang
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5. Riwayat Kesehatan yang Lalu
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6. Riwayat Keluarga
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 GENOGRAM :

6. Pola Kesehatan Klien Saat Ini

a. Pola pemeliharaan dan persepsi kesehatan
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b. Pola nutrisi dan cairan elektrolit
1) Nutrisi
Sebelum Sakit :
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Saat sakit :
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2) Cairan elektrolit
Sebelum Sakit :
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Saat sakit :
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c. Aktivitas dan latihan
1) Aktivitas
Sebelum sakit :
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Saat sakit :
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 Kemampuan ADL :
Jenis kegiatan 0 1 2 3 4
Makan dan minum
Mandi
Toileting
Berpakaian
Berubah posisi
Keterangan :
0 : mandiri
1 : dengan alat bantu
2 : dengan bantuan orang lain
3 : dengan alat bantu dan bantuan orang lain
4 : tergantung total
2) Perawatan diri/ Pola Kebersihan Diri
a) Frekuensi mandi : ……………………………………………...
b) Frekuensi Mencuci rambut : ……………………………………………...
c) Frekuensi Gosok gigi : ……………………………………………...
d) Keadaan kuku : ……………………………………………...
e) Frekuensi ganti baju : ……………………………………………...
3) Latihan
Sebelum sakit :
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Saat sakit :
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d. Pola Tidur dan istirahat
Sebelum sakit :
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Saat sakit :
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e. Pola Eliminasi
1) Eliminasi fekal/bowel :
Sebelum sakit :
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Saat sakit :
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 2) Eliminasi urin :
Sebelum sakit :
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Saat sakit :
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f. Pola Hubungan dan Komunikasi

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g. Pola toleransi stress dan koping
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h. Pola kognitif dan persepsi
1) Sensori, persepsi dan kognitif
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2) Kenyamanan dan nyeri
a) Nyeri : Ya / tidak
Paliatif/provokatif :……………………………………..........................
Qualitas :……………………………………..........................
Region :……………………………………..........................
Severity :……………………………………..........................
Time :……………………………………..........................
i. Pola konsep diri
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j. Pola seksual dan reproduksi
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k. Pola nilai dan kepercayaan
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7. Pengkajian Fisik
a. Kondisi Umum :
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b. Tanda-tanda vital :
TD : .................................... RR : ....................................
N : .................................... S : ....................................
 c. Keadaan fisik :
1) Kepala dan leher
a) Kulit : .............................................................................................
b) Kepala : .............................................................................................
c) Mata : .............................................................................................
d) Telinga : .............................................................................................
e) Hidung : .............................................................................................
f) Mulut dan Tenggorokan :............................................................................
g) Leher : .............................................................................................
2) Thoraks
a) Inspeksi : .............................................................................................
b) Palpasi : .............................................................................................
c) Perkusi : .............................................................................................
d) Auskultasi : .............................................................................................
3) Abdomen
a) Inspeksi : .............................................................................................
b) Palpasi : .............................................................................................
c) Perkusi : .............................................................................................
d) Auskultasi : .............................................................................................
4) Ekstremitas : ............................................................................................
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5) Integumen : ............................................................................................
6) Genitalia : ............................................................................................
7) Anus dan rektum : ............................................................................................
8) Neurologi : ............................................................................................
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8. DataLaboratorium
Hari/Tanggal : ………………
Jenis Pemeriksaan : ………………
No Jenis Pemeriksaan Nilai Lab Nilai Normal Interpretasi

9. Hasil Pemeriksaan diagnostik lain :

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10. Pengobatan :
Terapi yg diberikan :
No. NamaObat Dosis Kegunaan

Sampit, Januari 2018

Mahasiswa

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NIM
B. ANALISA DATA

No Data Etiologi Problem

1 DS :

DO :

Data Penunjang :

2 DS :

DO :

Data Penunjang :

3 DS :

DO :

Data Penunjang :

C. PRIORITAS MASALAH

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D. DIAGNOSA KEPERAWATAN
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E. PROSES KEPERAWATAN

RENCANA KEPERAWATAN
NO DX. KEP TUJUAN/KRITERIA IMPLEMENTASI EVALUASI
INTERVENSI
HASIL
F. CATATAN PERKEMBANGAN

NO HARI/TGL/JAM DX. KEP PERKEMBANGAN KEPERAWATAN TTD