STIKES RS.

BAPTIS KEDIRI
PRODI KEPERAWATAN PROGRAM SARJANA
ASUHAN KEPERAWATAN MEDIKAL BEDAH

NAMA MAHASISWA : ………………………………………………………………………….

NIM : ………………………………………………………………………….

RUANG : ………………………………………………………………………….

TANGGAL : ………………………………………………………………………….

1. BIODATA :
Nama : ……………………………………………….No.Reg……………………
Umur : …………………………………………………………………………….
Jenis Kelamin : …………………………………………………………………………….
Agama : …………………………………………………………………………….
Alamat : …………………………………………………………………………….
Pendidikan : …………………………………………………………………………….
Pekerjaan : …………………………………………………………………………….
Tanggal MRS : …………………………………………………………………………….
Tanggal Pengkajian : …………………………………………………………………………….
Golongan Darah : …………………………………………………………………………….
Diagnosa medis : …………………………………………………………………………….

2. KELUHAN UTAMA
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3. RIWAYAT PENYAKIT SEKARANG

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4. RIWAYAT PENYAKIT MASA LALU
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5. RIWAYAT KESEHATAN KELUARGA
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Genogram :
6. RIWAYAT PSIKO SOSIAL DAN SPIRITUAL
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7. POLA AKTIFITAS SEHARI – HARI
( Makan, istirahat, tidur, eliminasi, aktifitas, kebersihan dan seksual )
No Activity daily living Di rumah Di rumah sakit
1 Pemenuhan kebutuhan Makan/minum Makan/minum
nutrisi dan cairan Jumlah : Jumlah :
Jenis : Jenis :
1) Nasi : ................ (porsi) 1) Nasi : ................ (porsi)
2)Lauk : ada/tidak, 2)Lauk : ada/tidak,
Nabati/Hewani Nabati/Hewani
3) Sayur : Ada/tidak 3) Sayur : Ada/tidak
4) Minum :....................cc/hari 4) Minum :....................cc/hari
Pantangan : Pantangan :

Kesulitan Makan/Minum : Kesulitan Makan/Minum :

Usaha Mengatasi Kesulitan : Usaha Mengatasi Kesulitan :

2 Pola eliminasi BAK : .............................x/hari BAK : .............................x/hari

Jumlah :............................cc Jumlah :............................cc

BAB : BAB :
Konsistensi : Konsistensi :

Masalah dan cara mengatasi : Masalah dan cara mengatasi :

3 Pola istirahat tidur Siang : ..............................Jam Siang : ..............................Jam

Sore :.................................Jam Sore :.................................Jam

Malam :.............................Jam Malam :.............................Jam

Gangguan Tidur : Gangguan Tidur :

Penggunaan Obat Tidur : Penggunaan Obat Tidur :

4 Personal Hygiene 1. Frekuensi Mandi : .......x/hari 1. Frekuensi Mandi : .......x/hari

(kebersihan diri)

2. Frekuensi mencuci rambut : 2. Frekuensi mencuci rambut :

 3. Frekuensi gosok gigi : 3. Frekuensi gosok gigi :

4. Keadaan kuku : 4. Keadaan kuku :

5. Ganti baju : 5. Ganti baju :

5 Aktivitas lain Aktivitas Rutin : Aktivitas Rutin :

Aktivitas yang dilakukan pada Aktivitas yang dilakukan pada

waktu luang : waktu luang :

8. KEADAAN/PENAMPILAN/KESAN UMUM PASIEN

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9. TANDA-TANDA VITAL
Suhu Tubuh : ……………………………ºC
Denyut Nadi : ……………………………x/menit
Tekanan Darah : ……………………………mmHg
Pernafasan :……………………………x/menit
TT / TB : ……………………………Kg, …………….cm

10.PEMERIKSAAN FISIK
A. Pemeriksaan Kepala dan Leher
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B. Pemeriksaan Integumen Kulit dan Kuku :
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C. Pemeriksaan Payudara dan Ketiak ( Bila diperlukan ):
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D. Pemeriksaan Dada /Thorak
Inspeksi Thorax :...................................................................................................................
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Paru :.....................................................................................................................................
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E. Pemeriksaan Jantung :
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F. Pemeriksaan Abdomen :
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G. Pemeriksaan Kelamin dan daerah sekitarnya ( bila diperlukan ):
Genetalis :..............................................................................................................................
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Anus :...................................................................................................................................
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H. Pemeriksaan Muskuloskeletal :
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H. Pemeriksaan Neurologi :
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J. Pemeriksaan Status Mental :
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11. Pemeriksaan Penunjang Medis :

Tanggal :
No Pemeriksaaan Hasil Nilai Norma Interpretasi Hasil
12. Pelaksanaan / Therapi :
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13. Harapan Klien / Keluarga sehubungan dengan penyakitnya :

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Kediri,......................................................
Tanda Tangan Mahasiswa

( )
 ANALISA DATA

NAMA PASIEN : ...............................................................

UMUR : ..............................................................
NO. REGISTER : ..............................................................

DATA GAYUT MASALAH KEMUNGKINAN PENYEBAB

DATA OBYEKTIF
DATA SUBYEKTIF
 DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN : ...............................................................

UMUR : ..............................................................
NO. REGISTER : ..............................................................
NO TANGGAL DIAGNOSA KEPERAWATAN TANGGAL TANDA TANGAN
MUNCUL TERATASI
 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN :...................................................................................................

UMUR :...................................................................................................
NO. REGISTER :...................................................................................................

Diagnosa Keperawatan : .........................................................................................

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1. NOC............................................................................................................ (Kode...............)
a........................................................ Dipertahankan/ditingkatkan pada ...........................
b....................................................... Dipertahankan/ditingkatkan pada ...........................
c. ...................................................... Dipertahankan/ditingkatkan pada ...........................
d. ..................................................... Dipertahankan/ditingkatkan pada ...........................
e. ...................................................... Dipertahankan/ditingkatkan pada ...........................
f. ...................................................... Dipertahankan/ditingkatkan pada ...........................
g. ..................................................... Dipertahankan/ditingkatkan pada ...........................
h. ..................................................... Dipertahankan/ditingkatkan pada ...........................
i. ...................................................... Dipertahankan/ditingkatkan pada ...........................
j. ...................................................... Dipertahankan/ditingkatkan pada ...........................
k. ..................................................... Dipertahankan/ditingkatkan pada ...........................

2. NOC............................................................................................................ (Kode...............)
a. ...................................................... Dipertahankan/ditingkatkan pada ...........................
b. ..................................................... Dipertahankan/ditingkatkan pada ...........................
c. ...................................................... Dipertahankan/ditingkatkan pada ...........................
d. ..................................................... Dipertahankan/ditingkatkan pada ...........................
e. ...................................................... Dipertahankan/ditingkatkan pada ...........................
f. ...................................................... Dipertahankan/ditingkatkan pada ...........................
g. ..................................................... Dipertahankan/ditingkatkan pada ...........................
h. ..................................................... Dipertahankan/ditingkatkan pada ...........................
i. ...................................................... Dipertahankan/ditingkatkan pada ...........................
j. ...................................................... Dipertahankan/ditingkatkan pada ...........................
k. ..................................................... Dipertahankan/ditingkatkan pada ...........................

3 NOC............................................................................................................ (Kode...............)
a. ...................................................... Dipertahankan/ditingkatkan pada ...........................
b. ..................................................... Dipertahankan/ditingkatkan pada ...........................
c. ...................................................... Dipertahankan/ditingkatkan pada ...........................
d. ..................................................... Dipertahankan/ditingkatkan pada ...........................
e. ...................................................... Dipertahankan/ditingkatkan pada ...........................
f....................................................... Dipertahankan/ditingkatkan pada ...........................
g. ..................................................... Dipertahankan/ditingkatkan pada ...........................
h. ..................................................... Dipertahankan/ditingkatkan pada ...........................
i. ...................................................... Dipertahankan/ditingkatkan pada ...........................
j. ...................................................... Dipertahankan/ditingkatkan pada ...........................
k.. .................................................... Dipertahankan/ditingkatkan pada ...........................
 RENCANA ASUHAN KEPERAWATAN
NAMA PASIEN : ...............................................................
UMUR : ……………………………………….
NO.REGISTER : .............................................................

NO DIAGNOSA KEPERAWATAN INTERVENSI RASIONAL TTD

 TINDAKAN KEPERAWATAN

NAMA PASIEN : ...............................................................

UMUR : ...............................................................
NO.REGISTER : .............................................................

NO NO.DX TGL/JAM TINDAKAN KEPERAWATAN TANDA

TANGAN
 CATATAN PERKEMBANGAN

NAMA PASIEN : ...............................................................

UMUR : ...............................................................tahun / bulan
TANGGAL : ...............................................................

NO NO.DX JAM EVALUASI