PRODI S1 KEPERAWATAN

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa : ……………………………………………………...........

NIM : ……………………………………………………...........
Ruang : ……………………………………………………...........

2.1 PENGKAJIAN
2.1.1 Identitas
1. Identitas Pasien
Nama : .....................................................................................
Umur : .....................................................................................
Agama : .....................................................................................
Jenis Kelamin : .....................................................................................
Status Marital : .....................................................................................
Pendidikan : .....................................................................................
Pekerjaan : .....................................................................................
Asuransi : .....................................................................................
Suku Bangsa : .....................................................................................
Alamat : .....................................................................................
Tanggal Masuk : .....................................................................................
Tanggal Pengkajian : .....................................................................................
No.Register : .....................................................................................
Diagnosa Medis : .....................................................................................

2. Identitas Penanggung Jawab

Nama Penanggung :

Hubungan dengan pasien :

Alamat :

Nomor Kartu Identitas :

Jenis Kelamin :

Pekerjaan :
2.1.2 Riwayat Kesehatan
1. Keluhan Utama
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2. Riwayat Penyakit Sekarang

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3. Riwayat Kesehatan Dahulu
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4. Riwayat Kesehatan Keluarga
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Genogram :
5. Riwayat Sosiokultural
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6. Review Pola Sehat – Sakit

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7. Pola Fungsi Kesehatan Gordon
1) Pola Persepsi dan Manajemen Kesehatan
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2) Pola Nutrisi – Metabolik

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3) Pola Eliminasi
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4) Pola Aktivitas dan Latihan
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5) Pola Kognitif dan Persepsi

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6) Pola Persepsi Konsep Diri
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7) Pola Tidur dan Istirahat
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8) Pola Peran – Hubungan
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9) Pola Seksual – Reproduksi
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10) Pola Toleransi Stress – Koping
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11) Pola Nilai – Kepercayaan

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2.1.3 Pemeriksaan Fisik
1. Keadaan Umum
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Tanda Vital
Suhu :......................... Nadi: ...................... Napas :..................... T.Darah ......................
2. Kepala
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3. Mata
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4. Hidung
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5. Telinga
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6. Mulut
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7. Leher
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8. Dada dan Punggung

9. Abdomen
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10. Ekstremitas
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11. Genetalia
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12. Anus
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2.1.4 Data Penunjang ( Pemeriksaan Diagnostik )

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2.1.5 Data Tambahan ( Penatalaksanaan )
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 Kediri, …………………
Mahasiswa

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2.2 ANALISA DATA

No. Data Etiologi Masalah Keperawatan

2.3 DIAGNOSA KEPERAWATAN
Tanggal / Jam Diagnosa Keperawatan /Masalah Tanggal / Jam
No.
ditemukan kolaboratif Teratasi
 2.4 RENCANA SUHAN KEPERAWATAN ( NCP / NURSING CARE PLANS )
Diagnosa
Tujuan dan kriteria
No Keperawatan /Masalah Rencana Keperawatan Rasional
hasil
kolaboratif
 Diagnosa
Tujuan dan kriteria
No Keperawatan /Masalah Rencana Rasional
hasil
kolaboratif
2.5 IMPLEMENTASI
Tanggal,
Diagnosa Keperawatan Implementasi
Jam
2.6 EVALUASI
Tanggal, jam Diagnosa keperawatan Evaluasi