Lengkapilah Format Pengkajian, Rencana dan Implementasi

Asuhan Keperawatan Berikuti ini !!!!

………Semoga Sukses……….

Judul Asuhan Keperawatan

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Nama Mahasiswa :
NIM :
Ruang Ujian :

Penguji Akademik :
Penguji Klinik :

Program Studi Profesi Ners

Sekolah Tinggi Ilmu Kesehatan Wiyata Husada
Samarinda
2020

Patofisiologi/ Patway Kasus Kelolaan:

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PROGRAM STUDI S1 KEPERAWATAN STIKes WHS

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

I. Identitas diri klien

Nama : Pendidikan :
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Umur : Pekerjaan :
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Jenis Kelamin :
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Alamat : ………………………
………………………….. Tanggal Pengkajian :

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Status Perkawinan :
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Agama :
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Suku :
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II. Riwayat Penyakit

1. Keluhan utama saat masuk RS
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2. Riwayat penyakit sekarang
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3. Riwayat penyakit dahulu
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4. Diagnosa Medik pada saat MRS dan Diagnosa Medik Utama yang saat
pengkajian
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III. Pengkajiaan saat ini (Data ini disesuaikan dengan kondisi klien setelah masuk
rumah sakit)
1. Persepsi dan Pemeliharaan kesehatan
Pengetahuan tentang penyakit / perawatan
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2. Pola nutrisi / metabolik
Program di rumah sakit
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Intake makanan
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Intake cairan
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3. Pola eliminasi
a. Buang air besar
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b. Buang air kecil
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4. Pola Aktivitas dan Latihan
Kemampuan 0 1 2 3 4
perawatan diri
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi / ROM

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 0 : mandiri, 1 : dengan alat bantu, 2 : dibantu orang lain, 3 : dibantu orang lain dan
alat, 4 : tergantung total
Oksigenasi
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5. Pola tidur dan istirahat

(lama tidur, gangguan tidur, perasaan saat bangun tidur )
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6. Pola Peceptual
(penglihatan, pendengaran, pengecap, sensasi )
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7. Pola Persepsi diri
(Pandangan klien tentang sakitnya, kecemasan, konsep diri)
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8. Pola seksualitas dan reproduksi
(Fertilitas, libido, menstruasi, kontrasepsi, dll )
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9. Pola peran dan hubungan
(Komunikasi, hubungan dengan orang lain, kemampuan keuangan)
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10. Pola Managemen koping stress
(Perubahan terbesar dalam hidup pada akhir-akhir ini )
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11. Sistem nilai dan kepercayaan
(Pandangan klien tentang agama, kegiatan keagamaan, dll )
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IV. Pemeriksaan Fisik
( Cephalocaudal )
Keluhan yang dirasakan saat ini
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TD : mmHg P: x/menit N: x/menit
S: ºC
BB / TB : ..............................
Kepala termasuk (Mata, Hidung, Telinga, Mulut) :
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Leher :
Inpseksi
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Palpasi
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 Thorak :
Inpseksi
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Palpasi
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Auskultasi
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Perkusi
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Abdomen :
Inpseksi
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Palpasi
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 Auskultasi
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Perkusi
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Ekstrimitas ( termasuk keadaan kulit, kekuatan )
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Program terapi
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Hasil Pemeriksaan Penunjang dan laboratorium
(cantumkan tanggal pemeriksaan dan kesimpulan hasilnya)

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V. Analisa Data
Kemungkinan
No Data Penunjang Masalah
Penyebab

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Diagnosa Keperawatan
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N
Diagnosa Rencana
Keperawata
o Tujuan Intervensi Rasionalisasi
n

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Tgl No Jam Tujuan Implementasi Evaluasi

Dx

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Catatan:
Apabila kolom yang disediakan tidak mencukupi untuk pengisian
data, maka saudara dapat menggunakan kolom dibalik lembar,
dengan menuliskan keterangan.

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