FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :
NIM :
Tempat Praktek :
Tanggal :
I. PENGKAJIAN

A. No Registerasi Pasien :

Identitas pasien
Nama : ............................................................ L/P
Tanggal lahir : ............................................................
Pendidikan terakhir : ............................................................
Agama : ............................................................
Status perkawinan : ............................................................
Pekerjaan : ............................................................
TB/BB : ............................................................
Alamat : ............................................................
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Tanggal pengkajian : ............................................................
Tangal MRS : ............................................................
DX Medis : ............................................................
B. Status kesehatan

1. Keluhan utama :
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2. Riwayat penyakit sekarang :
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3. Riwayat penyakit dahulu

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4. Riwayat penyakit keluarga

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5. Keadaan umum : .........................................................................................................

Tanda-tanda vital : Nadi : ......... Temp : ......... RR : ......... Tensi : .........

II. PENGKAJIAN SISTEM

1. B1 (BREATHING)

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2. B2 (BLOOD)

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3. B3 (BRAIN)

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4. B4 (BLADDER)

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5. B5
(BOWEL) ...........................................................................................................
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6. B6 (BONE)

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III. PEMERIKSAAN PENUNJANG
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IV. TERAPI
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V. ANALISA DATA

N DATA INTERPRETASI MASALAH

O (SIGN/SYMTOM) (ETIOLOGI) (PROBLEM)
 VI. DIAGNOSA KEPERAWATAN (PRIORITAS MASALAH)
1. ..............................................................................................................................
2. ..............................................................................................................................
3. ..............................................................................................................................
4. ..............................................................................................................................
VII. RENCANA KEPERAWATAN

N TUJUAN & KRITERIA INTERVENSI RASIONAL

O HASIL
DX
N TUJUAN & KRITERIA INTERVENSI RASIONAL
O HASIL
DX
 VIII. IMPLEMENTASI

N HARI & IMPLEMENTASI RESPON TTD

O TANGGAL
DX PUKUL
N HARI & IMPLEMENTASI RESPON TTD
O TANGGAL
DX PUKUL
IX. EVALUASI

N HARI S-O-A-P TTD

O TANGGAL
DX PUKUL