LAPORAN ASUHAN KEPERAWATAN

KEPERAWATAN MEDIKAL BEDAH

ASUHAN KEPERAWATAN PADA :

DENGAN DIAGNOSA :
DI RUANGAN INTERNE :
TANGGAL :

I.       PENGKAJIAN
1.       Identitas
a.      Identitas Pasien
Nama                        : ______________________________________________
Umur                        : _______________________________________________
Agama                      : ______________________________________________
Jenis Kelamin           : ______________________________________________
Status                        : ______________________________________________
Pendidikan                : ______________________________________________
Pekerjaan                  : ______________________________________________
Alamat                      : ______________________________________________
Tanggal Masuk         :_______________________________________________
Tanggal Pengkajian   : ______________________________________________
No. Register              :_______________________________________________
Diagnosa Medis        : ______________________________________________

b.      Identitas Penanggung Jawab

Nama                        : ______________________________________________
Umur                        : _______________________________________________
Hub. Dengan Pasien : ______________________________________________
Pekerjaan                  : ______________________________________________
Alamat                      : ______________________________________________
2.      Status Kesehatan
a.      Status Kesehatan Saat Ini
1)      Keluhan Utama (Saat ini)
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2)      Alasan masuk rumah sakit dan perjalanan penyakit saat ini

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3)      Upaya yang dilakukan untuk mengatasinya

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b.      Satus Kesehatan Masa Lalu

1)      Penyakit yang pernah dialami
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2)      Pernah dirawat
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3)      Alergi
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4)      Kebiasaan (merokok/kopi/alkohol dll)

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c.       Riwayat Penyakit Keluarga

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d.      Diagnosa Medis
Diagnosa medis :
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3.      Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)

a.       Pola Persepsi dan Manajemen Kesehatan
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b.      Pola Nutrisi-Metabolik
   Sebelum sakit          :
 - Makan
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- Minum
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   Saat sakit                 :
- Makan
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- Minum
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c.       Pola Eliminasi
1)   BAB
   Sebelum sakit          :
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    Saat sakit                 :
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2)   BAK
      Sebelum sakit       :
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      Saat sakit              :
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d.      Pola aktivitas dan latihan
1)   Aktivitas
Kemampuan 0 1 2 3 4
Perawatan Diri
Makan dan
minum
Mandi
Toileting
Berpakaian
Berpindah
0: mandiri, 1: Alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4:
tergantung total : 16

e.       Pola kognitif dan Persepsi

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f.       Pola Persepsi-Konsep diri

hal yang dipikirkan klien saat ini
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harapan klien setelah perawatan
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Perubhan setelah sakit

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g.       Pola Tidur dan Istirahat

 Sebelum sakit     
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 Saat sakit         
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h.      Pola Peran-Hubungan
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i.        Pola Seksual-Reproduksi
   Sebelum sakit     :
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   Saat sakit
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j.        Pola Toleransi Stress-Koping

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k.      Pola Nilai-Kepercayaan
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4.       Pengkajian Fisik
a.       Keadaan umum
Tingkat kesadaran __________________________________________
GCS _____________________________________________________
b.      Tanda-tanda Vital :
Nadi =   , Suhu = , TD = RR=

c.       Keadaan fisik
a.       Kepala  dan leher       
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b.      Dada  :
   Paru
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   Jantung
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c.       Payudara dan ketiak   

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d.      abdomen        
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e.       Genetalia        
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f.       Integumen
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g.       Ekstremitas     :
         Atas
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         Bawah
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h.      Neurologis      :
         Status mental da emosi
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         Pengkajian saraf kranial

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         Pemeriksaan refleks
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d. Pemeriksaan Penunjang
1.      Data laboratorium yang berhubungan
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2.      Pemeriksaan radiologi
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3.      Hasil konsultasi
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4.      Pemeriksaan penunjang diagnostic lain

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ANALISIS DATA

MASALAH
NO DATA ETIOLOGI
KEPERAWATAN
 FORMAT
RENCANA ASUHAN KEPERAWATAN

Nama Pasien : Nama Mahasiswa :

Ruang : NIM :
No MR :

N
DIAGNOSA KEPERAWATAN SLKI SIKI
O
 CATATAN PERKEMBANGAN

Nama Klien :
Diagnosa Medis :
Ruang Rawat :

TANGGAL DIAGNOSA JAM SOAP PARAF