FORMAT

ASUHAN KEPERAWATAN MEDIKAL BEDAH

DISUSUN OLEH :

NAMA : ______________________________
NIM : ______________________________

POLTEKKES KEMENKES MALANG

JURUSAN KEPERAWATAN
PRODI D3 KEPERAWATAN TRENGGALEK
Jl. Dr. Soetomo No. 5 Telp. (0355) 791293 Kode Pos
66312

TRENGGALEK
 KEMENTERIAN KESEHATAN RI
BADAN PENGEMBANGAN DAN PEMBERDAYAAN SDM KESEHATAN
POLITEKNIK KESEHATAN KEMENKES MALANG
- Kampus Pusat : Jl. Besar Ijen No. 77 C Malang, 65112 Telp (0341) 566075, 571388 Fax (0341) 556746
- Kampus I : Jl. Srikoyo No. 106 Jember Telp (0331) 486613
- Kampus II : Jl. A. Yani Sumberporong Lawang Telp (0341) 427847
- Kampus III : Jl. Dr. Soetomo No. 46 Blitar Telp (0342) 801043
- Kampus IV : Jl. KH Wakhid Hasyim No. 64B Kediri Telp (0354) 773095
- Kampus V : Jl. Dr. Soetomo No. 5 Trenggalek Telp (0355) 791293
- Kampus VI : Jl. Dr. Cipto Mangunkusomo No. 82A Ponorogo Telp (0352) 461792
Website : Http://www.poltekkes-malang.ac.id Email : direktorat@poltekkes-malang.ac.id

FORMAT PENGKAJIAN
DATA – DATA KEPERAWATAN

1. BIODATA :
 Nama : ________________________________________
 Jenis kelamin : ________________________________________
 Umur : ________________________________________
 Status perkawinan : ________________________________________
 Pekerjaan : ________________________________________
 Agama : ________________________________________
 Pendidikan terakhir : ________________________________________
 Alamat : ________________________________________
 Tanggal/Jam MRS : ________________________________________
 Tanggal/Jam pengkajian : ________________________________________

2. DIAGNOSA MEDIS  :........................................

3. KELUHAN UTAMA :........................................
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4. RIWAYAT PENYAKIT SEKARANG ( P Q R S T )
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5. RIWAYAT KESEHATAN / PENYAKIT YANG LALU
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6. RIWAYAT KESEHATAN KELUARGA

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7. POLA AKTIVITAS SEHARI – HARI

NO. AKTIVITAS DI RUMAH DI RS

a. Makan dan minum ...................................... ......................................
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b. Pola eliminasi ......................................
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c. Pola istirahat / tidur ...................................... ......................................

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 d. Kebersihan diri ...................................... ......................................
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8. RIWAYAT PSIKOSOSIAL
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9. PEMERIKSAAN FISIK
a. Keadaan umum : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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b. Tanda – tanda vital :
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c. Pemeriksaan kepala dan leher :
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d. Pemeriksaan integumen :
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 ..............................................................
e. Pemeriksaan dada / thorax :
Inspeksi :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Palpasi :.........................................................

Perkusi :.........................................................

Auskultasi : ........................................................

f. Pemeriksaan payudara :
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g. Abdoment :
Inspeksi :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Auskultasi :.........................................................

Perkusi :.........................................................

Palpasi : ........................................................

h. Genetalia :
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i. Ekstremitas :
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10. PEMERIKSAAN NEUROLOGIS
Kesadaran/GCS : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 Kemampuan sensorik :...................................................
Kemampuan motorik : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reflek :..............................................................
Nervus cranialis :……………………………………………………………………

11. PEMERIKSAAN PENUNJANG

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12. PENATALAKSANAAN ( TERAPI / PENGOBATAN )
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Trenggalek, . . . . . . . . . . . . . . . . . . . . . .

Pembimbing

_________________________
 ANALISA DATA

NAMA PASIEN :

UMUR :

NO. REGISTER :

RUANG :

NO. DATA MASALAH ETIOLOGI

 DIAGNOSA KEPERAWATAN

NAMA PASIEN :

UMUR :

NO. REGISTER :

RUANG :

NO TANGGAL DIAGNOSA TANGGAL TANDA

MUNCUL KEPERAWATAN TERATASI TANGAN
 RENCANA TINDAKAN KEPERAWATAN

No. Tanggal No. Dx. Kep. NOC NIC Rasionalisasi Tanda Tangan
 IMPLEMENTASI

NAMA : UMUR :

NO. REG : RUANG :

No. Tanggal/ Diagnosa Tindakan/ Tanda

Jam Keperawatan Implementasi Tangan
 EVALUASI

NAMA : UMUR :

NO. REG. : RUANG :

NO. DX Tanggal / Diagnosa Keterangan

Jam Keperawatan
 CATATAN PERKEMBANGAN
Tanggal/ Diagnosa Implementasi Evaluasi ( S O A P )
Jam Kep.