FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Tgl. Pengkajian : No. Register :

Jam Pengkajian : Tgl. MRS :
Ruang/Kelas :

I. IDENTITAS
1. Identitas Pasien 2. Identitas Penanggung Jawab N a
ma : Nama :
Umur : Umur :
Jenis Kelamin : Jenis Kelamin :
Agama : Agama :
Pendidikan : Pekerjaan :
Pekerjaan : Alamat :
Gol. Darah : Hubungan dengan Klien : A
lamat :

II. KELUHAN UTAMA

1. Keluhan Utama Saat MRS

2. Keluhan Utama Saat Pengkajian

III. DIAGNOSA MEDIS

IV. RIWAYAT KESEHATAN

1. Riwayat Penyakit Sekarang

2. Riwayat Kesehatan Yang Lalu

3. Riwayat Kesehatan Keluarga

V. RIWAYAT POLA FUNGSI KESEHATAN KLIEN

1. Pola Aktifitas Sehari-hari (ADL)

ADL Sebelum Saat Sakit
Sakit
Pola persepsi - manajemen
kesehatan

Pola nutrisi - metabolik

Pola eliminasi

Pola latihan – aktivitas

Pola kognitif perseptual

 ADL Sebelum Saat Sakit
Sakit
Pola istirahat tidur

Pola konsep diri – persepsi diri

Pola peran dan hubungan

Pola reproduksi/seksual

Pola pertahanan diri (koping toleransi

stress)
 ADL Sebelum Saat Sakit
Sakit
Pola keyakinan dan nilai

VI. PEMERIKSAAN FISIK

A. Keadaan Umum

B. Pemeriksaan Tanda-tanda Vital

C. Pemeriksaan Wajah

D. Pemeriksaan Kepala Dan Leher

E. Pemeriksaan Fungsi Penglihatan

F. Pemeriksaan Fungsi Pendengaran/Penghidu/tengorokan

G. Pemeriksaan Thoraks/dada

H. Pemeriksaan Abdomen

I. Pemeriksaan Punggung Dan Tulang Belakang

J. Pemeriksaan Kulit/Integument

K. Pemeriksaan Ektremitas/Muskuloskeletal
L. Pemeriksaan Fungsi Neurologis

M. Pemeriksaan Genetalia dan Rektal

VIIPEMERIKSAAN PENUNJANG/DIAGNOSTIK MEDIK

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VIII TINDAKAN DAN TERAPI

Perawat yang mengkaji

( )
 ANALISIS DATA

NO DATA ETIOLOGI MASALAH

RUMUSAN DIAGNOSIS KEPERAWATAN

1. ………………………………………………………………………………………………................................................................................................................
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PRIORITAS DIAGNOSIS KEPERAWATAN

1. ………………………………………………………………………………………………................................................................................................................
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 PERENCANAAN

NO DIAGNOSIS TUJUAN INTERVENSI RASIONAL TT

KEPERAWATAN ( SLKI ) ( SIKI ) NAMA
( SDKI ) JELAS
 CATATAN TINDAKAN KEPERAWATAN (IMPLEMENTASI)

NO HARI/TGL/JAM DX KEPERAWATAN TINDAKAN KEPERAWATAN TT

( SDKI ) NAMA
JELAS
 EVALUASI

NO HARI/TGL/JAM DX KEPERAWATAN CATATAN PERKEMBANGAN TT

( SDKI ) (SOAP/SOAPIER) NAMA
JELAS