ASUHAN KEPERAWATAN

KEPERAWATAN MEDIKAL BEDAH

DI RUMAH SAKIT ……………………………………….
PADA PASIEN DENGAN ………………………………………

Disusun oleh :
(Nama Mahasiswa)

PRODI SARJANA TERAPAN KEPERAWATAN PROFESI NERS PONTIANAK

POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN PONTIANAK
TAHUN AJARAN 2020/2021
 LEMBAR PENGESAHAN

ASUHAN KEPERAWATAN
KEPERAWATAN MEDIKAL BEDAH
DI RUMAH SAKIT ……………………………………….
PADA PASIEN DENGAN ………………………………………

Disusun oleh :

(………………………………)

Mengetahui,

Pembimbing Klinik / CI Pembimbing Akademik / CT

(…………………………………..) (…………………………………..)
 FORMAT ASUHAN KEPERAWATAN

PENGKAJIAN
1. Pengumpulan Data
a. Identitas pasien
Nama Inisial : ………………………………………………………………………..
No. RM : ………………………………………………………………………..
Umur : ………………………………………………………………………..
Jenis kelamin : ………………………………………………………………………..
Agama : ………………………………………………………………………..
Suku : ………………………………………………………………………..
Pendidikan : ………………………………………………………………………..
Alamat : ………………………………………………………………………..
Pekerjaan : ………………………………………………………………………..
Tanggal masuk : ………………………………………………………………………..
Tanggal pengkajian : ………………………………………………………………………..
Diagnosa medis : ………………………………………………………………………..
DPJP : ………………………………………………………………………..
b. Identitas penanggung jawab
Nama : ………………………………………………………………………..
Hub. dengan pasien : ………………………………………………………………………..
2. Riwayat Kesehatan
a. Riwayat Keperawatan
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 kesehatan keluarga
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Genogram
 3. Pengkajian Pola Fungsi Gordon
a. Persepsi terhadap kesehatan dan manajemen kesehatan
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b. Pola aktivitas dan latihan

Aktivitas 0 1 2 3 4 Keterangan :
Mandi 0 = Mandiri
Berpakaian 1 = Dibantu sebagian
2 = Perlu bantuan orang lain
Eliminasi
3 = Perlu bantuan orang lain dan alat
Mobilisasi ditempat tidur 4 = Tergantung orang lain tidak mandiri
Pindah
Makan dan minum

c. Pola istirahat dan tidur

SMRS : ………………………………………………………………………………..
MRS : ………………………………………………………………………………..
d. Pola nutrisi metabolik
SMRS : ………………………………………………………………………………..
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MRS : ………………………………………………………………………………..
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e. Pola eliminasi
SMRS : ………………………………………………………………………………..
MRS : ………………………………………………………………………………..
f. Pola kognitif dan perseptual
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g. Pola konsep diri
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h. Pola koping
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i. Pola seksual-reproduksi
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j. Pola peran berhubungan
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k. Pola nilai dan kepercayaan
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4. Pemeriksaan Fisik
a. Keadaan umum
1) Kesadaran : E……M …… V….. (GCS = ……) = ...…………………………………...
2) Kondisi pasien secara umum
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3) Tanda Tanda Vital
a) Tekanan darah : ……/…… mmHg
b) Nadi / HR : …………. x/menit
c) Napas / RR : …………. x/menit
d) Suhu / T : …………. oCelcius
4) Pertumbuhan fisik
a) Berat Badan : ……………………………………………………………………
b) Tinggi Badan : ……………………………………………………………………
c) BBI / IMT : ……………………………………………………………………
d) Postur tubuh : ……………………………………………………………………
5) Keadaan kulit
a) Warna : ……………………………………………………………………
b) Turgor : ……………………………………………………………………
c) Kelembaban : ……………………………………………………………………
d) Edema : ……………………………………………………………………
e) Kelainan lain : ……………………………………………………………………
b. Pemeriksaan secara sistemik
1) Kepala
Inspeksi : ……………………………………………………………………………
Palpasi : ……………………………………………………………………………
2) Mata
Inspeksi : ……………………………………………………………………………
Palpasi : ……………………………………………………………………………
3) Telinga
Inspeksi : ……………………………………………………………………………
Palpasi : ……………………………………………………………………………
4) Hidung
Inspeksi : ……………………………………………………………………………
Palpasi : ……………………………………………………………………………
5) Mulut
Inspeksi : ……………………………………………………………………………
6) Leher
Inspeksi : ……………………………………………………………………………
Palpasi : ……………………………………………………………………………
7) Dada (Paru dan Jantung)
a) Paru-paru
Inspeksi : ………………………………………………………………………..
Palpasi : ………………………………………………………………………..
Perkusi : ………………………………………………………………………..
Auskultasi : ………………………………………………………………………..
b) Jantung
Inspeksi : ………………………………………………………………………..
Palpasi : ………………………………………………………………………..
Perkusi : ………………………………………………………………………..
Auskultasi : ………………………………………………………………………..
c) Payudara
Inspeksi : ………………………………………………………………………..
Palpasi : ………………………………………………………………………..
8) Abdomen
Inspeksi : ……………………………………………………………………………
Auskultasi : ……………………………………………………………………………
Perkusi : ……………………………………………………………………………
Palpasi : ……………………………………………………………………………
9) Genetalia
Inspeksi : ……………………………………………………………………………
Palpasi : ……………………………………………………………………………
10) Anus dan Rektum
Inspeksi : ……………………………………………………………………………
Palpasi : ……………………………………………………………………………
11) Ekstremitas
a) Atas : ………………………………………………………………………….
b) Bawah : ………………………………………………………………………….
c) Kemampuan otot
Keterangan :
… … … … … … … … Skala 0 : Kemampuan otot 0 %
Kontraksi otot tidak terdeteksi (paralisis sempurna)
… … … … … … … …
Skala 1 : Kemampuan otot 10 %
Tidak ada gerakan, kontraksi otot dapat di palpasi
atau dilihat

Skala 2 : Kemampuan otot 25 %

Gerakan otot penuh melawan gravitasi, dengan
topangan

Skala 3 : Kemampuan otot 50 %

Gerakan yang normal melawan gravitasi

Skala 4 : Kemampuan otot 75 %

Gerakan penuh yang normal melawan gravitasi
dan melawan tahanan minimal

Skala 5 : Kemampuan otot 100 %

Kekuatan otot normal, gerakan penuh yang normal
melawan gravitasi dan melawan tahanan penuh
5. Pemeriksaan penunjang

LABORATORIUM
Tanggal …………………………..
Jenis Pemeriksaan Nilai Satuan Nilai Normal

RADIOLOGI
Tanggal …………………………..
6. Terapi yang diberikan

Tanggal : ………………………….
Nama terapi Waktu
Dosis Rute Indikasi
medis/obat/infus Pemberian

Tanggal : ………………………….
Nama terapi Waktu
Dosis Rute Indikasi
medis/obat/infus Pemberian

Tanggal : ………………………….
Nama terapi Waktu
Dosis Rute Indikasi
medis/obat/infus Pemberian

Nama perawat yang melakukan pengkajian

Nama

Hari / Tanggal / Jam

Tanda tangan
 ANALISA DATA
Masalah
No. Data Etiologi
Keperawatan
Data Subjektif
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Data Objektif
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 DIAGNOSA KEPERAWATAN
Tanggal Masalah
No. Diagnosa Keperawatan Paraf
Ditemukan Teratasi

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 INTERVENSI KEPERAWATAN

Tgl. No. Diagnosa Keperawatan Luaran Intervensi Keperawatan

(Tujuan dan Kriteria Hasil)
Setelah dilakukan intervensi
…………………………………………………….. keperawatan selama ….. x ….. jam, ………………………………………………..
…………………………………………………….. Maka …………………………………. 1.
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2.
Dengan kriteria hasil :
3.
Data Subjektif ………………………………………….
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5.
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1.
Data Objektif ………………………………………….
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3.
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4.
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 IMPLEMENTASI EVALUASI KEPERAWATAN

No. Evaluasi Keperawatan Paraf

Hari/Tgl/Jam Implementasi Keperawatan Paraf (Per-
Dx Implementasi) (SOAP) Evaluasi
(Per-Shift)

Diagnosa : …………………..………………………. Shift : Pagi/Siang/Malam - Pukul…………

………………………………………………………… Subjek
1. …………………………………………………… ………………………………………………………………….
R/H : …………………………………… ………………………………………………………………….
2. …………………………………………………… ………………………………………………………………….
R/H : …………………………………… Objek
3. …………………………………………………… ………………………………………………………………….
R/H : …………………………………… ………………………………………………………………….
4. ………………………………………………........ ………………………………………………………………….
R/H : …………………………………… ………………………………………………………………….

5. ……………………………………………………. ………………………………………………………………….

R/H : …………………………………… Asesmen

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Planning
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