FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

A. Pengkajian
1. Identitas
 Pasien
 Nama :
 Umur :
 Jenis Kelamin :
 Pendidikan :
 Pekerjaan :
 Status Perkawinan :
 Agama :
 Suku :
 Alamat :
 Tanggal Masuk :
 Tanggal Pengkajian :
 Sumber Informasi :
 Diagnosa Masuk :
 Penanggung
 Nama :
 Hubungan Dengan Pasien :
2. Riwayat Keluarga
 Genogram (kalau perlu)
  Keterangan Genogram
: Laki-laki

: Perempuan

: Sudah Meninggal

---------- : Tinggal Serumah

: Klien

3. Status Kesehatan
a. Status Kesehatan Saat Ini
 Keluhan utama :
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 Alasan masuk Rumah Sakit dan perjalanan Penyakit saat ini:
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 Upaya yang dilakukan untuk mengatasinya :
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 b. Status Kesehatan Masa Lalu
 Penyakit yang pernah dialami
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 Pernah dirawat
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 Riwayat alergi :  Ya  Tidak
Jelaskan :
 Riwayat tranfusi :  Ya  Tidak
 Kebiasaan :
 Merokok :  Ya  Tidak
Sejak: Jumlah:
 Minum kopi  Ya  Tidak
Sejak: Jumlah:
 Penggunaan Alkohol  Ya  Tidak
Sejak: Jumlah:

4. Riwayat Penyakit Keluarga :

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5. Diagnosa Medis dan therapy :
Diagnosa: ...........................................................................................................
Therapy:..............................................................................................................
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6. Pola Fungsi Kesehatan
a. Pemeliharaan dan persepsi terhadap kesehatan:
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b. Nutrisi/ metabolic:
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c. Pola eliminasi:
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d. Pola aktivitas dan latihan
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan
alat, 4: tergantung total.
Keterangan :
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e. Pola tidur dan istirahat:
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f. Pola kognitif-perseptual
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g. Pola persepsi diri/konsep diri
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h. Pola seksual dan reproduksi
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i. Pola peran-hubungan
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j. Pola manajemen koping stress
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 k. Pola keyakinan-nilai
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7. Riwayat Kesehatan dan Pemeriksaan fisik
Keadaan umum :  Baik  Sedang  Lemah Kesadaran:
TTV TD: Nadi : x/menit Suhu: RR: x/menit
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a. Kulit, Rambut dan Kuku
Distribusi rambut :
Lesi  Ya  Tidak
Warna kulit  Ikterik  Sianosis  Kemerahan  Pucat
Akral  Hangat  Panas  Dingin kering
 Dingin
Turgor:
Oedem  Ya  Tidak Lokasi:
Warna kuku:  Pink  Sianosis  lain-lain
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b. Kepala dan Leher
Kepala  Simetris  Asimetris
Lesi  ya  Tidak
Deviasi trakea  Ya  Tidak
Pembesaran kelenjar tiroid  Ya  Tidak
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c. Mata dan Telinga
Gangguan pengelihatan  Ya  Tidak
Menggunakan kacamata  Ya  Tidak
Visus:
Pupil  Isokor  Anisokor
Ukuran:
Sklera/ konjungtiva  Anemis  Ikterus
Gangguan pendengaran  Ya  Tidak
Menggunakan alat bantu dengar  Ya  Tidak
Tes weber:
Tes Rinne:
Tes Swabach:
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d. Sistem Pernafasan:
Batuk:  Ya  Tidak
Sesak:  Ya  Tidak
 Inspeksi:
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 Palpasi :
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 Perkusi :
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 Auskultasi :
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e. Sistem Kardiovaskular :
Nyeri dada  Ya  Tidak
Palpitasi  Ya  Tidak
CRT  < 3 dtk  > 3 dtk
 Inspeksi:
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 Palpasi :
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 Perkusi :
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 Auskultasi :
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f. Payudara Wanita dan Pria:

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g. Sistem Gastrointestinal:
Mulut  Bersih  Kotor  Berbau
Mukosa  Lembab  Kering  Stomatitis
Pembesaran hepar  Ya  Tidak
Abdomen  Meteorismus  Asites  Nyeri tekan
Peristaltik: x/mnt
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h. Sistem Urinarius :
Penggunaan alat bantu/ kateter  Ya  Tidak
Kandung kencing, nyeri tekan  Ya  Tidak
Gangguan  Anuria  Oliguria  Retensi  Inkontinensia
 Nokturia  Lain-lain:
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i. Sistem Reproduksi Wanita/Pria :
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j. Sistem Saraf:
GCS: Eye: Verbal: Motorik:
Rangsangan meningeal  Kaku kuduk  Kernig
 Brudzinski I  Brudzinski II

Refleks fisiologis  Patela  Trisep

 Bisep  Achiles

Refleks patologis  Babinski  Chaddock

 Oppenheim  Rossolimo  Gordon
 Schaefer  Stransky  Gonda
Gerakan involunter :.............................................................................................
Lainnya :
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k. Sistem Muskuloskeletal:
Kemampuan pergerakan sendi  Bebas  Terbatas
Deformitas  Ya  Tidak
Lokasi:
Fraktur  Ya  tidak
Lokasi:
Kekakuan  Ya  Tidak
Nyeri sendi/otot  Ya  Tidak
Kekuatan otot :
Lainnya :
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l. Sistem Imun:
Perdarahan Gusi  Ya  Tidak
Perdarahan lama  Ya  Tidak
Pembengkakan KGB  Ya  Tidak
Lokasi:
Keletihan/kelemahan  Ya  Tidak
Lainnya :
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m. Sistem Endokrin:
Hiperglikemia  Ya  Tidak
Hipoglikemia  Ya  Tidak
Luka gangrene  Ya  Tidak
Lainnya :
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8. Pemeriksaan Penunjang
a. Data laboratorium yang berhubungan
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b. Pemeriksaan radiologi
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c. Hasil konsultasi
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d. Pemeriksaan penunjang diagnostik lain

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 9. Analisa Data
No Tgl Data Penyebab/Interpretasi Masalah
 10. Diagnosa Keperawatan (berdasarkan prioritas)
No Dx Tgl Muncul Dx Keperawatan Tgl teratasi TTD
 11. Perencanaan
Hari/Tgl No Dx Rencana Keperawatan

Tujuan dan kriteria hasil Intervensi Rasional

 12. Pelaksanaan (Implementasi)
Hari/Tgl No Dx Jam Tindakan Keperawatan Respon Klien TTD
 13. Evaluasi (Catatan Perkembangan)
No Hari/Tgl No Dx Jam Evaluasi TTD