Lampiran

Asuhan Keperawatan Medikal Bedah

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No RM : ...............................................................................................................
Hari/tanggal : ...............................................................................................................
Tempat : ...............................................................................................................

I. Pengkajian
A. Identitas Pasien
Nama :...................................................................................
Umur :...................................................................................
Tempat tanggal lahir :...................................................................................
Jenis kelamin :...................................................................................
Suku/bangsa :...................................................................................
Agama :...................................................................................
Pekerjaan :...................................................................................
Pendidikan :...................................................................................
Alamat :...................................................................................
Tanggal MRS :...................................................................................
Diagnosa Medis :...................................................................................
Ruangan :...................................................................................
Golongan Darah :...................................................................................
Sumber Informasi :...................................................................................

B. Identitas Penanggung Jawab

Nama :...................................................................................
Umur :...................................................................................
Jenis kelamin :...................................................................................
 Suku/bangsa :...................................................................................
Agama :...................................................................................
Pekerjaan :...................................................................................
Pendidikan :...................................................................................
Alamat :...................................................................................
Hubungan dengan pasien :...............................................................................
C. Riwayat Kesehatan Saat Ini (Nursing History)
1. Keluhan Utama
Jelaskan :...................................................................................
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2. Alasan Masuk Rumah Sakit
Jelaskan :...................................................................................
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3. Riwayat Penyakit
Jelaskan :...................................................................................
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D. Riwayat Kesehatan Masa Lalu

1. Penyakit Yang Pernah Dialami
Penyebab :...................................................................................
Riwayat Perawatan :...................................................................................
Riwayat operasi :...................................................................................
Riwayat pengobatan:...................................................................................
2. Kecelakaan Yang Pernah Dialami
Jelaskan :...................................................................................
 3. Riwayat Alergi
Jelaskan :...................................................................................

E. Riwayat Psikologi dan Spiritual

1. Riwayat Psikologi
Tempat Tinggal :...................................................................................
Lingkugan Rumah :...................................................................................
Hubungan Antar Keluarga :........................................................................
Pengasuh Anak :...................................................................................
2. Riwayat Spiritual
Support System :...................................................................................
Kegiatan Kegamaan:...................................................................................
3. Riwayat Hospitalisasi
Jelaskan :...................................................................................

F. Pola Fungsi Kesehatan (11 Pola Fungsional Gordon)

1. Pemeliharaan dan persepsi terhadap kesehatan
Jelaskan :...................................................................................
2. Pola Nutrisi/metabolic
Jelaskan :...................................................................................
3. Pola eliminasi
Jelaskan :...................................................................................
4. Pola aktivitas dan latihan
Jelaskan :...................................................................................
5. Pola tidur dan istirahat
Jelaskan :...................................................................................
6. Pola kognitif-perseptual
Jelaskan :...................................................................................
7. Pola persepsi diri/konsep diri
Jelaskan :...................................................................................
8. Pola seksual dan reproduksi
Jelaskan :...................................................................................
 9. Pola peran-hubungan
Jelaskan :...................................................................................
10. Pola manajemen koping stress
Jelaskan :...................................................................................
11. Pola keyakinan-nilai
Jelaskan :...................................................................................
G. Pemeriksaan Fisik
Hari...........................................................................................................................
Tanggal :........................... Jam :...............
1. Keadaan Umum
a. Kesadaran
Jelaskan :...................................................................................
b. Penampilan Digabungkan dengan usia
Jelaskan :...................................................................................
c. Ekspresi Wajah
Jelaskan :...................................................................................
d. Personal hygiene/Kebersihan Secara Umum
Jelaskan :...................................................................................
e. Vital Sign
Jelaskan :...................................................................................
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2. Pemeriksaan Fisik Head To Toe

a. Kulit/Integument
Inspeksi :...................................................................................
:...................................................................................
Palpasi :...................................................................................
:...................................................................................
b. Kepala dan Rambut
Inspeksi :...................................................................................
:...................................................................................
Palpasi :...................................................................................
:...................................................................................
c. Kuku
Inspeksi :...................................................................................
:...................................................................................
Palpasi :...................................................................................
:...................................................................................
d. Mata/Penglihatan
Inspeksi :...................................................................................
:...................................................................................
Palpasi :...................................................................................
:...................................................................................
e. Hidung /penciuman
Inspeksi :...................................................................................
:...................................................................................
Palpasi :...................................................................................
:...................................................................................
f. Telinga/Pendengaran
Inspeksi :...................................................................................
:...................................................................................
Palpasi :...................................................................................
:...................................................................................
g. Mulut dan gigi
Inspeksi :...................................................................................
:...................................................................................
h. Leher
Inspeksi :...................................................................................
:...................................................................................
Palpasi :...................................................................................
:...................................................................................
i. Thorak/Dada
Inspeksi :...................................................................................
:...................................................................................
Palpasi :...................................................................................
 :...................................................................................
Perkusi :...................................................................................
:...................................................................................
Auskultasi :...................................................................................
:...................................................................................
j. Jantung
Inspeksi :...................................................................................
:...................................................................................
Palpasi :...................................................................................
:...................................................................................
Perkusi :...................................................................................
:...................................................................................
Auskultasi :...................................................................................
:...................................................................................
k. Abdoment
Inspeksi :...................................................................................
:...................................................................................
Auskultasi :...................................................................................
:...................................................................................
Palpasi :...................................................................................
:...................................................................................
Perkusi :...................................................................................
:...................................................................................
l. Perinium dan Genetalia
Inspeksi :...................................................................................
:...................................................................................
m. Ekstermitas Atas dan Bawah
Inspeksi :...................................................................................
:...................................................................................
Palpasi :...................................................................................
:...................................................................................
3. Pengkajian Data Fokus (Pengkajian Sistem)
a. Sistem Respiratori
Jelaskan :...................................................................................
:...................................................................................
:...................................................................................
b. Sistem Kardiovaskuler
Jelaskan :...................................................................................
:...................................................................................
:...................................................................................
c. Sistem Gastrointestinal
Jelaskan :...................................................................................
:...................................................................................
:...................................................................................
d. Sistem Urinari
Jelaskan :...................................................................................
:...................................................................................
:...................................................................................
e. Sistem Reproduksi
Jelaskan :...................................................................................
:...................................................................................
f. Sistem Muskuloskeletal
Jelaskan :...................................................................................
:...................................................................................
:...................................................................................
g. Sistem Neurologi
Jelaskan :...................................................................................
:...................................................................................
:...................................................................................
4. Data penunjang
a. Program Terapi
1) …………………………………………….
2) ……………………………………………..
3) ……………………………………………..
4) ……………………………………………..
5) ……………………………………………..
6) ……………………………………………..

b. Pemeriksaan Foto Rontgen

Hari/Tanggal :.....................................
Hasil Pemeriksaan
c. Pemeriksaan Penunjang Laboratorium
Hari/Tanggal :.....................................
Hasil Pemeriksaan

Singaraja,..................2023
Yang Mengkaji,
...........................................
NIM...................................
II. Analisa Data
Nama :.................................. No. RM :................................................
Umur :.................................. Dx Medis :................................................
Ruang rawat:.................................. Alamat :................................................
No Data Fokus Etiologi Problem
Subjektif Objektif
No Data Fokus Etiologi Problem
Subjektif Objektif
III. Diagnosa Keperawatan
1. .
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2. .
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3. .
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IV. Perencanaan Keperawatan
Diagnosa Luaran dan Kriteria Hasil Intervensi Keperawatan
No
Keperawatan (SDKI) (SLKI) (SIKI)
V. Implementasi Keperawatan

No Tgl/jam Implementasi Tindakan Keperawatan Paraf

VI. Evaluasi Keperawatan
No Hari/tanggal Diagnosa Keperawatan Evaluasi Keperawatan (SOAP) Paraf