STIKES RS.

BAPTIS KEDIRI
PROGRAM STUDI KEPERAWATAN PROGRAM SARJANA (ALIH JENJANG)
ASUHAN KEPERAWATAN MEDIKAL BEDAH

NAMA MAHASISWA : …………………………………………

NIM : …………………………………………
RUANG : ………………………………………...
TANGGAL : ………………………………………....

1. BIODATA :
Nama : ……………………………………………….No.Reg……….……
Umur : ………………………………………………………………..……
Jenis Kelamin : ……………………………………………………………….….…
Agama : ………………………………………………………………..……
Alamat : ………………………………………………………………..……
Pendidikan : ………………………………………………………………..……
Pekerjaan : ………………………………………………………….…….……
Tanggal MRS : ..……………………………………………………………………
Tanggal Pengkajian : ………………………………………………………………..……
Golongan Darah : ………………………………………………………………..……
Diagnosa Medis : ………………………………………………………………..…....

2. KELUHAN UTAMA
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................

3. RIWAYAT PENYAKIT SEKARANG

..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................

4. RIWAYAT PENYAKIT MASA LALU

....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

5. RIWAYAT KESEHATAN KELUARGA

....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Genogram :
6. RIWAYAT PSIKO SOSIAL DAN SPIRITUAL
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
7. POLA AKTIFITAS SEHARI – HARI ( Makan, istirahat, tidur, eliminasi, aktifitas,
kebersihan dan seksual ).
No Activity Sebelum Sakit Sesudah Sakit
Daily
Living
(ADL)
1. Pemenuhan Makan/Minum Makan/Minum
kebutuhan Jumlah : Jumlah :
Nutrisi dan Jenis : Jenis :
Cairan 1) Nasi : ....................(porsi) 1) Nasi :.......................(porsi)
2) Lauk : ada/tidak, nabati/hewani 2) Lauk : ada/tidak, nabati/hewani
3) Sayur : ada/tidak 3) Sayur : ada/tidak
4) Minum :...............cc/hari 4) Minum :....................cc/hari
Pantangan : Pantangan :

Kesulitan Makan/Minum : Kesulitan Makan/Minum :

Usaha mengatasi kesulitan : Usaha Mengatasi Kesulitan :

2. Pola BAK :.........................x/hari BAK :..............................x/hari

Eliminasi Jumlah :.......................cc Jumlah :............................cc

BAB : BAB :
Konsistensi : Konsistensi :

Masalah dan cara mengatasi: Masalah dan cara mengatasi:

3. Pola Siang : ........................jam Siang : ..............................jam

Istirahat
Tidur Sore :...........................jam Sore : ................................jam

Malam : ......................jam Malam : ............................jam

Gangguan Tidur : Gangguan Tidur :

Penggunaan Obat Tidur : Penggunaan Obat Tidur :

No Activity Sebelum Sakit Sesudah Sakit
Daily
Living
(ADL)

4. Personal 1.Frekuensi Mandi :......x/hari 1.Frekuensi Mandi :......x/hari

Hygiene
(Kebersihan
Diri)
2.Frekuensi mencuci rambut : 2.Frekuensi mencuci rambut :

3.Frekuensi gosok gigi : 3.Frekuensi gosok gigi :

4.Keadaan Kuku : 4.Keadaan Kuku :

5.Ganti Baju : 5.Ganti Baju :

5. Aktivitas Aktivitas rutin : Aktivitas rutin :

Lain

Aktivitas yang dilakukan pada Aktivitas yang dilakukan pada

waktu luang : waktu luang :

8. KEADAAN/PENAMPILAN/KESAN UMUM PASIEN

.....................................................................................................................................................
….................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

9. TANDA-TANDA VITAL
Suhu Tubuh : ……………………………ºC
Denyut Nadi : ……………………………x/menit
Tekanan Darah : ……………………………mmHg
Pernafasan :……………………………x/menit
TT / TB : ……………………………Kg, …………….cm

10.PEMERIKSAAN FISIK
A. Pemeriksaan Kepala dan Leher
...............................................................................................................................................
...............................................................................................................................................
 ...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

B. Pemeriksaan Integumen Kulit dan Kuku :

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

C. Pemeriksaan Payudara dan Ketiak ( Bila diperlukan ):

...............................................................................................................................................
...............................................................................................................................................

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

D. Pemeriksaan Dada /Thorak

Inspeksi Thorax :...................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
Paru :.....................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................

E. Pemeriksaan Jantung :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

F. Pemeriksaan Abdomen :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

G. Pemeriksaan Kelamin dan daerah sekitarnya ( bila diperlukan ):

Genetalis :..............................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
 ...............................................................................................................................................
Anus :...................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

H. Pemeriksaan Muskuloskeletal :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

H. Pemeriksaan Neurologi :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

J. Pemeriksaan Status Mental :

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

11. Pemeriksaan Penunjang Medis

Tanggal :
No Pemeriksaan Hasil Nilai Normal Interprestasi Hasil
 No Pemeriksaan Hasil Nilai Normal Interprestasi Hasil

12. Pelaksanaan / Therapi :

.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

12. Harapan Klien / Keluarga sehubungan dengan penyakitnya :

.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Kediri ,
……………………….
Tanda Tangan Mahasiswa,
 ANALISA DATA

NAMA PASIEN : ..............................................................

UMUR : ..............................................................
NO. REGISTER : ...............................................................

DATA OBYEKTIF (DO) FAKTOR YANG MASALAH

DATA SUBYEKTIF (DS) BERHUBUNGAN/RISIKO KEPERAWATAN
(E) (P)
 DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN : ...............................................................

UMUR : ..............................................................
NO. REGISTER : ..............................................................

NO TANGGAL DIAGNOSA KEPERAWATAN TANGGAL TANDA

MUNCUL (SDKI) TERATASI TANGAN
 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN :
UMUR :
NO REGISTER :

DIAGNOSIS KEPERAWATAN :

1. SIKI :
a. Dipertahankan/ditingkatkan pada
b. Dipertahankan/ditingkatkan pada
c. Dipertahankan/ditingkatkan pada
d. Dipertahankan/ditingkatkan pada
e. Dipertahankan/ditingkatkan pada
f. Dipertahankan/ditingkatkan pada
g. Dipertahankan/ditingkatkan pada
h. Dipertahankan/ditingkatkan pada
i. Dipertahankan/ditingkatkan pada
j. Dipertahankan/ditingkatkan pada

2. SIKI :
a. Dipertahankan/ditingkatkan pada
b. Dipertahankan/ditingkatkan pada
c. Dipertahankan/ditingkatkan pada
d. Dipertahankan/ditingkatkan pada
e. Dipertahankan/ditingkatkan pada
f. Dipertahankan/ditingkatkan pada
g. Dipertahankan/ditingkatkan pada
h. Dipertahankan/ditingkatkan pada
i. Dipertahankan/ditingkatkan pada
j. Dipertahankan/ditingkatkan pada
k. Dipertahankan/ditingkatkan pada

3. SIKI :
a. Dipertahankan/ditingkatkan pada
b. Dipertahankan/ditingkatkan pada
c. Dipertahankan/ditingkatkan pada
d. Dipertahankan/ditingkatkan pada
e. Dipertahankan/ditingkatkan pada
f. Dipertahankan/ditingkatkan pada
g. Dipertahankan/ditingkatkan pada
h. Dipertahankan/ditingkatkan pada
i. Dipertahankan/ditingkatkan pada
 j. Dipertahankan/ditingkatkan pada
k. Dipertahankan/ditingkatkan pada

Keterangan : (dipertahankan/ditingkatkan) coret salah satu

 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN : ..............................................................

UMUR : ...............................................................
NO. REGISTER : ..............................................................
NO DIAGNOSA KEPERAWATAN INTERVENSI RASIONAL
(SIKI)
 TINDAKAN KEPERAWATAN

NAMA PASIEN : ..............................................................

UMUR : ...............................................................
NO.REGISTER : .............................................................

NO NO.DX TGL/JAM TINDAKAN KEPERAWATAN TANDA

TANGAN
 CATATAN PERKEMBANGAN

NAMA PASIEN : ..............................................................

UMUR : ...............................................................
NO.REGISTER : ...............................................................

NO NO.DX JAM EVALUASI TTD

16