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

a. Kulit/Integument
Inspeksi : ...................................................................................
: ...................................................................................
Palpasi : ...................................................................................
: ...................................................................................
b. Kepala dan Rambut
Inspeksi : ...................................................................................
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Palpasi : ...................................................................................
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c. Kuku
Inspeksi : ...................................................................................
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Palpasi : ...................................................................................
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d. Mata/Penglihatan
Inspeksi : ...................................................................................
 : ...................................................................................
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Palpasi : ...................................................................................
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e. Hidung /penciuman
Inspeksi : ...................................................................................
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Palpasi : ...................................................................................
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f. Telinga/Pendengaran
Inspeksi : ...................................................................................
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Palpasi : ...................................................................................
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g. Mulut dan gigi
Inspeksi : ...................................................................................
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h. Leher
Inspeksi : ...................................................................................
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Palpasi : ...................................................................................
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i. Thorak/Dada
Inspeksi : ...................................................................................
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Palpasi : ...................................................................................
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Perkusi : ...................................................................................
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Auskultasi : ...................................................................................
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j. Jantung
Inspeksi : ...................................................................................
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Palpasi : ...................................................................................
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Perkusi : ...................................................................................
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Auskultasi : ...................................................................................
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k. Abdoment
Inspeksi : ...................................................................................
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Auskultasi : ...................................................................................
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Palpasi : ...................................................................................
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Perkusi : ...................................................................................
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l. Perinium dan Genetalia
Inspeksi : ...................................................................................
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m. Ekstermitas Atas dan Bawah
Inspeksi : ...................................................................................
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Palpasi : ...................................................................................
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3. Pengkajian Data Fokus (Pengkajian Sistem)
a. Sistem Respiratori
Jelaskan : ...................................................................................
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: ...................................................................................
b. Sistem Kardiovaskuler
Jelaskan : ...................................................................................
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: ...................................................................................
c. Sistem Gastrointestinal
Jelaskan : ...................................................................................
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d. Sistem Urinari
Jelaskan : ...................................................................................
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e. Sistem Reproduksi
Jelaskan : ...................................................................................
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f. Sistem Muskuloskeletal
Jelaskan : ...................................................................................
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g. Sistem Neurologi
Jelaskan : ...................................................................................
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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,
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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 N
o Hari/tanggal Diagnosa Keperawatan Evaluasi Keperawatan (SOAP) Paraf