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ASUHAN KEPERAWATAN MEDIKAL BEDAH

PADA ............... DENGAN .......................................................

DI RUANG .........................................................................................

I. PENGKAJIAN

Tanggal Pengkajian : ...................................

Tanggal Masuk Ruangan : ...................................

Ruang : ...................................

A. IDENTITAS

1. Identitas Klien

Nama : ...................................

No. Rekam Medis : ...................................

Umur : ...................................

Jenis Kelamin : ...................................

Agama : ...................................

Pekerjaan : ...................................

Suku : ...................................

Bahasa : ...................................

Alamat : ...................................

Pembiayaan Kesehatan : ...................................

2. Identitas Penanggung Jawab

Nama : ...................................

Umur : ...................................

Pekerjaan : ...................................

Suku : ...................................

Hubungan dg Klien : ...................................

Bahasa : ...................................

Alamat : ...................................

No.Telpon : ...................................

B. KELUHAN UTAMA

1. Pertama kali masuk RS (............................................................................)

Keluhan utama :

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

Keluhan lainnya :

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

2. Saat Pengkajian (Tanggal: ..............................., Pukul ..........................)

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

C. RIWAYAT PENYAKIT SEKARANG

1. Pertama kali masuk RS (............................................................................)

a. Keluhan : ..............................................................................................

b. Keadaan :

KU = ........................

Kesadaran = ........................

GCS = ........................

Tekanan Darah = ........................

RR = ........................

HR = ........................

Suhu = ........................

c. Terapi yang diberikan : ........................................................................

d. Follow up : ...........................................................................................

2. Ruang rawat inap (......................................................................................)

a. Dx. Medis

1) Primer : ........................

2) Sekunder : ........................

b. Keluhan :

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

c. Keadaan

KU = ........................

Kesadaran = ........................

GCS = ........................

Tekanan Darah = ........................

RR = ........................

HR = ........................

d. Terapi yang diberikan

Diit = .................................................................................

e. Support system

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

D. RIWAYAT PENYAKIT DAHULU

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

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

E. RIWAYAT PENYAKIT KELUARGA

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

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

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

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

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

F. PEMERIKSAAN FISIK

Tanggal ...............................................

1. Keadaan Klien

a. Keadaan Umum : ........................

b. Kesadaran : ........................

c. GCS : ........................

d. TTV

TD = ........................

RR = ........................

HR = ........................

T = ........................

2. Pemeriksaan Fisik

a. Kepala

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

b. Mata

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

c. Leher

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

d. Hidung

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

e. Mulut

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

f. Telinga

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

g. Dada dan Paru

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

h. Payudara

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

i. Jantung

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

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

j. Abdomen

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

k. Genitalia

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

l. Kulit dan Kuku

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

m. Ekstremitas atas dan ekstremitas bawah

Inspeksi : ......................................................................................

Kekuatan otot :

Kanan Kiri

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

Pergerakan

Kanan Kiri

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

ROM Ekstremitas atas

Kanan : ..................................................................................

Kiri : ..................................................................................

ROM Ekstremitas bawah

Kanan : ..................................................................................

Kiri : ..................................................................................

n. Pemeriksaan lain

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

G. PENGKAJIAN KEBUTUHAN DASAR

1. Kebutuhan Oksigenasi

Sebelum sakit :

a. A (Airway)

: ..........................................................................................................

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

b. B (Breathing) :

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

c. C (Circulation) :

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

Selama sakit :

a. A (Airway)

: ............................................................................................................

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

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

b. B (Breathing) :

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

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

c. C (Circulation) :

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

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

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

2. Kebutuhan Nutrisi dan Cairan

Nutrisi

Indeks Sebelum sakit Selama sakit

(Antropometri)

B (Biokimia)

C (Clinis)

D (Diet)

Cairan

a. Sebelum sakit

Intake

Output

Balance cairan

Hematokrit

b. Selama sakit

Intake

Output

Balance cairan

Hematokrit

3. Kebutuhan Eliminasi

Kategori Sebelum Sakit Selama Sakit

Frekuensi

Jumlah

Konsistensi

Frekuensi

Jumlah

Konsistensi

4. Kebutuhan Termoregulasi

Sebelum sakit Selama sakit

Suhu tubuh

Produksi keringat

Adaptasi suhu

lingkungan

5. Kebutuhan Aktivitas dan Latihan

Sebelum Sakit :

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

Indeks KATZ klien sebelum sakit

Kategori Mandiri Tergantung

Bathing

Dressing

Toileting

Transferring

Continence

Feeding

Selama Sakit :

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

Indeks KATZ klien selama sakit

Kategori Mandiri Tergantung

Bathing

Dressing

Toileting

Transferring

Continence

Feeding

6. Kebutuhan Seksualitas

Kebutuhan dicintai

dan mencintai

Status pernikahan

Alat kontrasepsi

Kebutuhan akan seks

7. Kebutuhan Psikososial (stress, koping, dan konsep diri)

Stress dan koping

Konsep diri :

1. Gambaran

2. Identitas diri

3. Peran diri

4. Ideal diri

5. Harga diri

8. Kebutuhan aman dan nyaman

a. Kebutuhan rasa aman

Keamanan

lingkungan

Lingkungan yang

b. Kebutuhan rasa nyaman

Rasa nyaman:

1. Nyeri

2. Mual dan

muntah

3. Gangguan

nyaman

lain :

pusing,

gatal,

dikubitus

9. Kebutuhan Spiritual

Kegiatan

beribadah

10. Kebutuhan Hygiene

Kebiasaan hygiene Sebelum sakit Saat sakit

Mencuci rambut

Menggososk gigi

Berganti pakaian

Berhias

Kebersihan kuku

tangan dan kaki

11. Kebutuhan Istirahat dan Tidur

Jam tidur

Pola tidur

Posisi tidur yang

disukai

Lingkungan

12. Kebutuhan Rekreasi

13. Kebutuhan Informasi dan Komunikasi

Pengetahuan dan

informasi mengenai

penyakit

Pengetahuan dan

informasi mengenai

terapi/rencana terapi

yang diberikan

Minat belajar mengenai

suatu topik (penyakit

yang diderita)

14. Kebutuhan Aktualisasi Diri

H. PEMERIKSAAN PENUNJANG

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

I. TERAPI

JenisTerapi

Dosis RuteIndikasi & Cara Kerja

Kontra Indikasi

Efek Samping

JenisTerapi

Dosis RuteIndikasi & Cara Kerja

Kontra Indikasi

Efek Samping

II. ANALISA DATA

No. Hari/tanggal Data fokus Masalah Etiologi

III. DIAGNOSA KEPERAWATAN

No.Tgl/jam

ditemukanDiagnosa Keperawatan Ttd

IV. RENCANA KEPERAWATAN

NoHari/

Tanggal

DxTujuan dan Kriteria Hasil Intervensi Rasional

NoHari/

Tanggal

NoHari/

Tanggal

NoHari/

Tanggal

No Hari/ No. Tujuan dan Kriteria Hasil Intervensi Rasional

Tanggal Dx

V. IMPLEMENTASI

No Tanggal JamNo. Dx.

KeperawatanImplementasi Respon TTD

No Tanggal Jam No. Dx. Implementasi Respon TTD

Keperawatan

VI. EVALUASI

NoTanggal/

jamDiagnosa Keperawatan Evaluasi TTD

NoTanggal/

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