Format Askep Medikal Bedah

PEMERINTAH KABUPATEN LUMAJANG DINAS KESEHATAN AKADEMI KEPERAWATANJL. BRIGJEN KATAMSO TELP (0334) 882262 LUMAJANG

FORMAT PENGKAJIAN MEDIKAL BEDAH

NAMA MAHASISWAN I MTINGKAT / SEMESTERTANGGAL PRAKTIKTEMPAT PRAKTIK

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

I. PENGKAJIAN :A. IDENTITAS KLIEN DAN KELUARGA :

Inisial Pasien U m u r Jenis KelaminAgamaPendidikan PekerjaanStatusGolongan DarahInisial InformanHubungan KeluargaU m u rAlamatPekerjaanTanggal MRS / PukulTanggal Pengkajian / Pukul

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

B. RIWAYAT KEPERAWATAN DAN KESEHATAN KLIEN 1. Keluhan Utama

Keluhan saat MRS................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Keluhan saat ini................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2. Riwayat Penyakit Sekarang................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. Riwayat Penyakit Masa Lalu................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4. Pola Fungsi Kesehatan :a. Pola Persepsi dan Tata Laksana Kesehatan................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

b. Pola Nutrisi dan Metabolik................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

c. Pola Eliminasi................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................d. Pola Tidur dan Istirahat................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................e. Pola Aktifitas dan Istirahat................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................f. Pola sensori dan pengetahuan................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................g. Pola hubungan interpersonal dan peran................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................h. Pola persepsi dan konsep diri (gambaran diri, ideal diri, identitas, harga diri & peran)................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................i. Pola reproduksi dan seksual................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................j. Pola penanggulangan stress................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................k. Pola tata nilai dan kepercayaan................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

C. PEMERIKSAAN FISIK / REVIEW OF SISTEM (ROS)1. Keadaan / penampilan / kesan / umum klien :

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

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

........................................................................................................................................................................................................2. Tanda-tanda vital :

- Suhu Tubuh : ..................oC- Denyut Nadi : ..................kali / menit- Tekanan Darah : ..................mmHg- Respirasi : ..................kali / menit- TB / BB : ..........cm / ........... kg

3. Pemeriksaan Fisik :KepalaRambutWajahMataHidungTelingaMulut & faringLeher

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

4. Pemeriksaan integumen/kulit & kuku................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

5. Pemeriksaan payudara................................................................................................................................................................................................................................................................................................................................................................................................................

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

........................................................................................................................................................................................................6. Pemeriksaan Thoraks / Dada

Inspeksi Thoraks :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

7. Pemeriksaan Paru (Inspeksi, Palpasi, Perkusi, Auskultasi)................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

8. Pemeriksaan Jantung (Inspeksi, Palpasi, Perkusi, Auskultasi)................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9. Pemeriksaan Abdomen (Inspeksi, Auskultasi, Perkusi, Palpasi)................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

10. Pemeriksaan Kelamin dan Daerah Sekitar (bila diperlukan) :a. Pemeriksaan Genetalia........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................b. Pemeriksaan Anus........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

11. Pemeriksaan Muskuloskeletal (ekstremitas) atas & bawah................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

12. Pemeriksaan Neurologi................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

D. PEMERIKSAAN PENUNJANG1. Laboratorium

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

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

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

........................................................................................................................................................................................................2. Radiologi

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

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

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

........................................................................................................................................................................................................E. PENATALAKSANAAN TERAPI

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

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

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

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

F. DIAGNOSA MEDIS................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Lumajang, ............................................Mahasiswa AKPER

(..............................................)NIM


ANALISA DATA

NO DATA PENYEBAB MASALAH

MASALAH KEPERAWATAN1. ......................................................................................................................................................................................................

2. ......................................................................................................................................................................................................

3. ......................................................................................................................................................................................................

4. ......................................................................................................................................................................................................

5. ......................................................................................................................................................................................................

6. ......................................................................................................................................................................................................

7. ......................................................................................................................................................................................................

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

1. ......................................................................................................................................................................................................

2. ......................................................................................................................................................................................................

3. ......................................................................................................................................................................................................

4. ......................................................................................................................................................................................................

5. ......................................................................................................................................................................................................

6. ......................................................................................................................................................................................................

7. ......................................................................................................................................................................................................


INTERVENSI KEPERAWATANNO DX TUJUAN KRITERIA HASIL RENCANA KEPERAWATAN RASIONAL


IMPLEMENTASI KEPERAWATAN

TANGGAL NO DX KEP JAM IMPLEMENTASI


EVALUASI KEPERAWATAN( CATATAN PERKEMBANGAN )

TANGGAL NO DX KEP SOAPIER


EVALUASI KEPERAWATAN( CATATAN PERKEMBANGAN )

NO DX KEP

HARI / TANGGAL

Format Askep Medikal Bedah

Documents

Transcript of Format Askep Medikal Bedah