PENGKAJIANASUHAN KEPERAWATAN MEDIKAL BEDAH STIKES

MUHAMMADIYA BANJARMASIN

NAMA MAHASISWA : MUHAMMAD HIPNI

N P M : -

TEMPAT PARAKTIK_: Ruang ICU RSUD Ulin

TANGGAL : 23 s/d 25 Maret 2015

A. IDENTITAS KLIEN

1) Nama    : ________________________________________________

2) Umur : ________________________________________________

3) Jenis kelamin : ________________________________________________

4) Alamat : ________________________________________________

5) Agama : ________________________________________________

6) Pekerjaan : ________________________________________________

7) Diagnosa medik : ________________________________________________

8) No. Medical Record : ________________________________________________

9) Tanggal masuk RS : ________________________________________________

10) Tanggal pengkajian : ________________________________________________

Identitas Penanggung jawab

1) Nama : ________________________________________________

2) Umur : ________________________________________________

3) Hubungan dengan klien : ________________________________________________

B. KELUHAN UTAMA

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C. RIWAYAT PENYAKIT

1) Riwayat penyakit sekarang 

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PARAF CI

2) Kondisi saat dikaji (P Q R S T) :

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3) Riwayat penyakit dahulu

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4) Riwayat keluarga keluarga

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D. PEMERIKSAAN FISIK

1. Keadaan umum

a. Kesadaran :

b. GCS :

c. Tanda-Tanda vital :

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2. Pengkajian B1-B6

a. B1 (Breating)

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b. B2 (Blood)

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c. B3 (Brain)2

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d. B4 (Bladder)

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e. B5 (Bowel)

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f. B6 (Bone)

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E. KEBUTUHAN FISIK, PSIKOSOSIAL DAN SPRITUAL

a. Aktifitas dan istirahat :

Di rumah :

Di RS :

b. Personal Hygine

Di rumah :

Di RS :

c. Nutrisi

Di rumah :

Di RS :

d. Eliminasi

Di rumah :

Di RS :

e. Seksualitas

Di rumah :

Di RS :

f. Psikososial

Di rumah :

Di RS :

3

g. Spritual

Di rumah :

Di RS :

F. DATA PENUNJANG

G. THERAPHY

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