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PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :

NIM :

Tempat Pengkajian :

Tanggal :

I. Identitas Klien

Nama : No. RM :

Umur : Pekerjaan :

Jenis Kelamin : Status Perkawinan :Agama : Tanggal MRS :

Peniikan : Tanggal Pengkajian :

Alamat : Sum!er In"ormasi :

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Mobilitas di tempat tidur

Berpindah

Ambulasi / ROM

0. Pola tiur 3 istirahat : se!elum MRS an Saat MRS1. Pola kogniti" 3 perseptual%%%%%..%%%%%%%%%%%%%%%%%%%...

6. Pola persepsi iri%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

7. Pola seksualitas 3 reprouksi%%%%%%%%%%%%%%%%%%%%%%%%

8. Pola peran 3 hu!ungan%%%%%%%%%%%%%%%%%%%%%%%%%%..#9. Pola manajemen koping/stress%%%%%%%%%%%%%%%%%%%%%%%...

##. Sistem nilai 3 ke(akinan%%%%%%%%%%%%%%%%%%%%%%%%%..

IV. Pe(e'i$saan Fisi$

Keaaan umum:%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%...

Tana 5ital:%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

#. Kepala%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%.&. Mata %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..

'. Telinga.%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%...

). iung.%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%..0. Mulut.%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

1. ;eher.%%%%%%%%%%%%%%%%%%%%...................................................

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REN1ANA KEPERAWATAN

NO D- KEPERAWATANPEREN1ANAAN

INTERVENSI RASIONALTUJUAN KRITERIA HASIL

Setela" 2- 3 %a(

$lien a$an 2..

4ses)ai t)%)an

(asin#05

Ha')s ada

indi$at,' nilai

n,'(al ata) !an#

di"a'a&$an

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1ATATAN PERKEMBANGAN

DIAGNOSA KEPERAWATAN sat) dia#n,sa 4di+)at (asin#0 dia#n,sa6 / dia#n,sa / le(+a' te'sendi'i7 %an#an di8a(&)'5

WAKTU IMPLEMENTASI PARAF EVALUASI

Isin!a tan##al

dan %a(

JAM

SOAP

Pa'a9

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RESUME KEPERAWATAN

Na(a NO RM

U()' Dia#n,sa Medis

Kel)"an Uta(a Tan##al MRS

Ria!at Pen!a$it Se$a'an# Tan##al Res)(e

K,ndisi U()( Meli&)ti $,ndisi )()( dan TTV

Wa$t) Dia#n,sa Ke&e'aatan Inte':ensi I(&le(entasi E:al)asi

Tan##al

dan

%a(

DS

DO

D-. Ke&

Ja(

SOAP

Pa'a9