FORMAT

ASUHAN KEPERAWATAN MEDIKAL BEDAH

Tanggal pengkajian: ____________ Pukul: ______

Nama Mahasiswa : ____________

A. PENGKAJIAN
I. Identitas
1. Klien 2. Penanggung Jawab
Inisial Klien: ………………….............. Nama: …………………
Umur: ……………………….................. Umur: ………………….
Jenis Kelamin: P/ L Pekerjaan: ………….
Suku/Bangsa: ……………................ Pendidikan: …………
Agama: ………………………............... Alamat: ……………….
Pekerjaan: ………………........…....... …………………………….
Pendidikan: ………………................. Hubungan keluarga
Alamat: ………………………............... ……………………………..

Tgl Masuk RS: ……………………………. Diagnosa Medis:

No. MR: …………………………………….. ...................................................

II. Riwayat Perawatan

1. Keluhan Utama …………………………………………………...........................................................
2. Riwayat Penyakit
a. Riwayat Kesehatan/Keperawatan Sekarang
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b. Riwayat Kesehatan/Keperawatan Dahulu:

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c. Riwayat Kesehatan/Keperawatan Keluarga:

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Format Pengkajian KMB

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 Genogram Keluarga (3 generasi):

Keterangan:
O= Perempuan
= Laki-laki
X= Meninggal
= Pasien
….= Serumah
 = Bercerai

d. Riwayat Kesehatan Lingkungan

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e. Riwayat Psikososial
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III. Pola Fungsi Kesehatan

1. Pola Persepsi-pemeliharaan Kesehatan
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2. Pola Aktivitas-Latihan
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3. Pola Nutrisi dan Metabolik

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4. Pola Eliminasi
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5. Pola Tidur-Istirahat
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6. Pola Kognitif-perseptual
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7. Pola Toleransi-Koping Stres

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8. Pola Persepsi Diri/ Konsep Diri

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9. Pola Seksual-Reproduktif
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Format Pengkajian KMB

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 10. Pola Hubungan dan Peran
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11. Pola Nilai dan Keyakinan

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IV. Observasi dan pemeriksaan fisik

1. Keadaan Umum :…………………………...........................………………………………………………………

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

3. Pemeriksaan kulit,rambut dan kelenjar getah bening

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4. Pemeriksaan Kepala dan Leher

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5. Pemeriksaan Dada
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6. Pemeriksaan Abdomen
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7. Pemeriksaan Anggota Gerak dan Neurologis

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V. Hasil Pemeriksaan Penunjang

1. Pemeriksaan laboratorium

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Format Pengkajian KMB

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 2. Pemeriksaan diagnostik

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VI. Terapi
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Nama dan Tanda tangan Mahasiswa

(..................................................)

B. ANALISA DATA

Data Fokus Kemungkinan Penyebab Masalah

(Subyektif & Obyektif)

Format Pengkajian KMB

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C. DAFTAR DIAGNOSA KEPERAWATAN

No Diagnosa Keperawatan (Secara Prioritas)

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D. Intervensi Keperawatan

N Diagnosa Tujuan & Kriteria Hasil Intervensi Keperawatan Rasional Nama &
o Keperawatan Paraf

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E. IMPLEMENTASI

No Diagnosa Tanggal & Jam Pelaksanaan Evaluasi Tindakan/ Respon Pasien Nama &
Keperawatan Paraf

Format Pengkajian KMB

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F. EVALUASI KEPERAWATAN

No Tanggal Catatan Perkembangan Nama &

DK & Jam (SOAP/SOAPIER) Paraf

Format Pengkajian KMB

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 RENCANA PEMULANGAN KLIEN

(DISCHARGE PLANNING)

Format Pengkajian KMB

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