departemen surgikal

DEPARTEMENKEPERAWATAN SURGIKAL

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FORMAT ASUHAN KEPERAWATAN

PENGKAJIAN 1. Pengumpulan Data

a. Biodata 1) Nama : 2) No Register :.............................................. 3) Jenis Kelamin : ..............................................4) Umur : 5) Status Perkawinan : .............................................6) Pekerjaan : ..............................................7) Agama : 8) Pendidikan Terakhir.......................................... : 9) Alamat : 10)Tanggal MRS : ..............................................11)Tanggal pengkajian..............................................:

b. Diagnosa Medis : ..............................................c. Keluhan Utama :

Saat MRS.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Saat Pengkajian .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

d. Riwayat Penyakit Sekarang ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

e. Riwayat Kesehatan/Penyakit Yang Lalu ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

f. Riwayat Kesehatan Keluarga ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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g. Pola Aktivitas Sehari-hari1) Makan dan minum

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2) Pola eliminasi ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3) Pola istirahat dan tidur ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4) Kebersihan diri ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

h. Riwayat Psikologis ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

i. Pemeriksaan Fisik 1)Keadaan umum.....................................................: 2)Tanda vital :

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3)Pemeriksaan kepala leher :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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4)Pemeriksaan integumen................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

5)Dada dan thorax ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

6)Payudara................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

7)Abdomen ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

8)Genetalia ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9) Ekstremitas ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

j. Pemeriksaan Neurologis ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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k. Pemeriksaan Penunjang................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

l. Terapi/Pengobatan/penatalaksanaan ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Malang, …………….Yang mengkaji,

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A. ANALISA DATANama : ………………………….Usia : ………………………….No. Reg : ………………………….

No Kelompok Data Penyebab Masalah

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B. DIAGNOSA KEPERAWATANNama : ………………………….Usia : ………………………….No. Reg : ………………………….

No Tgl/Jam Diagnosa Tgl/Jam Teratasi TT

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D. INTERVENSI (RENCANA TINDAKAN)Nama : ………………………….Usia : ………………………….No. Reg : ………………………….

Tgl/

Jam

Dx.Kep Kriteria Standart Rencana Tindakan Rasional TT

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Tgl/

Jam

Dx.Kep Kriteria Standart Rencana Tindakan Rasional TT

E. IMPLEMENTASI (PELAKSANAAN)10

Nama : ………………………….Usia : ………………………….No. Reg : ………………………….

Tgl/Jam Dx.Kep Tindakan TT

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F.EVALUASI

Nama : ………………………….Usia : ………………………….No. Reg : ………………………….

Tgl/Jam Dx.Kep Evaluasi TT

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G.CATATAN PERKEMBANGAN

Nama : ………………………….Usia : ………………………….No. Reg : ………………………….

Tgl/Jam Dx.Kep CATATAN PERKEMBANGAN TT

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