BAGIAN KEPERAWATAN MEDIKAL BEDAH FORMAT PENGKAJIAN KESEHATAN UJIAN PRAKTEK



BAGIAN KEPERAWATAN MEDIKAL BEDAH
FORMAT PENGKAJIAN KESEHATAN
UJIAN PRAKTEK
Nama Klien     :                                                                                   No. RM   :
Umur               :                                                                                   Dx. Medis :

A.  PENGKAJIAN
  1. Riwayat.Kesehatan......................................................................................................................
1.      RKS............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................
2.      RKD....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
3.      RKK..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2.PENGKAJIAN FUNGSIONAL GORDON
·         Pola Persepsi dan Penanganan Kesehatan ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................................................
·         Pola  Nutrisi  &  Metabolik ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Pola Eliminasi ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Pola Aktivitas-Latihan ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Pola Istirahat & Tidur ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Pola Kognitif dan Persepsi ........................................................................................................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................
·         Pola Persepsi Diri-Konsep Diri
..................................................................................................................................................
..................................................................................................................................................
......................................................................................................................................................................................................................................................................................................
·         Pola Peran Hubungan ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Pola Seksualitas-Reproduksi ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Pola Koping-Tolaransi Stess ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Pola Nilai-   Kepercayaan ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

PEMERIKSAAN FISIK
·         Tanda Vital ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Kulit dan Kepala ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Leher .........................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Thorak ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Jantung ...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Abdomen ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Genetalia ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Rectal ........................................................................................................................................................................................................................................................................................................................................................................................................................................................
·         Muskuloskeletal ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................


PEMERIKSAAN PENUNJANG
.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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WEB OF COUTION (WOC)
























CATATAN PERKEMBANGAN
Hari / tanggal       : .................................................                                                                        Ruangan     : .......................
Nama                   : .................................................                                                                        No. RM      : .......................
Diagnosa Keperawatan
Implementasi
Evaluasi
Perawat & Paraf



















































ANALISA  DATA
No
DATA
DIAGNOSA



































NURSING OUTCOMES & INTERVENTION CLASSIFICATION
No
Diagnosa Keperawatan (NANDA)
Perencanaan
NOC
NIC

































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