NURSING STUDY PROGRAM DIPLOMA III

MEDICAL SURGICAL NURSING ASSESSMENT FORMAT

STUDENT NAME : ...................................................................................................................

NIM : ...................................................................................................................
ROOM : ...................................................................................................................

1. BIODATA
Name : ..........................................................................................................
Age : ..........................................................................................................
Gender : ..........................................................................................................
Religion : ..........................................................................................................
Address : ..........................................................................................................
Education : ..........................................................................................................
Profession / job : ..........................................................................................................
Date of entry : ..........................................................................................................
Date of assessment : ..........................................................................................................
Medical diagnoses : ..........................................................................................................

2. MAIN COMPLAINT
Hospitalized : ......................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
During the assessment : ......................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
3. HISTORY OF DISEASES OF THE PAST
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................

4. FAMILY HEALTH HISTORY

.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................

5. PSYCHO-SOCIAL HISTORY AND SPIRITUAL

.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
6. PATTERNS DAILY ACTIVITIES (eating, resting, sleeping, elimination, activity,
hygiene, and sexual)

Activity Daily Living

No. At Home At Hospital
(ADL)
1. Meeting the needs of Eating/Drinking Eating/Drinking
Nutrition and Fluids Eating : .............../day Eating : .............../day
Type : Type :

Drink: …………cc / day Drink: …………cc / day

Type : Type :

Abstinence : Abstinence :

Difficulty Eating / Difficulty Eating /

Drinking : Drinking :

Efforts to overcome the Efforts to overcome the

difficulties : difficulties :

2. Elimination Pattern Urination : …………/day Urination : …………/day

Total : ………… cc Total : ………… cc
Defecate : …………/day Defecate : …………/day
Consistency : Consistency :

Problems and how to Problems and how to

solve: solve:
3. The pattern of restful Eating Time : Eating Time :
sleep Lunch : ............... Lunch : ...............
Afternoon : .................. Afternoon : ..................
Tonight : ............... Tonight : ...............

Sleep Disorders : Sleep Disorders :

Use of Sleep Medicine : Use of Sleep Medicine :

4. Personal Hygiene 1. Frequency bath : 1. Frequency bath :

......... x/day ......... x/day

2. The frequency of hair 2. The frequency of hair

wash : wash :
......... x/day ......... x/day

3. The frequency of 3. The frequency of

brushing your teeth : brushing your teeth :
......... x/day ......... x/day

4. The state of the nail : 4. The state of the nail :

5. Change clothes : 5. Change clothes :

......... x/day ......... x/day
5. Other Activities Routine Activities : Routine Activities :
 Activity undertaken in Activity undertaken in
leisure time : leisure time :

6. GENOGRAM

7. STATE / APPEARANCE / GENERAL IMPRESSION OF PATIENTS

8. VITAL SIGNS
Temperature : ……………….. ° C
Pulse : ……………….. x / min
Blood Pressure : ……………….. mmHg
Respiratory : ……………….. x / min
Height / Weight : ………… Cm, ………… Kg
9. EXAMINATION
A. Cardiovascular System
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
B. Respiration System
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
C. The Digestive System
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
D. Urinary System
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
 .......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................

10. TREATMENT / THERAPY

.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
 DATA ANALYSIS

Patient Name : ………………………..

No. RM : ………………………..
Data Focus Problem Etiology
 NURSING DIAGNOSES

Patient Name : ………………………..

No. RM : ………………………..
Date of issue is
No. Date found problem Dx Initials
resolved
 NURSING INTERVENTION

Patient Name : ………………………..

No. RM : ………………………..
NIC (Nursing Interventions
Day / Date Dx NOC (Nursing Outcomes Classification) Initials
Classification)
 NURSING IMPLEMENTATION AND EVALUATION

Patient Name : ………………………..

No. RM : ………………………..
No.
Day / Date Time Implementation Time Evaluation
Dx