KEPERAWATAN MEDIKAL BEDAH

PROGRAM PENDIDIKAN PROFESI NERS

PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA
A. Pengkajian
1. Identitas
Pasien
Nama
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Umur
: ........................................
Jenis kelamin
: ........................................
Pendidikan
: ........................................
Pekerjaan
: ........................................
Status perkawinan
: .......................................
Agama
: .......................................
Suku
: .......................................
Alamat
: .......................................
Tanggal masuk
: ........................................
Tanggal pengkajian
: ........................................
Sumber Informasi : ........................................
Diagnosa masuk : ........................................
Penanggung
Nama
: ........................................
Hubungan dengan pasien
: ........................................
2. Riwayat keluarga
Genogram (kalau perlu)

Keterangan genogram
: Laki-laki
: Perempuan
: Sudah meninggal
: Tinggal serumah
: Klien
3. Status kesehatan

a. Status Kesehatan Saat Ini

Keluhan utama (saat MRS dan saat ini)
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Alasan masuk Rumah Sakit dan perjalanan Penyakit saat ini
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Upaya yang dilakukan untuk mengatasinya
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b. Status Kesehatan Masa Lalu
Penyakit yang pernah dialami
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Pernah dirawat
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Riwayat alergi
: Ya
Tidak
Jelaskan :
Riwayat tranfusi : Ya
Tidak
Kebiasaan :
Merokok
Ya
Tidak
Sejak: Jumlah:
Minum kopi
Ya
Tidak
Sejak:
Jumlah:
Penggunaan Alkohol
Ya
Tidak
Sejak:
Jumlah:
Lain-lain:
Jelaskan :
4. Riwayat Penyakit
Keluarga :.................................................................................

5. Diagnosa Medis dan

therapy .........................................................................................
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6. Riwayat Penyakit Saat Ini (11 Pola Fungsional Gordon)
a. Pemeliharaan dan persepsi terhadap kesehatan
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b. Nutrisi/ metabolic

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c. Pola eliminasi
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d. Pola aktivitas dan latihan
Kemampuan perawatan diri
0
1
2
3
4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu
orang lain dan alat, 4: tergantung total.

keterangan: .............................................................................
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e. Pola tidur dan istirahat
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f. Pola kognitif-perseptual
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g. Pola persepsi diri/konsep diri
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h. Pola seksual dan reproduksi
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i. Pola peran-hubungan
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j. Pola manajemen koping stress

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k. Pola nilai dan keyakinan
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7. Riwayat Kesehatan dan Pemeriksaan Fisik
Keadaan umum : Baik
Sedang Lemah
TTV

TD:

Nadi :

Kesadaran:

Suhu:

RR:

a.Kulit, Rambut dan Kuku

Distribusi rambut :
Lesi

Ya

Tidak

Warna kulit

Ikterik

Sianosis Kemerahan

Hangat

Panas

Pucat
Akral
Dingin
Turgor:

Dingin

kering

Oedem

Ya

Warna kuku:

Tidak
Pink

Lokasi:

Sianosis lain-lain

Lain-lain:
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b.Kepala dan Leher
Kepala

Simetris Asimetris,

Lesi:

ya

Tidak

Deviasi trakea

Ya

Tidak

Pembesaran kelenjar tiroid

Ya

Tidak

Lain-lain:
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c. Mata dan Telinga
Gangguan pengelihatan

Ya

Tidak

Menggunakan kacamata

Ya

Tidak

Visus:
Pupil

Isokor

Anisokor

Anemis

Ikterus

Ukuran:
Sklera/ konjungtiva
Gangguan pendengaran

Ya

Tidak

Menggunakan alat bantu dengar

Ya

Tidak

Tes weber:
Tes Rinne:
Tes Swabach:

Lain-lain:
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d.Sistem Pernafasan:
Batuk:

Ya

Tidak

Sesak:

Ya

Tidak

Inspeksi: ..................................................................................

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Palpasi:

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Perkusi:

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Auskultasi:

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Lain-lain:
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e.Sistem Kardiovaskular :

Nyeri dada

Ya

Tidak

Palpitasi

Ya

Tidak

CRT

< 3 dtk

> 3 dtk

Inspeksi: ....................................................................................
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Palpasi: ......................................................................................
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Perkusi: ......................................................................................
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Auskultasi: .................................................................................
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Lain-lain:

f. Payudara Wanita dan Pria:

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g. Sistem Gastrointestinal:
Mulut

Bersih

Mukosa

Lembab Kering

Pembesaran hepar

Ya

Abdomen

Meteorismus

tekan
Peristaltik:
Lain-lain :

x/mnt

Kotor

Berbau
Stomatitis

Tidak
Asites

Nyeri

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h. Sistem Urinarius :
Penggunaan alat bantu/ kateter Ya
Kandung kencing, nyeri tekan
Gangguan

Anuria

Tidak
Ya

Tidak

Oliguria Retensi

Inkontinensia
Nokturia Lain-lain:
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i. Sistem Reproduksi Wanita/Pria :
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j. Sistem Saraf:
GCS:

Eye:

Verbal:

Kaku kuduk

Kernig

Motorik:
Rangsangan meningeal
Brudzinski I

Brudzinski II

Refleks fisiologis

Patela

Trisep

Bisep

Achiles
Refleks patologis
Oppenheim

Babinski Chaddock

Rossolimo

 Gordon

Schaefer Stransky

Gonda
Gerakan involunter :
Lain-lain:

k. Sistem Muskuloskeletal:
Kemampuan pergerakan sendi

Bebas

Terbatas

Deformitas

Ya

Tidak

Lokasi:

Fraktur

Ya

tidak

Lokasi:

Kekakuan

Ya

Tidak

Nyeri sendi/otot

Ya

Tidak

Kekuatan otot :
Lain-lain

l. Sistem Imun:
Perdarahan Gusi

Ya

Tidak

Perdarahan lama

Ya

Tidak

Pembengkakan KGB

Ya

Tidak

Lokasi:
Keletihan/kelemahan

Ya

Tidak

Lain-lain:

m. Sistem Endokrin:
Hiperglikemia

Ya

Tidak

Hipoglikemia

Ya

Tidak

Luka gangrene

Ya

Tidak

Lain-lain:

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8.

Pemeriksaan Penunjang