KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI ILMU KEPERAWATAN (PSIK)

STIKES TRI MANDIRI SAKTI BENGKULU
FORMAT PENGKAJIAN
Nama Mahasiswa

Tanggal praktek

Nomor NPM

Tempat praktek

1. Data Biografi
Identitas Klien:
Nama

: ..

No Register :

.
Umur

: ..

Suku/ bangsa

: ..

Status perkawinan

: ..

Agama

: ..

Pendidikan

: ..............................

Pekerjaan

: ..............................

Alamat

: ..............................

Tanggal masuk RS

: ..............................

Tanggal pengkajian

: ..............................

Catatan kedatangan

: Kursi roda (

), Ambulans (

), Brankar (

Keluarga Terdekat yang dapat dihubungi :

Nama/ Umur

: .............................

Telepon : .........................
Pendidikan

: .............................

Pekerjaan

: .............................

Alamat

: .............................

Sumber informasi

: .............................

No

2. Riwayat Kesehatan/ Keperawatan

1) Keluhan utama/ alasan masuk RS :
........................................................................................................................
..................
......................................................................................................................
......................................................................................................................
........................................
......................................................................................................................
....................
2) Riwayat kesehatan sekarang :
Faktor
pencetus : ........................................................................................................
......
........................................................................................................................
..................
Sifat keluhan (mendadak/perlahan- lahan/ terus menerus/ hilang timbul
atau berhubungan dengan
waktu) : ..........................................................................................
........................................................................................................................
..................
........................................................................................................................
..................
Lokalisasi dan sifatnya (menjalar/ menyebar/ berpindah- pindah/ menetap)
:
.......................................................................................................................
..................
........................................................................................................................
..................
Berat ringannya keluhan (menetap/ cenderung bertambah atau berkurang) :
........................................................................................................................
..................

........................................................................................................................
..................
Lamanya
keluhan : ........................................................................................................
...
........................................................................................................................
..................
Upaya yang telah dilakukan untuk
mengatasi : ...............................................................
........................................................................................................................
..................
Keluhan saat pengkajian :
....

..

..

..

..
Diagnosa medik :
..........................................................
Tanggal .............................................................
..........................................................
Tanggal .............................................................
3) Riwayat Kesehatan Dahulu
Penyakit yang pernah dialami (jenis penyakit, lama dan upaya untuk
mengatasi, riwayat masuk
RS) : .........................................................................................................

........................................................................................................................
..................
........................................................................................................................
..................
Alergi : ...........................................................................................................
..................
........................................................................................................................
..................
Obat- obatan
(Resep/ obat bebas)

Dosis

Dosis terakhir

Frekuensi

4) Riwayat Kesehatan Keluarga :

Penyakit menular atau keturunan dalam
keluarga : .........................................................
........................................................................................................................
..................
........................................................................................................................
..................
3. Pola Fungsi Kesehatan (Gordon) :
1) Pola persepsi dan pemeliharaan kesehatan
Persepsi terhadap
penyakit :.............................................................................................
........................................................................................................................
..................
........................................................................................................................
..................
Penggunaan :

Tembakau (bungkus/ hari, pipa, cerutu, berapa lama, kapan

berhenti) :..........................
........................................................................................................................
..................
Alkohol (jenis,
jumlah/hari/minggu/bulan) : ...................................................................
........................................................................................................................
..................
Alergi (obat-obatan, makanan, plester,
dll) : ...................................................................
Reaksi
alergi ..............................................................................................................
......
2) Pola nutrisi dan metabolisme
Diet/ suplemen
khusus : ...................................................................................................
Instruksi diet
sebelumnya : ..............................................................................................
Nafsu makan (normal, meningkat,
menurun) : ................................................................
........................................................................................................................
..................
Penurunan sensasi kecap, mual-muntah,
stomatitis : .......................................................
........................................................................................................................
..................
Fluktuasi BB 6 bulan terakhir (naik/
turun) : ...................................................................
........................................................................................................................
..................
Kesulitan menelan
(disfagia) : .........................................................................................

Gigi (lengkap/ tidak, gigi

palsu) : ....................................................................................
........................................................................................................................
..................
Riwayat masalah kulit/ penyembuhan (ruam, kering, keringat berlebihan,
penyembuhan
abnormal : ................................................................................................
........................................................................................................................
..................
Jumlah minum/ 24 jam dan jenis (kehausan yang
sangat) ..............................................
........................................................................................................................
..................
Frekuensi
makan : ..........................................................................................................
..
Jenis
makanan : ......................................................................................................
..........
Pantangan/
alergi : ............................................................................................................
Lainlain : ...............................................................................................................
.........
........................................................................................................................
..................
3) Pola Eliminasi
Buang air besar (BAB) :
Frekuensi

: ......................................

Waktu : .........................................
Warna

: ......................................

Konsistensi : .................................

Kesulitan (diare, konstipasi,

inkontinensia) : .......................................................
............................................................................................................
..................
Buang air kecil (BAK) :
Frekuensi

: ......................................

Warna : .........................................
Kesulitan (disuria, nokturia, hematuria, retensi,
inkontinensia) : ........................
............................................................................................................
...................
Alat bantu (kateter intermitten, indweling, kateter
eksternal) : .......................................
........................................................................................................................
..................
Lainlain : ........................................................................................................................
........................................................................................................................
..................
4) Pola aktivitas dan latihan
Kemampuan perawatan diri :
0 = Mandiri

3 = Dibantu orang lain dan peralatan

1 = Dengan alat bantu

4 = Ketergantungan/ tidak mampu

2 = Dibantu orang lain

Kegiatan/ aktivitas
Makan/ minum
Mandi
Berpakaian/ berdandan
Toileting
Mobilisasi ditempat tidur
Berpindah
Berjalan
Menaiki tangga
Berbelanja

Memasak
Pemeliharaan rumah
Alat bantu (kruk, pispot, tongkat, kursi
roda) : ................................................................
Kekuatan
otot : ..............................................................................................................
...
........................................................................................................................
...................
Kemampuan
ROM : .........................................................................................................
........................................................................................................................
..................
Keluhan saat
beraktivitas : ...............................................................................................
........................................................................................................................
..................
Lainlain : ...............................................................................................................
.........
5) Pola istirahat dan tidur
Lama tidur : .................. jam/ malam .................... tidur
siang .................. tidur sore
Waktu : ..........................................................................................................
...................
Kebiasaan menjelang
tidur : ............................................................................................
Masalah tidur (insomnia, terbangun dini, mimpi
buruk) : ...............................................
........................................................................................................................
..................

Lain- lain (merasa segar/ tidak setelah

bangun) : ............................................................
........................................................................................................................
..................
6) Pola kognitif dan persepsi
Status mental (sadar/ tidak, orientasi baik/
tidak) : .........................................................
........................................................................................................................
..................
Bicara : Normal (

), tak jelas (

), gagap (

), aphasia ekspresif (

Kemampuan berkomunikasi : Ya (

), Tidak (

)
Kemampuan memahami : Ya (
Tingkat ansietas : Ringan (
Pendengaran : DBN (
dengar (

), Tidak (

), Sedang (

), tuli (

)
), berat (

), panik (

) kanan/ kiri, tinitus (

), alat bantu

Penglihatan (DBN, buta, katarak, kacamata, lensa kontak,

dll) : ....................................
........................................................................................................................
..................
Vertigo : .........................................................................................................
..................
Ketidaknyamanan/ nyeri (akut/
kronik) : .........................................................................
........................................................................................................................
..................
Penatalaksanaan
nyeri : ...................................................................................................
........................................................................................................................
..................

Lainlain : ...............................................................................................................
........
7) Persepsi diri dan konsep diri
Perasaan klien tentang masalah kesehatan
ini : ...............................................................
........................................................................................................................
..................
Lainlain : ...............................................................................................................
........
........................................................................................................................
..................
8) Pola peran hubungan
Pekerjaan : .....................................................................................................
..................
Sistem pendukung : pasangan (
keluarga serumah (

), tetangga/ teman (

), keluarga tinggal berjauhan (

), tidak ada (

),

Masalah keluarga berkenaan dengan perawatan di

RS : .................................................
........................................................................................................................
..................
Kegiatan
sosial : ............................................................................................................
..
........................................................................................................................
..................
Lainlain : ...............................................................................................................
........
9) Pola seksual dan reproduksi

Tanggal menstruasi akhir

(TMA) : ..................................................................................
Masalah
menstruasi : ...................................................................................................
....
Pap Smear
terakhir : ........................................................................................................
Masalah seksual b.d
penyakit : ........................................................................................
Lainlain : ...............................................................................................................
........
10) Pola koping dan toleransi stress
Perhatian utama tentang perawatan di RS atau penyakit (finansial,
perawatan diri) : ....
........................................................................................................................
..................
........................................................................................................................
..................
Kehilangan/ perubahan besar dimasa
lalu : .....................................................................
Hal yang dilakukan saat ada masalah (sumber
koping) : ................................................
........................................................................................................................
..................
Penggunaan obat untuk menghilangkan
stress : ..............................................................
Keadaan emosi dalam sehari- hari (santai/
tegang) : .......................................................

Lainlain : ...............................................................................................................
........
11) Keyakinan dan kepercayaan
Agama : .........................................................................................................
..................
Pengaruh agama dalam
kehidupan : ................................................................................
........................................................................................................................
..................
4. Pemeriksaan Fisik :
1) Keadaan umum :
Penampilan
umum : .........................................................................................................
Klien tampak sehat/ sakit/ sakit
berat : ............................................................................
Kesadaran

: ....................................... GCS ......................

BB

: ................... Kg

TB

: ................... cm

2) Tanda- tanda vital :

TD

: ..................... mmHg

ND

: ..................... x/menit

RR

: ..................... x/menit

: ..................... oC

3) Kulit
Warna kulit (sianosis, ikterus, pucat, eritema,
dll) : ........................................................
Kelembapan : ................................................................................................
...................

Turgor
kulit : .............................................................................................................
.......
Ada/tidaknya
oedema : ....................................................................................................
4) Kepala/ rambut
Inspeksi
: ..........................................................................................................
......
Palpasi
: ..........................................................................................................
......
5) Mata
Fungsi penglihatan

: .............................................. Palpebra

terbuka / tertutup
Ukuran pupil

: .............................................. Isokor / an isokor

Konjungtiva

: ..............................................

Sklera : ......................................
Lensa / iris
: ....................................................................................................
Oedema palpebra
: ....................................................................................................
6) Telinga
Fungsi pendengaran : ................................. Fungsi
keseimbangan ..............................
Kebersihan

: .................................

Sekret .......................................................
Daun telinga

: .................................

Mastoid ....................................................
7) Hidung dan sinus
Inspeksi
: ....................................................................................................

Fungsi penciuman
: ....................................................................................................
Pembengkakan

: ......................................

perdarahan : ........................................
Kebersihan

: ......................................

sekret : ................................................
8) Mulut dan tenggorok
Membran mukosa : ............................................ kebersihan
mulut ................................
Keadaan
gigi : ..............................................................................................................
...
Tanda radang (bibir, gusi,
lidah) : ...................................................................................
Trismus : ........................................................................................................
..................
Kesulitan
menelan : .......................................................................................................
..
9) Leher
Trakea (simetris/
tidak) : .................................................................................................
Karotid
bruit : .............................................................................................................
.....
JVP : ..............................................................................................................
..................
Kelenjar
limfe : ............................................................................................................
...

Kelenjar
tiroid : ............................................................................................................
...
Kaku
kuduk : ...........................................................................................................
........
10) Thorak / paru
Inspeksi
: ..........................................................................................................
.....
Palpasi

: ..............................................................................................

.................
Perkusi

: ..............................................................................................

.................
Auskultasi

: ..............................................................................................

.................
11) Jantung
Inspeksi
: ..........................................................................................................
.....
Palpasi

: ..............................................................................................

.................
Perkusi

: ..............................................................................................

.................
Auskultasi

: ..............................................................................................

.................
12) Abdomen
Inspeksi
: ..........................................................................................................
.....
Auskultasi
.................

: ..............................................................................................

Perkusi

: ..............................................................................................

.................
Palpasi

: ..............................................................................................

.................
13) Genetalia
: ..........................................................................................................
.....
14) Rektal
: ..........................................................................................................
.....
15) Ekstremitas
Ekstremitas
atas : ............................................................................................................
Ekstremitas
bawah : ........................................................................................................
ROM : ............................................................................................................
.................
Kekuatan
otot : ..............................................................................................................
.
16) Vaskular perifer
Capilary Refille
: ...................................................................................................
Clubbing

: ..................................................................................

.................
Perubahan warna (kuku, kulit, bibir) :

17) Neurologis
Kesadaran (GCS) :
..
Status mental : ..
...

Motorik (kejang, tremor, parese dan

paralisis) : .............................................................
Sensorik :

Tanda rangsang meningeal :

...
Saraf kranial :
.
Reflek fisiologis :

Reflek patologis :

5. Pemeriksaan Penunjang
(dibuat setiap dilakukan pemeriksaan berdasarkan tanggal dilakukan)
Pemeriksaan diagnostik

...

...

...

...

...

...

...

...


...

...

...
Pemeriksaan laboratorium

...

...

...

...

...

...

...

...

...

...

...

...


...

...

...
6. Penatalaksanaan Pengobatan

...

...

...

...

...

...

...

...

...