FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa
NIM
A. Identitas Klien
Nama
Usia
Jenis Kelamin
Alamat
Status Pernikahan
Agama
Suku
Pendidikan
Pekerjaan
Lama Bekerja

:
:

Tempat Praktek
Tanggal Praktek

:
:

: ......................................... No. RM
: .................................
: ............................................ Tgl Masuk
: ................................
: ......................................... Tgl Pengkajian
: ................................
: ............................................. Sumber Informasi : ................................
:........................................... Nama keluarga dekat yang
: .......................................... dapat dihubungi
: ................................
: ........................................... Status
: ................................
: ........................................... Alamat
: ................................
: ........................................... Pendidikan
: ................................
: ............................................. Pekerjaan
: ................................

B. Status Kesehatan Saat Ini

1. Keluhan Utama
....................................................................................................................................................
2. Lama keluhan
.................................................................................................................................................
3. Kualitas keluhan
.................................................................................................................................................
4. Faktor pencetus
.................................................................................................................................................
5. Faktor pemberat
.................................................................................................................................................
6. Upaya yang telah dilakukan
.................................................................................................................................................
7. Diagnosa Medis
a. .................................................................................. Tanggal
b. .................................................................................. Tanggal
c. .................................................................................. Tanggal
8. Keluhan saat Masuk Rumah Sakit
.................................................................................................................................................
9. Keluhan Saat Pengkajian
.................................................................................................................................................
10. Keluhan Lain/Penyerta
.................................................................................................................................................
11. Riwayat Kesehatan Saat Ini
Saat MRS
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Format Pengkajian KMB/AKPER-NTB/2015

Saat Pengkajian
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C. Riwayat Kesehatan Terdahulu
1. Penyakit yang pernah dialami
a. Kecelakaan (jenis & waktu)
...................................................................................................................................................
b. Operasi (jenis & waktu)
:
...................................................................................................................................................
c. Penyakit
Kronis
: .........................................................................................................................
......
Akut
: .........................................................................................................................
......
2. Alergi (obat, makanan, plester, dll) :
Tipe
Reaksi
Tindakan
.......................................
......................................
..........................................
.......................................
......................................
..........................................
.......................................
......................................
..........................................
3. Kebiasaan
Jenis
Frekwensi
Jumlah
Lamanya
Merokok
............................
............................
............................
Kopi
............................
............................
............................
Alkohol
............................
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4. Obat-obat yang digunakan
Jenis
Lamanya
Dosis
.......................................
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..........................................
D. Riwayat Keluarga
.......................................................................................................................................................
.......................................................................................................................................................
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.......................................................................................................................................................
Genogram (minimal 3 generasi, riwayat penyakit keluarga)

Format Pengkajian KMB/AKPER-NTB/2015

E. Riwayat Lingkungan
Jenis
Kebersihan
Bahaya kecelakaan
Polusi
Ventilasi
Pencahayaan

Rumah
.......................................
.......................................
.......................................
.......................................
.......................................

Pekerjaan
......................................
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Rumah
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Rumah Sakit
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F. Pola Aktivitas Latihan

Makan/Minum
Mandi
Berpakaian/berdandan
Toileting
Mobilitas di tempat tidur
Berpindah
Berjalan
Naik Tangga

Pemberian Skor : 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain (1< orang), 3 =
dibantu orang lain (>1 orang), 4 = tidak mampu
G. Pola Nutrisi Metabolik

Jenis diit/ makanan

Frekwensi/pola
Porsi yang dihabiskan
Komposisi menu
Pantangan
Nafsu makan
Frekwensi BB 6 bln terakhir
Jenis minuman
Frekwensi/pola minum
Gelas yang dihabiskan
Sukar menelan (padat/cair)
Pemakaian gigi palsu (area)
Riw. mslh penyembuhan luka

Rumah
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Rumah Sakit
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Rumah

Rumah Sakit

.........................................
.........................................
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H. Pola Eliminasi

BAB
- Frekwensi/pola
- Konsistensi
- Warna & Bau

Format Pengkajian KMB/AKPER-NTB/2015

Kesulitan
Upaya Mengatasi
BAK
- Frekwensi/pola
- Konsistensi
- Warna & bau
- Kesulitan
- Upaya mengatasi

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I. Pola Tidur Istirahat

Rumah
Rumah Sakit
Tidur siang : Lamanya
.........................................
...........................................
Jam ......s/d ................................................
...........................................
Kenyamanan setelah tidur .............................
...........................................
Tidur malam: Lamanya
.........................................
...........................................
Jam ......s/d .......
.........................................
...........................................
Kenyamanan setelah tidur .............................
...........................................
Kebiasaan sebelum tidur :
.........................................
...........................................
Kesulitan
:
.........................................
...........................................
Upaya yg dilakukan
:
.........................................
...........................................

J. Pola Kebersihan Diri

Jenis
Mandi : Frekwensi
Penggunaan sabun
Keramas : Frekwensi
Gosok gigi : Frekwensi
Penggunaan odol
Kesulitan
Upaya yang dilakukan

Rumah
.........................................
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.........................................
.........................................
.........................................

Rumah Sakit
...........................................
...........................................
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...........................................
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...........................................
...........................................

K. Pola Toleransi-koping stress

1. Pengambilan keputusan : ( ) Sendiri
( ) Dibantu orang lain, Sebutkan .........................
2. Utama terkait perawatan di RS atau penyakit : biaya, perawatan diri dll)
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
3. Hal yang biasa dilakukan jika stress/menghadapi masalah
..............................................................................................................................................
4. Harapan setelah menjalani perawatan
..............................................................................................................................................
5. Perubahan yang dirasa setelah sakit
..............................................................................................................................................
L. Pola peran hubungan
1. Peran dalam keluarga
..............................................................................................................................................
2. Sistem pendukung :
suami/istri/anak/tetangga/teman/saudara
Tidak ada/Lain-lain, sebutkan ........................................................
3. Kesulitan dalam keluarga
( ) Hub. dengan orang tua
( ) Hub. dengan pasangan
Format Pengkajian KMB/AKPER-NTB/2015

( ) Hub. dengan sanak saudara

( ) Hub. dengan anak
( ) Lain-lain, sebutkan : .........................................................................................
4. Masalah peran/hubungan dengan keluarga selama dirawat di RS
..............................................................................................................................................
5. Upaya yang dilakukan untuk mengatasi
..............................................................................................................................................
M. Pola Komunikasi
1. Bicara
( ) Normal
( ) Bahasa utama : .........
( ) Tidak Jelas
( ) Bahasa Daerah
( ) Bicara berputar-putar
( ) Rentang perhatian
( ) Mampu mengerti pembicaraan orang lain ( ) Afek
2. Tempat tinggal
( ) Sendiri
( ) Kos/Asrama
( ) Bersama orang lain, yaitu : ..........................................................................................
3. Kehidupan keluarga
a. Adat istiadat yang dianut
..............................................................................................................................................
b. Pantangan adat dan agama yang dianut
..............................................................................................................................................
c. Penghasilan keluarga
( ) < Rp. 250.000,( ) Rp. 1 juta 1,5 juta
( ) Rp. 250.000 500.000,( ) Rp. 1,5 juta 2 juta
( ) Rp. 500.000 1 juta
( ) Rp. > 2 juta
N. Pola Seksualitas
a. Masalah dalam hubungan seksual selama sakit
( ) Tidak ada
b. Upaya yang dilakukan pasangan
( ) Perhatian
( ) Sentuhan

( ) Ada
( ) Lain-lain, seperti ..........

O. Pola Nilai dan Kepercayaan

a. Apakah Tuhan dan agama penting untuk anda : ( ) Ya
( ) Tidak
b. Kegiatan keagamaan yang dilakukan di rumah (jenis dan frekwensi)
..............................................................................................................................................
c. Kegiatan keagamaan yang tidak dapat dilakukan di RS
..............................................................................................................................................
d. Harapan klien terhadap perawat untuk melaksanakan ibadahnya
..............................................................................................................................................
P. Pemeriksaan Fisik
1. Keadaan Umum : .............................
a. Kesadaran
: .............................
b. Tanda-tanda Vital
:
Tekanan Darah
: ........................................
Respirasi
: ........................................
Nadi
: ........................................
Suhu
: ........................................
c. Tinggi Badan : ............................. Berat Badan : ................................. Kg
Format Pengkajian KMB/AKPER-NTB/2015

2. Kepala dan Leher

a. Kepala
Bentuk
: .......................................... Massa
: .....................................................
Distribusi rambut : .................................... Warna kulit kepala : ......................................
Keluhan : .........................................................................................................................
b. Mata
Bentuk
Pupil

: .......................................... Konjungtiva : ................................................

: ( ) reaksi terhadap cahaya
( ) Isokor
( ) Miosis
( ) pint point
( ) Midriasis

Tanda-tanda radang : ........................................................................................................

Fungsi penglihatan
: ( ) Baik
( ) Kabur
Penggunaan alat bantu : ( ) Ya
( ) Tidak
Apabila Ya menggunakan :
( ) Kaca mata ( ) Lensa kontak
( ) Minus ........ ka/ki
( ) Plus ....... ka/ki
( ) Silinder .....ka/ki
Pemeriksaan mata terakhir : .................................................................................................
Riwayat Operasi : ...............................................................................................................
c. Hidung
Bentuk : ................................Warna : ........................... Pembengakan : ..........................
Nyeri tekan : ......................... Perdarahan : ................... Sinus : ........................................
Riw. Alergi : ...........................Cara mengatasi : ..................................................................
Penyakit yang pernah terjadi : ..............................................................................................
d. Mulut dan Tenggorokan
Warna bibir : ......................... Mukosa : ......................... Ulkus : ......................................
Lesi : ..................................... Massa : ............................ Warna Lidah : ............................
Perdarahan gusi ................................................ Karies ......................................................
Kesulitan menelan ............................................ Gigi geligi ................................................
Sakit tenggorokan ............................................. Gangguan bicara .....................................
Pemeriksaan gigi terakhir ....................................................................................................
e. Telinga
Bentuk : ................................ Warna : ............................ Lesi : ..........................................
Massa : ................................. Nyeri : .................................................................................
Fungsi pendengaran : ...................................... Alat bantu dengar : ...................................
Masalah yang pernah terjadi ...............................................................................................
Upaya untuk mengatasi ......................................................................................................
f.

Leher
Kekakuan ....................................................... Nyeri/Nyeri tekan ......................................
Benjolan/massa................................................... Keterbatasan gerak .....................................
Vena jugularis ...................................... Tiroid ............................ Limfe ...........................
Trakhea ......................................................... Keluhan .....................................................
Upaya untuk mengatasi ......................................................................................................

3. Dada
Bentuk ....................................................... Pergerakan dada ..................................................
Nyeri ......................................................... Massa .................................................................
Taktil fremitus ........................................... Pola Nafas ..........................................................
Jantung :
Format Pengkajian KMB/AKPER-NTB/2015

 Inspeksi
Perkusi
Palpasi
Auskultasi
Paru
:
Inspeksi
Perkusi
Palpasi
Auskultasi

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

4. Payudara dan Ketiak

Benjolan/Massa ......................................... Nyeri/nyeri tekan ...............................................
Bengkak .................................................... Kesimetrisan ......................................................
5. Abdomen
Inspeksi
Auskultasi
Perkusi
Palpasi

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

6. Punggung
................................................................................................................................................
................................................................................................................................................
7. Genetalia
Inspeksi
Palpasi
Perempuan

Pria

: .....................................................................................................................
: ........................................................................................................................
: Siklus Menstruasi ........................................................................................
Kontrasepsi .................................................................................................
Kehamilan ...................................................................................................
Keluhan ......................................................................................................
: Keluhan .....................................................................................................

8. Ekstremitas
: Kekuatan Otot ............................................................................................
Kontraktur .................................................... Pergerakan ......................................................
Deformitas .................................................... Pembengkakan ...............................................
Edema ........................................................... Nyeri/nyeri tekan ...........................................
Refleks-refleks : ............................................ Sensasi ...........................................................
Bisep : ..................................................... Raba/sentuhan .............................................
Trisep : ....................................................Panas ...........................................................
Brakhioradialis : ...................................... Dingin .........................................................
Patelar ..................................................... Tekanan/tusuk .............................................
Achiles ....................................................
9. Kulit dan Kuku
Kulit :
- Warna ................................................. - Jaringan parut .............................................
- Lesi ..................................................... - Tekstur ........................................................
- Turgor ................................................
Kuku
Format Pengkajian KMB/AKPER-NTB/2015

Warna ................................................. - Bentuk ........................................................

Lesi .................................................... - Pengisian kapiler ........................................

Q. Pemeriksaan Penunjang
Laboratorium
Tanggal
Jenis Pemeriksaan

Hasil

Normal

R. Therapi Pengobatan
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Format Pengkajian KMB/AKPER-NTB/2015

S. Persepsi Klien Terhadap Penyakitnya

........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
T. Kesimpulan
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
U. Perencanaan Pulang
1. Tujuan pulang : ( ) ke rumah
( ) Tidak ada tujuan
2. Transportasi pulang
: ( ) Mobil
( ) Taxi
3. Dukungan keluarga
: ( ) Ambulans
( ) Belum dapat ditentukan sekarang
4. Antisipasi bantuan biaya setelah pulang
: ( ) Ada
( ) Tidak ada
5. Antisipasi masalah perawatan diri setelah pulang : (Ya)
( ) Tidak
6. Pengobatan:
........................................................................................................................................................
........................................................................................................................................................
7. Rawat jalan ke : ................................ waktu ............................ frekwensi ..............................
8. Hal-hal yang perlu diperhatikan di rumah :
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
9. Keterangan lain
........................................................................................................................................................

Format Pengkajian KMB/AKPER-NTB/2015

ANALISA DATA
Nama Klien
No. Reg.
NO

: .......................................................................
: .......................................................................
DATA-DATA

ETIOLOGI

MASALAH
KEPERAWATAN

DS
DO

Format Pengkajian KMB/AKPER-NTB/2015

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Format Pengkajian KMB/AKPER-NTB/2015

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RENCANA KEPERAWATAN
Nama Klien :
No. Reg
:
No
Diagnosa Kep.

Tujuan & Kriteria

Hasil

Format Pengkajian KMB/AKPER-NTB/2015

Tanggal Pengkajian :
Diagnosa Medis
Intervensi

;
Rasional

12

TINDAKAN KEPERAWATAN/ IMPLEMENTASI

Tanggal

No. Dx

Jam

Implementasi

Format Pengkajian KMB/AKPER-NTB/2015

Evaluasi Hasil

13

CATATAN PERKEMBANGAN
No

Tgl/jam

No

Catatan Perkembangan

Paraf

Dx

Format Pengkajian KMB/AKPER-NTB/2015

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Format Pengkajian KMB/AKPER-NTB/2015

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