FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS GADJAH MADA
Nama Mahasiswa : ______________________

Ruangan

Waktu Praktik

Pembimbing : ___________________

: ______________________

: ___________________

1. IDENTITAS DIRI KLIEN

Nama

: ____________________________________________________ ___

Umur

: _____________________________________________________

Jenis Kelamin

: ____________________________________________________ ___

Alamat

: ____________________________________________________ ___

Status Perkawinan

: ____________________________________________________ ___

Agama

: ____________________________________________________ ___

Suku Bangsa

: ____________________________________________________ ___

Pendidikan

: ____________________________________________________ ___

Pekerjaan

: ____________________________________________________ ___

Lama Bekerja

: ____________________________________________________ ___

Dx Medis

: ____________________________________________________ ___

Tanggal MRS

: ____________________________________________________ ___

No RM

: ____________________________________________________ ___

Tanggal Pengkajian

: ____________________________________________________ ___

Jam Pengkajian

: ____________________________________________________ ___

Sumber Informasi

: ____________________________________________________ ___

2. RIWAYAT PENYAKIT
Keluhan utama saat masuk RS:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Riwayat Penyakit Sekarang:
1

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Riwayat Penyakit Dahulu:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Diagnosa medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah dilakukan,
mulai dari pasien MRS (UGD/POLI), sampai diambil kasus kelolaan.
Masalah atau Dx Medis pada saat MRS:
___________________________________________________________________________
___________________________________________________________________________
Tindakan yang telah dilakukan di poliklinik atau UGD
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Catatan Penanganan Kasus (dimulai saat pasien di rawat di ruang rawat sampai pengambilan
kasus)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
C. PENGKAJIAN KEPERAWATAN
1. Persepsi dan pemeliharaan kesehatan (Pengetahuan tentang penyakit/ perawatan;
obat yang biasa dikonsumsi,faktor risiko tentang penyakit, seperti: riwayat keluarga,
kebiasaan, dll.; perlindungan kesehatan; kebiasaan dalam menangani sakit, seperti:
pilihan pengobatan; kebutuhan akan edukasi kesehatan/ discharge planning)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3

2. Pola Nutrisi/Metabolik
Program diit RS : ______________________________________________________
Intake makanan (Pengkajiam nutrisi ABCD/ skrining nutrisi; faktor spesifik dalam
memilih makanan, seperti: budaya, agama, ekonomi; faktor yang mempengaruhi
ingesti makanan, seperti: nafsu makan, kenyamanan, kesehatan gigi dan mulut, alergi,
nyeri, mual, muntah, pantangan makanan): __________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Intake cairan

: ______________________________________________________

_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3. Pola Eliminasi
a. Buang Air Besar (frekuensi, warna, jumlah, konsistensi, ketidaknyamanan, kontrol
saat defekasi, apakah ada perubahan khusus)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
b. Buang Air Kecil (frekuensi, warna, jumlah, bau, ketidaknyamanan, kontrol saat
defekasi, apakah ada perubahan khusus, nokturia)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
c. Balance Cairan
4

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. Pola Aktivitas dan latihan
Kemampuan Perawatan diri
0
1
2
3
4
Makan dan minum
Mandi
Toileting
Berpakaian
Mobilitas ditempat tidur
Berpindah
Ambulansi/ROM
Keterangan : 0: Mandiri, 1 : alat bantu, 2 : dibantu orang lain, 3: dibantu orang lain
dan alat, 4: tergantung total
a.
b.
c.
d.

Skor Pengkajian Fungsional ADL (BARTHEL INDEX):

Skor Risiko Jatuh (MORSE):
Skor Risiko Dekubitus (BRADEN SCALE):
Fungsi Respiratory:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

__________________________________________________________________
e. Fungsi Cardiovascular:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
f. Fungsi Neurologis:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
g. Fungsi Muskuloskeletal:
__________________________________________________________________
__________________________________________________________________

__________________________________________________________________
__________________________________________________________________
5. Pola Tidur dan Istirahat (lama tidur, gangguan tidur; penggunaan obat bantu tidur;
faktor terkait, seperti nyeri, kenyamanan lingkungan, suhu):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
6. Pola Perceptual (penglihatan; pendengaran; pengecap; sensasi; pembau; penggunaan
alat bantu; nyeri dan kenyamanan):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
7. Pola persepsi diri (pandangan klien tentang sakitnya; kecemasan; konsep diri):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
8. Pola Seksualitas dan Reproduksi (masalah seksual; fertilitas, libido, menstruasi,
kontrasepsi, dll.):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
9. Pola Peran-hubungan (perubahan peran, komunikasi, hubungan dengan orang lain,
kemampuan keuangan, significant others):
_____________________________________________________________________
_____________________________________________________________________
6

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
10. Pola Managemen Koping-Stress (stress saat ini; koping; perubahan terbesar dalam
hidup pada akhir-akhir ini/ kehilangan, dll):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
11. Sistem Nilai dan Keyakinan (budaya terkait kesehatan; pandangan klien tentang
agama; kegiatan agama, dll.):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

D. PEMERIKSAAN FISIK
(Chepalocaudal)
Keluhan yang dirasakan saat ini: _____________________________________________
_____________________________________________________________________
_____________________________________________________________________
Kesadaran:
Keadaan umum :
TD : ____________ mmHg
P : ____________ x/menit
N : ____________ x/menit
S : ____________ OC
7

BB/ TB: _________ kg/ __________ cm

Kepala:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Leher:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Thorak:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Abdomen:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Inguinal:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Ekstremitas:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
E. PENANGANAN KASUS (dimulai saat Anda mengambil sebagai kasus kelolaan,
sampai akhir praktik)