PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa
:
NIM
:
Kelompok
:
Tgl praktik/mgg ke
:
Tanggal/jam Pengkajian : Tanggal/jam MRS :
Identitas Pasien :
Nama
Umur
Jenis Kelamin
Alamat
Pendidikan terakhir

Keadaan Umum:
Keluhan Utama:

:
:
:
:
:

Suku
Agama
Status Perkawinan
Pekerjaan
No Rekam Medik

:
:
:
:
:

1. Pola Persepsi Kesehatan dan Penanganan Kesehatan

Alasan masuk rumah sakit:

Riwayat pengobatan
Sebelumnya ....
Saat ini

Persepsi klien tentang kesehatan

Riwayat medik dan sosial

Kecelakaan .
Dirawat ...
Operasi ...
Alergi ..
Penyakit ..
Lain-lain .

2. Pola Nutrisi Metabolik

Intake Nutrisi sebelum dan saat sakit
Makanan

Minuman

Nafsu makan

Muntah

Keluhan/masalah yang mempengaruhi asupan nutrisi

Perawatan kulit, rambut dan kuku

BB :

TB :

Suhu :

Kelembaban kulit..Warna kulit ...Turgor.

Kondisi kulit.....
Kuku.
Rambut dan kepala ..
Kelenjar tiroid .
JVP ..
Kaku kuduk .
Mukosa bibir ...

 Kebersihan mulut
Peradangan tonsil
Gigi ..
Penggunaan NGT
Terapi intravena / parenteral ....
Lain-lain ..

3. Pola Eliminasi
Tanggal defekasi terakhir :
Frekuensi defekasi KonsistensiWarna
Masalah defekasi
Penggunaan alat bantu (laksatif/pispot)...
Bising usus ..
Struktur abdomen
Distensi ...
Nyeri tekan ..
Lain-lain ..

 Frekuensi berkemih.Jumlah..Warna
Penggunaan alat bantu berkemih.
Keluhan /masalah berkemih ...
Sakit pinggang.
Palpasi ginjal....
Perkusi ginjal...
Kondisi blast....
Lain-lain...

4. Pola Aktivitas Latihan

Kemampuan perawatan diri:
Aktivitas

SMRS
1
2
3

MRS
1
2
3

Mandi
Berpakaian/berdanda
n
Eliminasi/toileting
Mobilitas di tempat
tidur
Berpindah
Berjalan
Naik tangga
Berbelanja
Memasak
Pemeliharaan rumah
Skor:
0 = mandiri 1 = alat bantu
orang lain & alat
4 = tergantung/tidak mampu
Kebersihan diri:
Di rumah
Mandi

2 = dibantu orang lain

dibantu

: ........................ /hr

Gosok gigi

: ........................ /hr

Keramas

: .................... /mgg

Potong kuku

: .................... /mgg

Di rumah sakit
Mandi

: ........................ /hr

Gosok gigi

: ........................ /hr

Keramas

: .................... /mgg

Potong kuku

: .................... /mgg

Pernapasan
Frekuensi napas : . kedalaman : irama : .
Bunyi napas..
Riwayat merokok..
Riwayat asma/bronchitis/emfisema .

 Riwayat penyakit paru dalam keluarga ...

Batuk.
Penggunaan otot bantu napas...
Suara napas tambahan..
Adanya sputum.
Lain-lain

Sirkulasi
Frekuensi nadi irama TD..
Perkusi dada. Nyeri dada .
Capillary refill...
Edema...
Palpitasi.
Suhu ekstrimitas
Riwayat penyakit jantung dalam keluarga

Mobilitas
Pola latihan yang biasa dilakukan.
Aktivitas di waktu luangsejak sakit .
Rentang gerak.. Skala kekuatan otot.
Keseimbangan dan cara jalan.. bentuk tulang belakang...
Genggaman tangan/refleks...
Penggunaan tongkat/walker/prostese.
Persendian: Nyerikekakuan..edemadeformitas.
Lain-lain ...

5. Pola Istirahat dan Tidur

Waktu tidur : sebelum sakit.... saat sakit..
Keluhan yang mempengaruhi tidur .
Keluhan letih : ..
Lingkaran gelap di mata ..
Penggunaan hipnotik / sedasi ...
Lain-lain ...

6. Pola Kognitif Persepsi

Fungsi penglihatan
Posisi bola mata
Gerakan mata
Konjungtiva..
Kornea...
Sklera
Pupil..
Keluhan nyeri
Pemakaian alat bantu penglihatan
Fungsi pendengaran
Struktur luar telinga
Cairan dari telinga

 Perasaan penuh dalam telinga..

Tinnitus
Keluhan nyeri..
Penggunaan alat bantu dengar.
Fungsi penciuman
Kondisi hidung
Cairan dari hidung...
Vertigo .. Pusing.
Tingkat kesadaran.. GCS
Kemampuan mengambil keputusan ...
Lain-lain .

7. Pola Persepsi Diri Konsep Diri

Persepsi klien tentang penyakitnya.
.
Harapan setelah dirawat.

Persepsi klien tentang diri ..

.
Ekspresi afek/emosi.....

Isyarat non verbal perubahan harga diri..

Lain-lain .

8. Pola Seksualitas Reproduksi

Dampak sakit terhadap seksualitas..

 Riwayat haid

Pemeriksaan payudara sendiri.

Keluhan mengenai keturunan..

Tindakan pengendalian kelahiran

Riwayat penyakit hubungan seksual

.
Keluhan gatal-gatal..

.
Lain-lain ..

9. Pola Koping Toleransi Stres

Cara pengambilan keputusan klien...

 Stresor dalam 1 tahun terakhir..

Koping yang biasa digunakan...
Pengobatan untuk mengatasi stress...
Kecemasan
Sistem pendukung.
Perilaku yang ditunjukkan klien...
Lain-lain

10. Pola Peran Hubungan

Peran dalam keluarga
Hubungan dengan orang terdekat.
Interaksi dengan pasien lain..
Cara berkomunikasi..
Efek perubahan peran...
Perilaku selama dirawat....
Bahasa yang digunakan sehari-hari
Lain-lain ...

11. Pola Nilai Kepercayaan

Persepsi klien tentang agama
Kegiatan keagamaan.
Sikap terhadap nilai..
Bantuan spiritual...
Lain-lain ...

PEMERIKSAAN PENUNJANG
1.

Laboratorium
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2.

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TERAPI MEDIS
Tanggal

Jenis Terapi

Rute
Terapi

Dosis

Indikasi Terapi

Banjarmasin, .....................
Mahasiswa

(...............................)
ANALISA DATA
Nama klien

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

Umur

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

Ruangan/kamar : ......................................................................................................
No. RM
No
.

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

Data (Symptom)

Penyebab (Etiologi)

Masalah (Problem)

PRIORITAS MASALAH
Nama klien

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

Umur

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

Ruangan/kamar : ......................................................................................................
No. RM

No.

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

Masalah Keperawatan

Paraf

Tanggal
Ditemukan

(Nama Perawat
Teratasi

RENCANA KEPERAWATAN
No

Diagnosa

Tujuan Dan Kriteria

Keperawatan

Hasil

Intervensi

Rasional

TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No.

Waktu

Dx Kep

Tgl/jam

Tindakan

TT

Waktu

Catatan Perkembangan

Tgl/jam

(SOAP)

TT