FORMAT PENGKAJIAN ASUHAN KEPERAWATAN MEDIKAL BEDAH

STIKES MUHAMMADIYAH PALEMBANG

Nama Mahasiswa

Tempat Praktek

Tanggal Praktek

Pengkajian Dilakukan Tanggal

1. Identitas Klien
Inisial
Usia
Jenis Kelamin
Alamat
No. Telp
Status
Agama
Suku
Pendidikan
Pekerjaan

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No. RM
Tgl Masuk
Tgl Pengkajian
Sumber Informasi
Keluarga Terdekat
Status
Alamat
No. Telp
Pendidikan

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Pekerjaan

2. Riwayat Kesehatan
a. Keluhan Utama (saat masuk RS)
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b. Keluhan Utama (saat pengkajian)
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c. Riwayat Kesehatan Saat ini
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d. Riwayat Kesehatan Terdahulu
1) Penyakit yang pernah dialami
a) Kecelakaan :..................................................................................................
b) Operasi (jenis dan waktu) :...........................................................................
c) Penyakit (kronis dan akut) :..........................................................................
d) Terakhir masuk RS :......................................................................................
2) Alergi (obat, makanan, plester, dsb)
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3) Imunisasi (tambahan ; flu, pneumonia, tetanus, dll)
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4) Kebiasaan
Jenis

Freku

Juml

Lama

en

ny

si

a. M
ero
ko
k
b. Ko
pi
c. Al
ko
hol

5) Obat-obatan yang digunakan

Jenis

Lamanya

3. Riwayat Keluarga
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Genogram

4.

Catatan penanganan kasus (dimulai saat pasien dirawat diruang rawat sampai
pengambilan kasus kelolaan)
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Dosis

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5.

Pengkajian Keperawatan (12 Domain NANDA)

Instruksi : beri tanda () pada istilah yang tepat/sesuai dengan data-data di bawah ini.
Gambarkan semua temuan abnormal secara objektif, gunakan kolom data tambahan bila
perlu.
a. Peningkatan Kesehatan
Pengetahuan tentang penyakit/perawatan :
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Masalah keperawatan :
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b. Nutrisi
1) Mulut
Bibir

: ( ) Trismus, ( ) Halitosis
: ( ) Lembab, ( ) pucat, ( ) sianosis, ( ) labio/palatoskizis,
( ) stomatitis

Gusi

: ( ) Baik,

Gigi

: ( ) Normal, ( ) Ompong, ( ) caries, jumlah gigi :

Lidah

: ( ) bersih,

2) Leher

( ) Plak putih, ( ) lesi

buah.

( ) kotor putih,( ) jamur.

: ( ) kaku kuduk, ( ) simetris,( ) Benjolan, ( ) Tonsil

Kel. Tiroid : ( ) normal,

( ) pembesaran

Tenggorok : ( ) kesulitan menelan

Dll............................................................................................................................
.................................................................................................................................
Kebutuhan Nutrisi dan Cairan
BB sebelum sakit :
Kg
BB setelah sakit :
Kg
Program Diit RS :
Makanan yang disukai :...........................................................................................
Selera makan :..........................................................................................................
Alat makan yang digunakan :..................................................................................
Pola makan (x/hari) :................................................................................................
Pola makan yang dihabiskan :.................................................................................
Pola minum (
gelas/hari) jenis air minum :.........................................................
Intake makanan :......................................................................................................
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Intake cairan :...........................................................................................................

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Eliminasi dan pertukaran
BAK

PENGKAJI
AN

SMRS

Penggunaan kateter :
Vesika urinaria : ( ) normal, membesar : ( ) nyeri tekan : ( )
Gangguan

: ( ) anuria, ( ) oliguria, ( ) retensi uria, ( ) nokturia,

( ) inkontinensia urin, ( ) poliuria,

( ) dysuria

Paru Paru :
Inspeksi

: RR

x/menit

Palpasi

: ( ) normal, ( ) ekspansi pernafasan, ( ) taktil fremitus

Perkusi

: ( ) sonor,

( ) redup/pekak,

Auskultasi : ( ) irama teratur,

Jalan nafas : ( ) Bersih,

( ) hiper sonor
( ) tidak teratur

( ) sputum, ( ) warna sputum, konsistensi .........

( ) Batuk, frekuensi : Dada

: ( ) simetris, ( ) barrel chest/dada tong, ( ) pigeon chest/dada

burung,

( ) benjolan, dll ................

Suara nafas : ( ) vesicular, ( ) bronkial, ( ) amforik, ( ) cog wheel breath

sound,
Suara Tambahan :

( ) metamorphosing breath sound

( ) Ronki,

( ) pleural friction

Data tambahan :.......................................................................................................

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Masalah Keperawatan :............................................................................................
c. Aktivitas/istirahat
Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang dibawa saat
tidur, dll)
Kebiasaa tidur siang :
Skala aktivitas :

jam/hari

Kemampuan perawatan diri

Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi/ROM

0 : mandiri, 1 : alat bantu, 2 : dibantu orang lain, 3 : dibantu orang lain dan alat,
4 : tergantung total
Persendian :
Nyeri sendi ( ), pergerakan sendi :...........................................................................
ROM (range of motion) :
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Kekuatan otot :
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Kelainan otot :
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Data tambahan :............................................................................................................
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Masalah Keperawatan :................................................................................................
Tonus / Aktivitas
( ) Aktif,

( ) tenang,

( ) letargi,

( ) kejang,

( ) lemah

( ) melengking ( ) sulit menangis

( ) menangis keras

Ektremitas
( ) Amelia,

( ) sindaktili, ( ) polidaktili

Reflek Patologis :
Babinsky

: +( ), - ( )

Kernig

: +( ), - ( )

Brudzinsky

: +( ), - ( )

Reflek Fisiologis :
Biceps

: +( ), - ( )

Triceps

: +( ), - ( )

Patella

: +( ), - ( )

Data tambahan :............................................................................................................

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Masalah Keperawatan :................................................................................................
Jantung
Inspeksi

: ( ) ictus cordis/denyut apeks, ( ) normal, ( ) melebar

Palpasi

: ( ) Kardiomegali

Perkusi

: ( ) Redup,

Auskultasi

: HR

( ) pekak

x/mnt, ( ) aritmia,

( ) disritmia, ( ) murmur

Data tambahan :............................................................................................................

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Masalah Keperawatan :................................................................................................
Mandi :
Sikat gigi :
Ganti pakaian :
Memotong kuku :
Data tambahan :............................................................................................................
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Masalah Keperawatan :................................................................................................
d. Persepsi/kognitif
Kesan umum
Tampak sakit : ( ) ringan, ( ) sedang, ( ) berat, ( ) pucat, ( ) sesak, ( ) kejang
1. Kepala
a. Rambut : warna hitam

( ) mudah dicabut, ( ) ketombe, ( ) kutu)

b. Kelainan bentuk kepala : Tidak ada benjolan, tidak ada lesi

2. Mata
Mata : ( ) Jernih, ( ) mengalir, ( ) kemerahan, ( ) sekret
Visus : ( ) 6/6,

( ) 6/300,

( ) 6/tak terhingga

Pupil : ( ) Isokor, ( ) anisokor, ( ) miosis ( ) midriasis

reaksi cahaya :

( ) kanan positif, ( ) negatif, ( ) kiri positif, ( ) negatif

Alat bantu :

( ) kacamata,

( ) softlens

Conjuctiva :

( ) merah jambu, ( ) anemis

Sklera

( ) putih,

( ) ikterik

3. Bibir, lidah
a. Bibir : ( ) normal, ( ) sumbing, ( ) Sumbung langit - langit/palatum
b. Lidah : ( ) bersih, ( ) kotor/putih, ( ) jamur
4. Telinga, hidung, tenggorok
a. Telinga : ( ) normal, ( ) abnormal, ( ) sekret
b. Hidung : ( ) simetris, ( ) asimetris, ( ) sekret, ( ) nafas cuping hidung
c. Tenggorok : ( ) tonsil, ( ) radang
Data tambahan :.......................................................................................................
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Masalah Keperawatan :............................................................................................
e. Persepsi diri
Perasaan klien terhadap penyakit yang dideritanya.....................................................
Persepsi klien terhadap dirinya.....................................................................................
Konsep diri...................................................................................................................
Tingkat kecemasan.......................................................................................................
Citra diri/body image....................................................................................................
Data tambahan :............................................................................................................
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Masalah Keperawatan :................................................................................................
f. Peran hubungan
Budaya :
Suku :
Agama yang dianut :
Bahasa yang digunakan :
Masalah sosial yang penting :
Hubungan dengan orang tua :
Hubungan dengan saudara kandung :
Hubungan dengan lingkungan sekitar :
Data tambahan :............................................................................................................
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Masalah Keperawatan :................................................................................................
g. Seksual dan reproduksi

Genetalia dan anus

Laki-laki
Penis : normal ( ), abnormal ( )
Scrotum dan testis : normal ( ), hernia (
Anus : normal ( ), atresia ani ( )

), hidrokel (

Perempuan
Vagina : sekret ( ), warna ( )
Anus : normal ( ), atresia ani ( )
Riwayat kehamilan dan kelahiran :
Data tambahan :............................................................................................................
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Masalah Keperawatan :................................................................................................
h. Toleransi/koping stress
GCS :
E:
V:
M:
Data tambahan :............................................................................................................
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Masalah Keperawatan :................................................................................................
i. Prinsip hidup
Budaya :
Spiritual/religius :
Harapan :
Psikososial :
1) Persepsi klien terhadap penyakitnya.....................................................................
2) Reaksi saat interaksi
Kooperatif ( ), tidak kooperatif ( )
3) Status emosional
Tenang ( ), cemas ( ), marah ( ), menarik diri ( ), tidak sabar ( ),
lainnya...................................................................................................................
Data tambahan :.....................................................................................................
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Masalah Keperawatan :.........................................................................................
j. Keselamatan/perlindungan

Tingkat kesadaran : composmentis (

), apatis (

), samnolen (

), sopor (

),

), oedema (

),

soporocoma ( ), coma ( )
TTV : suhu.....C, Nadi ......x/mnt, TD..............mmHg, RR.........x/mnt
Warna kulit :
Sianosis ( ), ikterus (
bula (

), gangren (

petekie ( )
Turgor kulit : elastis (

), eritematosus rash (
), nekrotik jaringan (
), tidak elastis (

), discoid lupus (
), hiperpigmentasi (

), echimosis ( ),

Data tambahan :............................................................................................................

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Masalah Keperawatan :................................................................................................
k. Kenyamanan
Provaiking :
Quality :
Regio :
Skala :
Time :
Data tambahan :............................................................................................................
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Masalah Keperawatan :................................................................................................
Terapi
Tanggal terapi :
Na

Dosis
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Cara
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Gol
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Kon
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Pemeriksaan penunjang
Laboratorium : Tanggal