PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN KEPERAWATAN BEDAH

Nama Mahasiswa
NIM
Tempat Pengkajian
Tanggal
I. Identitas Klien
Nama
:
Umur
:
Jenis
:
Kelamin
Agama
:
Pendidikan :
Alamat

:
:
:
:

No. RM
Pekerjaan
Status
Perkawinan
Tanggal MRS
Tanggal
Pengkajian
Sumber
Informasi

:
:
:
:
:
:

II. Riwayat Kesehatan

1. Diagnosa Medik:
...............
....................
2. Keluhan Utama:..
.....
.

3. Riwayat penyakit sekarang:

................................................................................................
...................

Panduan Profesi Ners Keperawatan Medikal Bedah PSIKUNEJ 2014

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................
4. Riwayat kesehatan terdahulu:
a. Penyakit yang pernah dialami:
...............
....................

...

..
...............
...................
b. Tindakan Operatif yang pernah dialami

...
c. Alergi (obat, makanan, plester, dll):
...............
....................

...............
....................
d. Imunisasi:
...............
....................

e.Kebiasaan/pola hidup/life style:

...............
....................

...................................

...................................

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e. Obat-obat yang digunakan:

...............
....................

...................................
...............
....................
...............
....................
5. Riwayat penyakit keluarga:
...............
....................

...........
........................
Genogram:

III. Pengkajian Keperawatan

1. Persepsi kesehatan & pemeliharaan kesehatan

Interpretasi :

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2. Pola nutrisi/ metabolik (ABCD)

- Antropometeri

Interpretasi :

Biomedical sign :

Interpretasi :

Clinical Sign :

Interpretasi :

Diet Pattern (intake makanan dan cairan):

Panduan Profesi Ners Keperawatan Medikal Bedah PSIKUNEJ 2014

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Interpretasi :

3. Pola eliminasi:
BAK
- Frekuensi
:
.
.
- Jumlah
:
.
.
- Warna
:
.
.
- Bau
:
.
.
- Karakter
:
.
.
- BJ
:
.
.
- Alat Bantu :
.
.
- Kemandirian : mandiri/dibantu
- Lain
:
.
.
BAB
-

Frekuensi
:
.
.
Jumlah
:
.
.
Konsistensi :
.
.
Warna
:
.
.

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Bau
:
.
.
Karakter
:
.
.
BJ
:
.
.
Alat Bantu :
.
.
Kemandirian : mandiri/dibantu
Lain
:
.
.

Interpretasi :
Balance cairan:

4. Pola aktivitas & latihan

c.1. Aktivitas harian (Activity Daily Living)

Kemampuan perawatan diri
0
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi / ROM

Ket: 0: tergantung total, 1: dibantu petugas dan alat, 2: dibantu

petugas, 3: dibantu alat, 4: mandiri
Status Oksigenasi :

Fungsi kardiovaskuler :

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Terapi oksigen :

Interpretasi :

5. Pola tidur & istirahat

Durasi :

Gangguan tidur :

.
Keadaan bangun tidur :
..
Lain-lain :

Interpretasi :

6. Pola kognitif & perceptual

Fungsi Kognitif dan Memori :

Fungsi dan keadaan indera :

........................
.......................................................................................................
......................................
Interpretasi :

7. Pola persepsi diri

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Gambaran diri :

Identitas diri :

Harga diri :

Ideal Diri :

Peran Diri :

Interpretasi :

8. Pola seksualitas & reproduksi

Pola seksualitas

Fungsi reproduksi
...........................................................
.......................................................................................................
.......................................................................................................
........................................................................
Interpretasi :

9. Pola peran & hubungan

..................
.......................................................................................................
.......................................................................................................
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.......................................................................................................
..........
Interpretasi :

10.Pola manajemen koping-stress

Interpretasi :

11.System nilai & keyakinan

Interpretasi :

IV. Pemeriksaan Fisik

Keadaan umum:
..
..........................................

Tanda vital:
- Tekanan Darah
:
mm/Hg
- Nadi
:
X/mnt
- RR
:
X/mnt
- Suhu
:
C

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Interpretasi :

Pengkajian Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi)

1. Kepala

2. Mata

3. Telinga
.
..
.......................................

4. Hidung

5. Mulut

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6. Leher

7. Dada
.

....

....

.
8. Abdomen

9. Urogenital

10.Ekstremitas
Interpretasi:

11.Kulit dan kuku

12.Keadaan lokal
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V. Terapi (jenis terapi, dosis, rute, indikasi, KI, implikasi

keperawatan)
.............................................................................................................
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VI. Pemeriksaan Penunjang & Laboratorium
a. Pemeriksaan laboratorium
N
o

Jenis
pemeriksaan

A.
1

DARAH
Eritrosit

2.

Hemoglobin
(Hb)

3.

Hematokrit

4.
5.
6.
7.
8.

Basofil
Eosionfil
Batang
Segmen
Limfosit

Nilai normal
(rujukan)
Satuan
nilai
4,0- 5,0
(p)
4,5-5,5 (L)
12,0-14,0
(P)
13,0-16,0
(L)
40-50 (P)
45-55 (L)
0,0-0,1
1,0-3,0
2,0-6,0
50,0-70,0
20,0-40,0

Hasil
(hari/tanggal)

Juta/l
g/dL

%
%
%
%
%
%

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9.
10
.
11
.
12
.
B.
1.

Monosit
Laju Endap
Darah (LED)
Leukosit

2,0-8,0
<15 (P)
<10 (L)
5,0-10,0

%
mm/ja
m
103/l

Trombosit

150-400

103/l
U/L

2.

AST/SGPT

3.

5-38

U/L

0,25-1,0
0,0-0,25

mg/dL
mg/dL

61-82
37-52

g/dL
g/dL

1.

Alkalin
Fosfatase
GGT (Gamma
GT)
Bilirubin total
Bilirubin
langsung
Protein total
Albumin
FUNGSI
GINJAL
Kreatinin

<23 (P)
<30 (L)
<21 (P)
<25 (L)
15-69

U/L

2.
3.

Urea
Natrium

60-50 (P)
70-160 (L)
8-25
135-145

4.

Klorid

94-111

5.

Kalium

3,5-5,0

D.
1.
2.

PROFIL LIPID
Kolesterol total
HDL

3.
E.
1.
2.
3.

Trigliserid
LAIN-LAIN
Glukosa
Amilase

4.
5.
6.
7.
8.
C.

FUNGSI HATI
ALT/SGPT

U/L
U/L

mg/dL
mmol/
L
mmol/
L
mmol/
L

150-200
45-65 (P)
35-55 (L)
120-190

mg/dL
mg/dL

70-100
30-130

mg/dL
U/L

mg/dL

Interpretasi:

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b. Pemeriksaan sinar X abdomen

Hasil:

..
Interpretasi:

..
c. Foto polos abdomen

Hasil:

Interpretasi:
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d. USG

Hasil:

Interpretasi:

e. kolesistografi

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Hasil:

Interpretasi:

f. ERCP

Hasil:

Interpretasi:

Panduan Profesi Ners Keperawatan Medikal Bedah PSIKUNEJ 2014

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g. CT scan

Hasil:

Interpretasi:

h. MRI

Hasil:

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Interpretasi:

,
...........................20...
Pengambil Data,

(__________________________)
NIM

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Lampiran 9
N
O

ANALISA DATA
DATA PENUNJANG
ETIOLOGI

MASALAH

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Lampiran 10
DIAGNOSA KEPERAWATAN
Daftar Diagnosa Keperawatan (sesuai prioritas):
N
Diagnosa
Tanggal
Tanggal
o
perumusan
pencapai
an

Keterang
an

Lampiran 11
N
O

DIAGNOSA

PERENCANAAN KEPERAWATAN
TUJUAN DAN
INTERVENSI
KRITERIA
HASIL

RASIONAL

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LAMPIRAN 12
CATATAN PERKEMBANGAN
DIAGNOSA:
WAKTU

IMPLEMENTASI

PARAF

EVALUASI

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JAM:

Lampiran 13
FORMAT RESUME KASUS KELOLAAN HARIAN
S (Subjektif):
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O (Objektif):
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A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan
DO):
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P(Perencanaan):
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I (Implementasi):
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E (Evaluasi):
S
(Subjektif): ...............................................................................................
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(analisa): .................................................................................................
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(Perencanaan: .........................................................................................
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DAFTAR PUSTAKA

1. Black, J.M., Matassarin E. (1997), Medical Surgical Nursing,

Clinical Management for Continuity of Care, J.B Lippincott Co.
2. Colmer, M.R., (1995), Moronys Surgery for Nurses, 16th ed.,
Livingstone
3. Donna, D., et al., (1991), Medical Surgical Nursing : A Nursing
Process Approach, Mosby Co.
4. Barbara C. Long and Wilma J.Phips, (1996), Essentials of Medical
Surgical Nursing.
5. Margare E. Amstrong, Handbook of Clinical Nursing.
6. Hoole, J.A. Pickard, C.G et al. (1995), Patient Care Guidancefor
Nurse Practioners , 4th ed., Philadelphia, J.B.Lippincot Co
7. Luckman and Sorensen (1990), Medical Surgical Nursing,
Philadelphia, W.B Saunders Co.
8. Smeltzer, S.C. (2002). Brunner & suddarths texsbook of
medical-surgical nursing. 8th edition, Philadelphia, Lippincott
Publishers.

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