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PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL

Nama Mahasiswa :
NIM :
Tempat Pengkajian :
Tanggal :

I. Identitas Klien
Nama : Alamat :
Umur : No. RM :
Jenis : Pekerjaan :
Kelamin
Agama : Status :
Perkawinan
BB : Tanggal MRS
TB : Tanggal :
Suku : Pengkajian
bangsa
Pendidikan : Sumber :
Informasi

II. Riwayat Kesehatan


1. Diagnosa Medik:
...............
....................

2. Keluhan Utama: ..
.....
.


3. Riwayat penyakit sekarang:




Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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





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

4. Riwayat kesehatan terdahulu:


a. Penyakit yang pernah dialami:
...............
....................



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



...............
....................
c.Imunisasi:
...............
....................


d.Kebiasaan/pola hidup/life style (suka minum-minuman


beralkohol atau tidak):
...............
....................


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


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

e. Obat-obat yang digunakan:


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


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

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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...............
....................
...............
....................
f. Pola Makan
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
..........................................................................

5. Riwayat penyakit keluarga:


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




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

Genogram:

III. Pengkajian Keperawatan


1. Persepsi kesehatan & pemeliharaan kesehatan











Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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Interpretasi :



.

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 PSIK UNEJ 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 :
.
.

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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- Konsistensi :
.
.
- Warna :
.
.
- 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 1 2 3 4
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

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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Status Oksigenasi :



Fungsi kardiovaskuler :



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 :

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

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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Interpretasi :



.

7. Pola persepsi diri
Gambaran diri :



Identitas diri :



Harga diri :



Ideal Diri :



Peran Diri :



Interpretasi :



.

8. Pola seksualitas & reproduksi
Pola seksualitas




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



.

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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9. Pola peran & hubungan



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



.

10.Pola manajemen koping-stress






Interpretasi :



.

11.System nilai & keyakinan






Interpretasi :



.

IV. Pemeriksaan Fisik


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

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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

Interpretasi :

Pengkajian Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi)


1. Kepala







2. Mata







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





4. Hidung






Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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5. Mulut





6. Leher





7. Dada
.

....

...



8. Abdomen






9. Urogenital





10.Ekstremitas
a) Sendi yang terserang:

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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Ada /
Tanda Keterangan
Tidak
Kalor:
-Kenaikan suhu tubuh Suhu = .. oC
-Sendi yang sakit
teraba hangat
P:
...................................................
...................................................
...................................................
...................................................
...................................................
...................................................
..........
Q: ..............................................
...................................................
...................................................
...................................................
...................................................
...................................................
...............
R:
...................................................
...................................................
...................................................
Dolor (Nyeri)
...................................................
...................................................
...................................................
..........
S:

T:
...................................................
...................................................
...................................................
...................................................
...................................................
...................................................
.........

Rubor (Kemerahan) Lokasi:



.

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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Perdarahan: Ada / Tidak
Lokasi:

Tumor (Bengkak)
.
Nyeri tekan: Ada/ Tidak
Adanya perubahan Lokasi:........................................
bentuk (deformitas) .................................

11.Kulit dan kuku








12.Keadaan lokal







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


keperawatan)
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
..................................................................................
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.................................

VI. Pemeriksaan Penunjang & Laboratorium (bisa dikembangkan)

a. Pemeriksaan Laboratorium
N Jenis Nilai normal Hasil

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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o pemeriksaan (rujukan) (hari/tanggal)
nilai Satu
an

b. Pemeriksaan Kultur Cairan Sendi


Hasil:






..
.
Interpretasi:





c. Pemeriksaan Rontgen Tulang


Hasil:






..
.
Interpretasi:



Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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

(-
__________________________)
NIM

Lampiran 9
ANALISA DATA
N DATA PENUNJANG ETIOLOGI MASALAH
O

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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Lampiran 10

DIAGNOSA KEPERAWATAN

Daftar Diagnosa Keperawatan (sesuai prioritas):


N Diagnosa Tanggal Tanggal Keterang
o perumusan pencapai an
an

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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Lampiran 11

PERENCANAAN KEPERAWATAN
N DIAGNOSA TUJUAN DAN INTERVENSI RASIONAL
O KRITERIA
HASIL

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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LAMPIRAN 12

CATATAN PERKEMBANGAN
DIAGNOSA:
WAKTU IMPLEMENTASI PARAF EVALUASI
JAM:

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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Lampiran 13

FORMAT RESUME KASUS KELOLAAN HARIAN

S (Subjektif):
.................................................................................................................
..............................................................
.................................................................................................................
..............................................................
.................................................................................................................
..............................................................

O (Objektif):
.................................................................................................................
..............................................................
.................................................................................................................
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Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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

A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan


DO):
.................................................................................................................
..............................................................
.................................................................................................................
..............................................................

P(Perencanaan):
.................................................................................................................
..............................................................
.................................................................................................................
............................................................
.................................................................................................................
..............................................................
.................................................................................................................
..............................................................

I (Implementasi):
.................................................................................................................
..............................................................
.................................................................................................................
..............................................................
.................................................................................................................
..............................................................
.................................................................................................................
..............................................................
.................................................................................................................
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E (Evaluasi):
S (Subjektif)
: ...............................................................................................................
................................................................
.................................................................................................................
..............................................................
.................................................................................................................
..............................................................
.................................................................................................................
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.................................................................................................................
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Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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O
(Objektif): ................................................................................................
...............................................................................
.................................................................................................................
..............................................................
.................................................................................................................
..............................................................
.................................................................................................................
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.................................................................................................................
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A (analisa) :
.................................................................................................................
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.................................................................................................................
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.................................................................................................................
..............................................................
.................................................................................................................
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P
(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.

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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