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PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN KEPERAWATAN BEDAH

Nama Mahasiswa :
NIM :
Tempat Pengkajian :
Tanggal :

I. Identitas Klien
Nama : No. RM :
Umur : Pekerjaan :
Jenis : Status :
Kelamin Perkawinan
Agama : Tanggal MRS :
Pendidikan : Tanggal :
Pengkajian
Alamat : 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:


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


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


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

e. Obat-obat yang digunakan:


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


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

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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

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 :
.
.
- Konsistensi :
.
.

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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- 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
Status Oksigenasi :

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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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 :

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

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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.

7. Pola persepsi diri
Gambaran diri :



Identitas diri :



Harga diri :



Ideal Diri :



Peran Diri :



Interpretasi :



.

8. Pola seksualitas & reproduksi
Pola seksualitas




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



.

9. Pola peran & hubungan

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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



.

10.Pola manajemen koping-stress






Interpretasi :



.

11.System nilai & keyakinan






Interpretasi :



.

IV. Pemeriksaan Fisik


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




Tanda vital:

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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- 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







5. Mulut


Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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6. Leher





7. Dada
.

....

...



Inspeksi dada (menggunakan otot bantu pernapasan, irama
pernapasan , kedalaman pernapasan)
.

....

...



Palpasi dada
.

....

...



Perkusi dada
.

....

...



Auskultasi dada (Adanya suara napas yang tidak normal seperti
wheezing, ronchi)
.

....

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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...



Pengkajian nyeri
P (Provoking/pencetus)
.

....

...



Q (Quality/Kualitas)
.

....

...



R (Region/ Lokasi)
.

....

...



S (Scale/ Skala)

T (Time/ Waktu)
.

....

...

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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Foto Thorack/Rontgen

8. Abdomen






9. Urogenital





10.Ekstremitas






11.Kulit dan kuku






12.Keadaan lokal

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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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


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

b. Pemeriksaan Sputum BTA

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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Hasil:






...
Interpretasi:





c. Pemeriksaan Polymerase chain reaction (PCR)


Hasil:






...
Interpretasi:





d. Uji tuberkulin / Tes mantoux


Hasil:






...
Interpretasi:

Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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e. Pemeriksaan BACTEC
Hasil:






...
Interpretasi:





f. Pemeriksaan serologi
Hasil:






...
Interpretasi:





,
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Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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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):
.................................................................................................................
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O (Objektif):
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A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan


DO):
.................................................................................................................
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.................................................................................................................
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P(Perencanaan):
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Panduan Profesi Ners Keperawatan Medikal Bedah PSIK UNEJ 2014


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I (Implementasi):
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E (Evaluasi):
S (Subjektif)
: ...............................................................................................................
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O
(Objektif): ................................................................................................
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A (analisa) :
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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.

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