PEMERINTAH KABUPATEN BANGGAI

AKADEMI KEPERAWATAN LUWUK

Alamat : Jl S. Musi no 15 Telp 0461- 22248 Luwuk
E-mail : akpeklwk@gmail.com
Website:http://akper-luwuk.ac.id

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Nama mahasiswa :
Nim :

1. IDENTITAS PASIEN DAN KELUARGA

a. Identitas Pasien
Nama :
Umur :
Jenis kelamin :
Agama :
Pendidikan :
Pekerjaan :
Suku/Bangsa :
Status Marital :
Tanggal Masuk RS :
Tanggal pengkajian :
No. MedRec :
Diagnosa Medis :
Alamat :
b. Identitas Penanggung Jawab :
Nama :
Umur :
Agama :
Pendidikan :
Pekerjaan :
Hubungan Dgn pasien :
Alamat :
2. RIWAYAT KESEHATAN
a. Keluhan Utama :
b. Riwayat Kesehatan Sekarang :
1) Alasan Masuk Rumah Sakit :

2) Riwayat Keluhan Saat Dikaji :

c. Riwayat Kesehatan Dahulu :

d. Riwayat Kesehatan Keluarga :

e. Riwayat Psikososial Spiritual :

1) Status emosi :
2) Kecemasan :
3) Pola koping :
4) Gaya komunikasi :
5) Konsep Diri :
a) Gambaran Diri :
b) Harga Diri :
c) Peran Diri :
d) Identitas Diri :
e) Ideal Diri :
6) Data Sosial :
7) Data Spiritual :

f. Genogram (Jika Diperlukan)

g. Pola Aktivitas Sehari-Hari

No Aktivitas Di Rumah Di Rumah Sakit
1 Nutrisi
a. Makan
b. Minum
 2 Eliminasi
a. BAK
b. BAB
3 Istirahat Tidur

4 Personal Hygiene
a. Mandi
b. Gosok gigi
c. Keramas
d. Gunting kuku
5 Aktivitas

3. PEMERIKSAAN FISIK
Status kesehatan umum
Kesadaran :
................................................................................................................................................................................
................................................................................................................................................................................
TTV: Suhu : ..............................................................................
TD : ..............................................................................
RR : ..............................................................................
Nadi : ..............................................................................

PEMERIKSAAN HEAD TO TOE

1. Kepala dan Leher
a. Kepala
...................................................................................................................................................................
...................................................................................................................................................................
b. Muka
...................................................................................................................................................................
...................................................................................................................................................................

.c. Mata
...................................................................................................................................................................
...................................................................................................................................................................
d. Telinga
...................................................................................................................................................................
...................................................................................................................................................................
.e. Hidung
..........................................................................................................................
..........................................................................................................................
f. Mulut dan faring
...................................................................................................................................................................
...................................................................................................................................................................
 g. Leher
..........................................................................................................................
.........................................................................................................................
2. Thoraks
a.Inpeksi
..............................................................................................................................................................
................................................................................................................................................................
b.Palpasi
................................................................................................................................................................
................................................................................................................................................................
c.Perkusi
..............................................................................................................................................................
................................................................................................................................................................
d.Auskultasi
................................................................................................................................................................
................................................................................................................................................................
3. Abdomen
a.Inpeksi
...................................................................................................................................................................
...................................................................................................................................................................
b.Palpasi
...................................................................................................................................................................
...................................................................................................................................................................
c.Perkusi
...................................................................................................................................................................
...................................................................................................................................................................
d.Auskultasi
...................................................................................................................................................................
...................................................................................................................................................................
4. Inguinal, genital dan Anus
......................................................................................................................................................................
5. Integumen
......................................................................................................................................................................
......................................................................................................................................................................
6. Muskuloskeletal
......................................................................................................................................................................
......................................................................................................................................................................
7. N e u r o l o g i s
......................................................................................................................................................................
......................................................................................................................................................................
Refleks : Fisilogis

Dextra Sinistra Dextra Sinistra

Biseps Triceps
 Dextra Sinistra Dextra Sinistra

Achiles Knee

Refleks : Patologis :

Dextra Sinistra Dextra Sinistra Dextra Sinistra

Babinski Chadok Oppenheim

PEMERIKSAAN PENUNJANG
1.Pemeriksaan Laboratorium
Tanggal: ..............................,
Jam:.....................................

PEMERIKSAAN HASIL NILAI RUJUKAN

Pemeriksaan Radiologi
................................................................................................................................................................................
1. Pemeriksaan Lain – lain
..........................................................................................................................................................................
..........................................................................................................................................................................
2. Terapi
..........................................................................................................................................................................
..........................................................................................................................................................................

DAFTAR MASALAH KEPERAWATAN

1……………………………………………………………………………………
2……………………………………………………………………………………
3……………………………………………………………………………………
4……………………………………………………………………………………

Analisa Data
NO DATA ETIOLOGI MASALAH
DIAGNOSA KEPERAWATAN (berdasarkan prioritas)
Masalah Masalah dipecahkan
No Diagnosa Keperawatan ditemukan
Tgl Paraf Tgl Paraf

PERENCANAAN KEPERAWATAN
Intervensi
No Diagnosa Keperawatan Tujuan dan Rencana Rasional
Kriteria hasil Tindakan

IMPLEMENTASI KEPERAWATAN
No No. Tindakan Keperawatan Paraf
Dx

CATATAN PERKEMBANGAN/EVALUASI
Tgl Diagnosa Keperawatan SOAP Paraf