FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS GADJAH MADA

Nama Mahasiswa : ______________________ Ruangan : ___________________

Waktu Praktik : ______________________ Pembimbing : ___________________
A. IDENTITAS DIRI KLIEN
Nama : ____________________________________________________ ___
Umur : _____________________________________________________
Jenis Kelamin : ____________________________________________________ ___
Alamat : ____________________________________________________ ___
Status Perkawinan : ____________________________________________________ ___
Agama : ____________________________________________________ ___
Suku Bangsa : ____________________________________________________ ___
Pendidikan : ____________________________________________________ ___
Pekerjaan : ____________________________________________________ ___
Lama Bekerja : ____________________________________________________ ___
Dx Medis : ____________________________________________________ ___
Tanggal MRS : ____________________________________________________ ___
No RM : ____________________________________________________ ___
Tanggal Pengkajian : ____________________________________________________ ___
Jam Pengkajian : ____________________________________________________ ___
Sumber Informasi : ____________________________________________________ ___

B. RIWAYAT PENYAKIT
Keluhan utama saat masuk RS:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

1
Riwayat Penyakit Sekarang:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Riwayat Penyakit Dahulu:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Diagnosa medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah dilakukan,
mulai dari pasien MRS (UGD/POLI), sampai diambil kasus kelolaan.
Masalah atau Dx Medis pada saat MRS:
___________________________________________________________________________
___________________________________________________________________________

Tindakan yang telah dilakukan di poliklinik atau UGD

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
2
Catatan Penanganan Kasus (dimulai saat pasien di rawat di ruang rawat sampai pengambilan
kasus)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

C. PENGKAJIAN KEPERAWATAN
1. Persepsi dan pemeliharaan kesehatan (Pengetahuan tentang penyakit/ perawatan; obat
yang biasa dikonsumsi, faktor risiko tentang penyakit, seperti: riwayat keluarga,
kebiasaan, dll.; perlindungan kesehatan; kebiasaan dalam menangani sakit, seperti:
pilihan pengobatan; kebutuhan akan edukasi kesehatan/ discharge planning)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3
2. Pola Nutrisi/Metabolik
Program diit RS : ______________________________________________________
Intake makanan (Pengkajiam nutrisi ABCD/ skrining nutrisi; faktor spesifik dalam
memilih makanan, seperti: budaya, agama, ekonomi; faktor yang mempengaruhi
ingesti makanan, seperti: nafsu makan, kenyamanan, kesehatan gigi dan mulut, alergi,
nyeri, mual, muntah, pantangan makanan): __________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Intake cairan : ______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3. Pola Eliminasi
a. Buang Air Besar (frekuensi, warna, jumlah, konsistensi, ketidaknyamanan,
kontrol saat defekasi, apakah ada perubahan khusus)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
b. Buang Air Kecil (frekuensi, warna, jumlah, bau, ketidaknyamanan, kontrol saat
defekasi, apakah ada perubahan khusus, nokturia)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4
 c. Balance Cairan
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

4. Pola Aktivitas dan latihan

Kemampuan Perawatan diri 0 1 2 3 4
Makan dan minum
Mandi
Toileting
Berpakaian
Mobilitas ditempat tidur
Berpindah
Ambulansi/ROM
Keterangan : 0: Mandiri, 1 : alat bantu, 2 : dibantu orang lain, 3: dibantu orang lain
dan alat, 4: tergantung total
a. Skor Pengkajian Fungsional ADL (BARTHEL INDEX):
b. Skor Risiko Jatuh (MORSE):
c. Skor Risiko Dekubitus (BRADEN SCALE):
d. Fungsi Respiratory:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
e. Fungsi Cardiovascular:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

5
 f. Fungsi Neurologis:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
g. Fungsi Muskuloskeletal:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

5. Pola Tidur dan Istirahat (lama tidur, gangguan tidur; penggunaan obat bantu tidur;
faktor terkait, seperti nyeri, kenyamanan lingkungan, suhu):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

6. Pola Perceptual (penglihatan; pendengaran; pengecap; sensasi; pembau; penggunaan

alat bantu; nyeri dan kenyamanan):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

7. Pola persepsi diri (pandangan klien tentang sakitnya; kecemasan; konsep diri):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
6
8. Pola Seksualitas dan Reproduksi (masalah seksual; fertilitas, libido, menstruasi,
kontrasepsi, dll.):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

9. Pola Peran-hubungan (perubahan peran, komunikasi, hubungan dengan orang lain,

kemampuan keuangan, significant others):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

10. Pola Managemen Koping-Stress (stress saat ini; koping; perubahan terbesar dalam
hidup pada akhir-akhir ini/ kehilangan, dll):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

11. Sistem Nilai dan Keyakinan (budaya terkait kesehatan; pandangan klien tentang
agama; kegiatan agama, dll.):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
7
D. PEMERIKSAAN FISIK
(Chepalocaudal)
Keluhan yang dirasakan saat ini: _____________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Kesadaran:
Keadaan umum :
TD : ____________ mmHg
P : ____________ x/menit
N : ____________ x/menit
S : ____________ OC
BB/ TB: _________ kg/ __________ cm

Kepala:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Leher:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

8
Thorak:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Abdomen:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Inguinal:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Ekstremitas:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

9
E. PENANGANAN KASUS (dimulai saat Anda mengambil sebagai kasus kelolaan,
sampai akhir praktik)

10