RUMAH SAKIT GUNUNG MARIA

Jl. Sejahtera 282, Kelurahan Kolongan, Kec. Tomohon Tengah

Kota Tomohon Sulawesi Utara 95442
 (0431) 351008, 351308, 352944 Fax. (0431) 352414
Email : rsgunungmaria@yahoo.co.id

FORMAT PENGKAJIAN KEPERAWATAN

KEPERAWATAN MEDIKAL BEDAH
NAMA PEGAWAI YANG MENGKAJI: NRP:

UNIT :………………………………………………………….TGL PENGKAJIAN :……………………………………….

RUANG/KAMAR:…………………………………………………………..WAKTU PENGKAJIAN:…………………………………..

TGL MASUK RS :…………………………………………………………….Auto Anamnese :

Allo Anamnese :

I. IDENTIFIKASI
A. KLIEN
NAMA INITIAL :………………………………………………………………………………………………..
TEMPAT /TGL LAHIR(UMUR) :…………………………………………………………………………………………………
JENIS KELAMIN : LAKI-LAKI PEREMPUAN
STATUS PERKAWINAN :
JUMLAH ANAK :
AGAMA/SUKU :
WARGA NEGARA : INDONESIA ASING
BAHASA YANG DIGUNAKAN : INDONESIA

DAERAH…………………………………………………………..

ASING……………………………………………………………….

PENDIDIKAN :………………………………………………………………………………………….

PEKERJAAN :…………………………………………………………………………………………

ALAMAT RUMAH :………………………………………………………………………………………….

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 B. PENANGGUNG JAWAB

NAMA :…………………………………………………………………………………………
ALAMAT :……………………………………………………………………………………………
HUBUNGAN DENGAN KLIEN :……………………………………………………………………………………………

II. DATA MEDIK

A. DIKIRIM OLEH : UGD DOKTER PRAKTEK
B. DIAGNOSA MEDIK :
 SAAT MASUK :

 SAAT PENGKAJIAN :

III. KEADAAN UMUM

A. KEADAAN SAKIT : Klien tampak sakit ringan/sedang/berat/tidak tampak sakit
B. ALASAN :Tak bereaksi/baring lemah/duduk/aktif/gelisah/posisi tubuh……..
…………………../pucat cyanotis/sesak napas/penggunaan alat medik……
………………………………………………………………………………………………………….
Lain-lain……………………………………………………………………………………………..
C. KELUHAN UTAMA :…………………………………………………..
D. RIWAYAT KELUHAN UTAMA: (PQRST.DI NARASIKAN)………………………………………………………..
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E. KELUHAN YANG MENYERTAI:……………………………………………...............................................
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F. TANDA-TANDA VITAL”
1. KESADARAN:
 Kualitatif : Compos mentis somnolens Coma
Apatis Soporocomateus
 Kuantitatif :
Skala Coma Glasgow :
 Respon Motorik : ………… Jumlah
 Respon Bicara :…………
 Respon membuka mata :…………
Kesimpulan :………………………………………………………………………………………..
 Flaping Tremor/asterixis : Positif negative

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 2. TEKANAN DARAH : …………………………………….mmhg
MAP : …………………………………….mmhg
Kesimpulan :………………………………………………………………………………………………
3. SUHU : ……….0C Oral Axillar Rectal

4. NADI :……………………….

5. PERNAPASAN : Frekuensi………………x/menit

Irama : Teratur Kusmaul Cheynes-stokes

Jenis : Dada Perut

G. PENGUKURAN :
1. Lingkar Lengan Atas : ………………………..cm
2. Lipat kulit Triceps :…………………………cm
3. Tinggi Badan :…………………………cm Berat Badan :………………kg
2
I.M.T( Indeks massa Tubuh ):…………………………kg/ m
Kesimpulan : …………………………………………………………………………………….
Catatan : …………………………………………………………………………………….

H. GENOGRAM :

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IV. PENGKAJIAN POLA KESEHATAN (11 GORDON)

A. KAJIAN PERSEPSI KESEHATAN-PEMELIHARAAN KESEHATAN

Riwayat Penyakit Yang Pernah Dialami:
Sakit berat, dirawat, kecelakaan, operasi,
Gangguan kehamilan / persalinan, abortus, transfusi. reaksi alergi
Kapan Catatan

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Kapan Catatan

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1. DATA SUBJEKTIF
a. Keadaan sebelum sakit
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b. Keadaan sejak sakit
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 2. DATA OBJEKTIF
a. Observasi
 Kebersihan rambut :………………………………………………………………………………….
 Kulit Kepala : …………………………………………………………………………………
 Kebersihan Kulit : …………………………………………………………………………………
 Higiene rongga mulut : ………………………………………………………………………………….
 Kebersihan genitalia : …………………………………………………………………………………...
 Kebersihan anus : ……………………………………………………………………………………
TANDA/SCAR VAKSINASI : BCG Cacar

B. KAJIAN NUTRISI METABOLIK

1. Data Subjektif
a. Keadaan sebelum sakit :
...............................................................................................................................
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b. Keadaan sejak sakit:
...............................................................................................................................
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2. Data Objektif
a. Observasi
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b. Pemeriksaan Fisik
 Keadaan Rambut .......................................................................................
 Hidrasi kulit................................................................................................
 Palpebrae .......................................... Conyungtiva ...................................
 Sclera .........................................................................................................
 Hidung .......................................................................................................
 Rongga mulut ..................................... Gusi ...............................................
 Gigi Geligi ...........................................Gigi palsu ........................................
 Kemampuan mengunyah keras ..................................................................
 Lidah .............................................Tonsil ...................................................

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  Pharing .......................................................................................................
 Kelenjar getah bening leher .......................................................................
 Kelenjar parotis ...............................Kelenjar tyroid...................................
 Abdomen
 Inspeksi : Bentuk....................................................................................
Bayangan vena .....................................................................
Benjolan vena ......................................................................
 Auskultasi : Peristaltik ..............x/menit
 Palapasi : Tanda nyeri umum ............................................................
Massa ...............................................................................
Hidrasi kulit.......................................................................
Nyeri tekan: R.Epigastrica Titik Mc.Burney
R.Suprapubica R.Illiaca
Hepar ................................................................................
Lien ..................................................................................
 Perkusi : .............................................................................................
Ascites : Negatif

Positif ,Lingkar perut ............/.........../...........cm

 Kelenjar limfe inguinal ...............................................................................

 Kulit :
o Spider naevi : Negatif Positif

o Uremic frost : Negatif Positif

o Edema : Negatif Positif

o Icterik : Negatif Positif

o Tanda Radang ..............................................................................

 Lesi : ..........................................................................................................

c. Pemeriksaan Diagnostik
 Laboratorium:

 Lain-lain

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 d. Terapi :
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................

C. KAJIAN POLA ELIMINASI

1. Data Subjektif
a. Keadaan Sebelum sakit :
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b. Keadaan sejak sakit :
.................................................................................................................................
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2. Data Objektif
a. Observasi
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b. Pemeriksaan Fisik
 Peristaltik usus :...............x/menit
 Palpasi Suprapubica: kandung kemih Penuh Kosong
 Nyeri ketuk ginjal : Kiri Negatif Positif
Kanan Negatif Positif
 Mulut Uretra : ........................................................................................
 Anus :
 Peradangan : Negatif Positif
 Fissura : Negatif Positif
 Hemorhoid : Negatif Positif

 Prolapsus recti : Negatif Positif

 Fistula ani : Negatif Positif

 Masa tumor : Negatif Positif

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 c. Pemeriksaan diagnostik
 Laboratorium :

 Lain-lain

d. Terapi : ...................................................................................................................
................................................................................................................................
.................................................................................................................................
.................................................................................................................................

D. KAJIAN POLA AKTIVITAS DAN LATIHAN

1. Data Subjektif
a. Keadaan sebelum sakit :
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b. Keadaan sejak sakit
................................................................................................................................
.................................................................................................................................
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2. Data Objektif
a. Observasi
 Aktivitas harian :
 Makan
 Mandi 0: Mandiri
 Berpakaian
1: bantuan dengan alat
 Kerapihan
2 : bantuan orang
 Buang air besar
3 : bantuan orang dan alat
 Buang air Kecil
4 : Bantuan penuh
 Mobilisasi di tempat tidur

 Ambulasi : mandiri/tongkat/kursi roda/tempat tidur

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  Postur tubuh ..............................................................................................
 Gaya jalan...................................................................................................
 Anggota gerak yang cacat...........................................................................
 Fiksasi.........................................................................................................
 Tracheostomie...........................................................................................

b. Pemeriksaan fisik
 JVP :.........................cmH2O.Ksimpulan.....................................................
 Perfusi pembuluh perifer kuku:..................................................................
 Thoraks dan Pernapasan
 Inspeksi : Bentuk thorax:....................................................................
Stridor : Negatif Positif
Dyspnoe d”Effort : Negatif Positif

Syanosis Negatif Positif

 Palpasi : Vokal fremitus
 Perkusi : Sonor Redup Pekak
Batas paru hepar :.............................................................
Kesimpulan :.....................................................................
 Auskultasi : Suara Nafas ................................................................
Suara Ucapan ...................................................................
Suara Tambahan .............................................................
 Jantung
 Inspeksi: Ictus Cordis ......................................................................
Klien menggunakan alat pacu jantung Negatif
Positif
 Palpasi : Ictus cordis :......................................................................
Thrill : Negatif Positif
 Perkusi : Batas atas jantung ............................................................
Batas kanan jantung .........................................................
Batas kiri jantung .............................................................
 Auskultasi: Bunyi jantung II A :.............................................................
Bunyi jantung II P : ...........................................................
Bunyi jantung I T :.............................................................
Bunyi jantung I M : ...........................................................
Bunyi jantung III Irama Gallop : negatif Positif

Murmur : Negatif Positif, Tempat :....................

Grade :....................
HR :...............................x/menit
Bunyi Aorta : Negatif Positif

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 Arteri Renalis: Negatif Positif
Arteri Femoralis : Negatif Positif

 Lengan dan Tungkai

 Atrofi otot : Negatif Positif, Tempat:.........................
 Rentang gerak :.............................................................................
 Mati sendi :........................................................................
 Kaku sendi :.......................................................................
 Uji Kekuatan otot : Kiri 1 2 3 4 5
1 2 2 2 2
Kanan
1 1 1 21 13 1 4 5
 Reflex Fisiologik :…………………………………………………………………………
1 1 1 1 1
 Reflex Patologik : Babinski,Kiri
1 1 1 Negatif
1 1 Positif
1 1 1 Negatif
Babinski Kanan, 1 1 Positif
 Clubing jari-jari : 1 1 1 Positif
Negatif 1 1
 Varices Tungkai : 1 1 1 Positif
Negatif 1 1
 Columna Vertebralis 1 1 1 1
 Inspeksi : Kelainan bentuk …………………………………………………………..
 Palpasi : Nyeri tekan Negatif Positif
 N III-IV-VI :……………………………………………………………………………………
 N VIII Romberg Test : Negatif Positif
 N XI : ……………………………………………………………………………………………
 Kaku Kuduk : ……………………………………………………………………………….
c. Pemeriksaan Diagnostik
 Laboratorium

 Lain-lain

d. Terapi :
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E. KAJIAN POLA TIDUR DAN ISTIRAHAT
1. Data Subjektif
a. Keadaan sebelum sakit:
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b. Keadaan sejak sakit :
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2. Data Objektif
a. Observasi :
 Ekspresi wajah mengantuk : Negatif Positif

 Banyak menguap : Negatif Positif

 Palpebrae Inferior berwarna gelap : Negatif Positif

b. Terapi
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F. KAJIAN POLA PERSEPSI KOGNITIF

1. Data Subjektif
a. Keadaan sebelum sakit
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 b. Keadaan Sejak sakit :
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2. Data Objektif
a. Observasi
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b. Pemeriksaan Fisik
 Penglihatan
 Cornea :………………………………………………………
 Visus :………………………………………………………
 Pupil : ……………………………………………………..
 Lensa mata : ……………………………………………………..
 Tekanan Intra Ocular( TIO) :………………………………………………………
 Pendengaran
 Pina :…………………………………………………………………..
 Canalis :…………………………………………………………………..
 Membran Tympani :……………………………………………………………………
 Tes Pendengaran :……………………………………………………………………
 Pengenalan rasa posisi pada gerakan lengan dan tungkai
………………………………………………………………………………………………………………..
 NI :…………………………………………………………………..
 N II :……………………………………………………………………
 N V Sensorik :…………………………………………………………………..
 N VIII Pendengaran :……………………………………………………………………
 Tes Rombeg :…………………………………………………………………..
c. Pemeriksaan Diagnostik
 Laboratorium

 Lain-lain

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 d. Terapi
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G. KAJIAN POLA PERSEPSI DAN KONSEP DIRI

1. Data Subjektif
a. Keadaan sebelum sakit :
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b. Keadaan Sejak sakit :
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2. Data Objektif
a. Observasi
 Kontak mata : …………………………………………………………………..
 Rentang perhatian :……………………………………………………………………
 Suara dan cara berbicara :…………………………………………………………………..
 Postur Tubuh :…………………………………………………………………..
b. Pemeriksaan Fisik
Kelainan Bawaan yang nyata: ……………………………………………………………………………….
 Abdomen : Bentuk :…………………………………………………………………..
Bayangan vena :………………………………………………………………….
Bayangan massa:…………………………………………………………………..
 Kulit : Lesi kulit : …………………………………………………………………
 Penggunaan Protesa : Hidung Payudara

Lengan Tungkai

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H. KAJIAN POLA PERAN DAN HUBUNGAN DENGAN SESAMA
1. DataSubjektif
a. Keadaan sebelum sakit :
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b. Keadaan sejak sakit :
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I. KAJIAN POLA REPRODUKSI-SEKSUALITAS

1. Data Subjektif
a. Keadaan sebelum sakit :
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b. Keadaan sejak sakit :
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2. Data Objektif
a. Observasi
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 b. Pemeriksaan Fisik
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c. Pemeriksaan Diagnostik
 Laboratorium

 Lain-lain

d. Terapi :
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J. KAJIAN MEKANISME KOPING DAN TOLERANSI TERHADAP STRES

1. Data Subjektif
a. Keadaan Sebelum sakit :
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b. Keadaan sejak sakit :
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 2. Data Objektif
a. Observasi
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b. Pemeriksaan Fisik
 Tekanan Darah : Berbaring : ……………………mmHg
Duduk : …………………..mmHg
Berdiri : …………………..mmHg
Kesimpulan Hipotensi Ortostatik : Negatif Positif
 HR : ………………………………..x/menit
 Kulit : Keringat dingin : ……………………………………………………………………
Basah : …………………………………………………………………..

c. Terapi
………………………………………………………………………………………………………………………………
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K.KAJIAN POLA SISTEM NILAI KEPERCAYAAN

1. Data Subjektif
a. Keadaan sebelum sakit :
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b. Keadaan sejak sakit :
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2. Data Objektif
a. Observasi
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Nama dan Tanda Tangan yang Mengkaji

( )

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 KLASIFIKASI DATA

NO DATA SUBYEKTIF DATA OBYEKTIF

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PATOFLOW /PENYIMPANGAN KDM

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 ANALISA DATA

NO DATA ETIOLOGI MASALAH

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 DIAGNOSA KEPERAWATAN

NAMA/UMUR :
RUMAH SAKIT :
RUANG/KAMAR :

NO DIAGNOSA KEPERAWATAN NAMA JELAS

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 ASUHAN KEPERAWATAN
DI UNIT RAWAT INAP RS:………………………..

NAMA PASIEN :………………… RUANGAN:……………….. NO RM :………………………………

T DIAGNOSA TUJUAN INTERVENSI Rasional Tgl/J Implementasi Tgl/ja Evaluasi
gl N KEPERAWATAN am m
/j o
a
m

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 CATATAN PERKEMBANGAN

NAMA/UMUR :
RUANG/KAMAR :
Tgl/Jam No EVALUASI/SOAP Tgl/Jam IMPLEMENTASI NAMA
NDx JELAS

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