FORM KEP MEDIKAL BEDAH

UNIVERSITAS MUHAMMADIYAH JEMBER

FAKULTAS ILMU KESEHATAN
PROGRAM STUDI NERS
Jl. Karimata No. 49 Telp.(0331) 336728 Fax. 337957 Kotak Pos 104 Jember 68121

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Tgl / jam MRS : ………………………………. Ruang : ………………….…

Tgl. Pengkajian :……………………………….. No. Register : ………………….…
Diagnosa Medis : …………………………………………………………………………..

A. IDENTITAS KLIEN
Nama : ………………………………... Suami / Istri / Orang tua :
Umur : ………………………………... Nama :.…………………..
Jenis Kelamin : ………………………………… Pekerjaan :…………………..
Agama : ………………………………… Alamat :…………………...
Suku / Bangsa : …………………………………
Bahasa :………………………. ……….. Penanggung jawab :
Pendidikan : …………………………… Nama :…………………..
Pekerjaan : ………………………………… Alamat :…………………..
Status : …………………………………
Alamat : …………………………………

B. KELUHAN UTAMA
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C. RIWAYAT PENYAKIT SEKARANG

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Upaya yang telah dilakukan :…………………………………………………………….................
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Terapi yang telah diberikan :…………………………………………………………….................
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D. RIWAYAT KESEHATAN DAHULU
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E. RIWAYAT KESEHATAN KELUARGA
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Genogram :

F. Perilaku dan Lingkungan Yang Mempengaruhi Kesehatan

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G. POLA FUNGSI KESEHATAN

1. Pola persepsi dan tata laksana kesehatan
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2. Pola nutrisi dan metabolisme
Frekuensi……………………………………………………………………………….............
Alat Bantu..…………………………………………………………………………….............
Diet …………………………………………………………………………………….............
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3. Pola eliminasi
BAK
Frekuensi………………………………………………………………………………............
Jumlah....……………………………………………………………………………….............
Karakteristik....…………………………………………………………………………............
Alat Bantu...…………………………………………………………………………….............
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BAB
Frekuensi…………………………………………………………………………….................
Konsistensi……………………………………………………………………………..............
Karakteristik…………………………………………………………………………................
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4. Pola aktifitas
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Aktivity Daily Living (Mandiri, dibantu sebagian, dibantu total)
Makan/minum………………………………………………………………………….............
Berpakain…………………………………………………………………………….............…
Toileting……………………………………………………………………………….............
Mobilisasi di tempat tidur..…………………………………………………………….............
Berpindah....................................................................................................................................
Ambulasi.....................................................................................................................................
Respon tubuh terhadap aktifitas
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5. Pola istirahat – tidur

Durasi.………………………………………………………………………………….............
Gangguan……………………………………………………………………………….............
Lain-lain.……………………………………………………………………………….............
6. Pola kognitif dan persepsi sensori
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7. Pola konsep diri
Citra Tubuh………………………………………………………………….............…………
Identitas Diri......……………………………………………………………………….............
Harga diri……………………………………………………………………………….............
Ideal Diri……………………………………………………………….............………………
Peran Diri………………………………………………………………………….............
8. Pola hubungan – peran
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9. Pola fungsi seksual – seksualitas
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10. Pola mekanisme koping
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11. Pola nilai dan kepercayaan
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H. STATUS MENTAL ( PSIKOLOGIS)
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I. PEMERIKSAAN FISIK
1. Status kesehatan umum
Keadaan / penampilan umum :
Kesadaran :…………………………. GCS :
BB sebelum sakit :…………………………. T B : ..……………………...
BB saat ini :…………………………. BB ideal:………………………
Status gizi :…………………………..
Tanda– tanda Vital :
TD : ……………………… mmHg Suhu :……………….. C
N : ……………………… x/mnt RR : ……………... x/mnt
2. Pengkajian Nyeri
Skala Nyeri....................... Lokasi.................................... Frekuensi..........................................
Gambaran Nyeri..........................................................................................................................
Tanda Objektif............................................................................................................................
Respon emosional.......................................................................................................................
Cara mengatasi nyeri...................................................................................................................
3. Kepala & Leher
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4. Thorax (dada)
Pemeriksaan Paru Pemeriksaan Jantung
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5. Abdomen
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6. Tulang belakang
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6. Ekstrimitas
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7. Integumen
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8. Genetalia dan anus

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9. Pemeriksaan neurologis
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J. PEMERIKSAAN DIAGNOSTIK
Tgl Jenis Hasil Nilai Normal
Pemeriksaan

K. TERAPI
Nama Obat Rute Dosis Efek Samping Nama Obat Rute Dosis Efek Samping
1 6
2 7
3 8
4 9
5 10

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Mahasiswa,

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NIM : …………………….

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