SEKOLAH TINGGI ILMU KESEHATAN BANYWUANGI (STIKES)

(INSTITUTE OF HEALTH SCIENCES)

BANYUWANGI
Kampus 1 : Jl. Letkol Istiqlah 40 Telp. (0338) 421610 Banyuwangi
Kampus 2 : Jl. Letkol Istiqlah 109 Telp (0338) 425270 Banyuwangi
Website : www.stikesbanyuwangi.ac.id

FORMAT PENGKAJIAN
( KEPERAWATAN MEDIKAL BEDAH )

A. PENGKAJIAN
1. Biodata
a. Nama : .......................................................................
b. Umur : .......................................................................
c. Jenis Kelamin : .......................................................................
d. Agama : ......................................................................
e. Suku/Bangsa : .......................................................................
f. Alamat : .......................................................................
g. Pekerjaan : .......................................................................
h. Nomor Register : ........................................................................
i. Tanggal MRS : ........................................................................
j. Tanggal Pengkajian : ........................................................................
k. Diagnosa Medis : .......................................................................

Biodata Penanggung Jawab

a. Nama : .....................................................................
b. Umur : ....................................................................
c. Jenis Kelamin : ....................................................................
d. Agama : ....................................................................
e. Pekerjaan : ...................................................................
f. Pendidikan : ...................................................................
g. Status Perkawinan : ...................................................................
h. Suku Bangsa : ....................................................................
i. Alamat : ....................................................................

2. Keluhan Utama / Alasan Masuk rumah Sakit

a. Keluhan MRS
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b. Keluhan Saat Pengkajian

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3. Riwayat Penyakit Sekarang
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4. Riwayat Penyakit Masa Lalu
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5. Riwayat Kesehatan keluarga
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6. Riwayat Psikososial
a. Riwayat Psikologis
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 b. Aspek Sosial
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c. Aspek Spiritual / Sistem Nilai Kepercayaan
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7. Pola kebiasaan Sehari – hari
a. Pola Nutrisi
1) Sebelum Sakit
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Keterangan Sebelum Sakit
Frekuensi makanan
Jenis Makanan
Porsi
Keluhan
2) Saat Sakit
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Keterangan Sebelum Sakit
Frekuensi makanan
Jenis Makanan
Porsi
Keluhan
b. Pola Eliminasi
1) Buang Air Besar
a) Sebelum Sakit
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Keterangan Sebelum Sakit
Warna
Bau
Konsistensi
Frekuensi
b) Saat Sakit
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Keterangan Saat Sakit
Warna
Bau
Konsistensi
Frekuensi

2) Buang Air Kecil

a) Sebelum Sakit
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Keterangan Sebelum Sakit
Warna
Bau
Konsistensi
Frekuensi
b) Saat Sakit
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Keterangan Saat Sakit
Warna
Bau
Konsistensi
Frekuensi
c. Pola kebersihan diri
1) Sebelum Sakit
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2) Saat Sakit
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d. Pola Aktivitas, Latihan dan bermain
1) Sebelum Sakit
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2) Saat Sakit
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e. Pola Istirahat tidur

1) Sebelum Sakit
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2) Saat Sakit
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8. Pemeriksaan Fisik
Keadaan Umum
a. Keadaan Sakit
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b. Tanda – tanda Vital
Tensi : ........................................... Nadi : ....................................................
RR : ........................................... Suhu : ....................................................
BB : ........................................... TB : ....................................................
c. Pemeriksaan cepalo caudal
1) Kepala dan Rambut
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2) Hidung
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3) Telinga
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4) Mata
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5) Mulut, Gigi, Lidah, Tonsil, dan Pharing
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6) Leher dan Tenggorokan
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7) Dada / Thorax
a. Pemeriksaan Paru
1) Inspeksi
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2) Palpasi
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3) Perkusi
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4) Auskultasi
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b.Pemeriksaan jantung
1) Inspeksi
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2) Palpasi
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3) Perkusi
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4) Auskultasi
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c. Payudara
1) Inspeksi
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2) Palpasi
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 d.Pemeriksaan Abdomen
1) Inspeksi
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2) Palpasi
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3) Perkusi
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4) Auskultasi
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9. Ekstrimitas, Kuku dan Kekuatan otot
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10. Genetalia & Anus
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11. Pemeriksaan Neurologi
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Pemeriksaan Penunjang
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12. Penatalaksanaan
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13. Harapan Klien/ Keluarga sehubungan dengan penyakitnya
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14. Genogram

Banyuwangi,........................... 2018
Mahasiswa
 ANALISA DATA

Nama Pasien :
No. Register :
NO KELOMPOK DATA MASALAH ETIOLOGI
 DIAGNOSA KEPERAWATAN

Nama Pasien :
No. Register :
TANGGAL TANGGAL TANDA
DIAGNOSA KEPERAWATAN
MUNCUL TERATASI TANGAN
 RENCANA ASUHAN KEPERAWATAN

Nama Pasien :
No. Register :
GL NO TUJUAN KRITERIA HASIL INSTERVENSI RASIONAL TT
 RENCANA ASUHAN KEPERAWATAN

Nama Pasien :
No. Register :
GL NO TUJUAN KRITERIA HASIL INSTERVENSI RASIONAL TT
 CATATAN KEPERAWATAN

Nama Pasien :
No. Register :
NO
TANGGAL JAM TINDAKAN KEPERAWATAN TT
DX
 CATATAN PERKEMBANGAN

Nama Pasien :
No. Register :
NO
TANGGAL TANGGAL TANGGAL
DX