FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS GADJAH MADA

Nama Mahasiswa : ______________________ Ruangan : ____________________

Waktu Praktik : ______________________ Pembimbing : ____________________

FORMAT LAPORAN KASUS KEPERAWATAN MEDIKAL BEDAH

DI INSTALASI BEDAH SENTRAL

I. Asuhan Keperawatan Preoperatif

1. Identitas
Nama : __________________________________________________
Umur : __________________________________________________
Status : __________________________________________________
Agama : __________________________________________________
Tanggal masuk : __________________________________________________
Tanggal pengkajian : __________________________________________________
Sumber informasi : __________________________________________________
2. Pengkajian
A. Riwayat kesehatan
Dx Medis : __________________________________________________
Jenis operasi : __________________________________________________
Jenis anastesi : __________________________________________________
Keluhan utama : __________________________________________________
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 Riwayat Penyakit Sekarang: ______________________________________________
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Riwayat Penyakit dahulu: ________________________________________________

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B. 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)
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2. Pola Nutrisi/ Metabolik
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): __________________________________
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Intake cairan : ______________________________________________________
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3. Pola Eliminasi
a. Buang Air Besar (frekuensi, warna, jumlah, konsistensi, ketidaknyamanan,
kontrol saat defekasi, apakah ada perubahan khusus)
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b. Buang Air Kecil (frekuensi, warna, jumlah, bau, ketidaknyamanan, kontrol saat
defekasi, apakah ada perubahan khusus, nokturia)
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 c. Balance Cairan
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4. Pola Aktivitas dan latihan

Skor barthel index:
Skor Risiko Jatuh (Morse):
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilisasi di tempat tidur
Berpindah
Ambulasi ROM
0: mandiri, 1: alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4:
tergantung total
Oksigenasi:
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5. Pola Tidur dan Istirahat (lama tidur, gangguan tidur; penggunaan obat bantu tidur;
faktor terkait, seperti nyeri, kenyamanan lingkungan, suhu):
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6. Pola Perceptual (penglihatan; pendengaran; pengecap; sensasi; pembau; penggunaan

alat bantu; nyeri dan kenyamanan):
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7. Pola persepsi diri (pandangan klien tentang sakitnya; kecemasan; konsep diri):
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8. Pola Seksualitas dan Reproduksi (masalah seksual; fertilitas, libido, menstruasi,

kontrasepsi, dll.):
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9. Pola Peran-hubungan (perubahan peran, komunikasi, hubungan dengan orang lain,

kemampuan keuangan, significant others):
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 10. Pola Managemen Koping-Stress (stress saat ini; koping; perubahan terbesar dalam
hidup pada akhir-akhir ini/ kehilangan, dll):
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11. Sistem Nilai dan Keyakinan (budaya terkait kesehatan; pandangan klien tentang
agama; kegiatan agama, dll.):
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Riwayat Pertumbuhan dan Perkembangan

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II. Pemeriksaan Fisik

Keluhan yang dirasakan saat ini: _____________________________________________
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1. Keadaan umum:
TD : ____________ mmHg
P : ____________ x/menit
N : ____________ x/menit
S : ____________ OC
BB/ TB: _________ kg/ __________ cm
2. Kulit
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3. Kepala
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4. Mata
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5. Telinga
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6. Hidung
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7. Mulut
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8. Leher
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9. Dada
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10. Payudara
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11. Paru-paru
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12. Abdomen
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13. Genitalia
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14. Anus dan rectum
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15. Muskuloskeletal
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16. Neurology
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Pemeriksaan Laboratorium

Persiapan Operasi

Persiapan saat di ruang penerimaan

 ANALISIS DATA KEPERAWATAN

Pre Operasi

No. Data Diagnosa Keperawatan Tujuan Intervensi

 IMPLEMENTASI DAN EVALUASI

No Diagnosa Keperawatan Hari/ Implementasi Evaluasi

Tanggal
III. Asuhan Keperawatan Intraoperatif

Pengkajian
Persiapan Perawat

Persiapan Alat dan Ruang

Alat steril:

Alat tidak steril:

Bahan medis habis pakai:

Set yang dipakai (instrumen yang digunakan):

Persiapan Pasien

Prosedur Operasi
 ANALISA DATA

Intra Operasi

Hari/Tgl Data Dx. Kep NOC NIC

 CATATAN PERKEMBANGAN

Diagnosa Hari/Tgl Waktu IMPLEMENTASI EVALUASI

IV. Asuhan Keperawatan Post Operatif
Pengkajian pasien
(Tanda-tanda vital, aldrete skor)
 ANALISA DATA
Post Operasi

Hari/Tgl Data Dx. Kep NOC NIC

 CATATAN PERKEMBANGAN

Diagnosa Hari/Tgl Waktu IMPLEMENTASI EVALUASI