FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI ILMU KEPERAWATAN
FK-KMK UNIVERSITAS GADJAH MADA

Nama Mahasiswa : ______________________ Ruangan : ___________________

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

B. RIWAYAT PENYAKIT
Keluhan utama saat masuk RS:
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Riwayat Penyakit Sekarang:

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Riwayat Penyakit Dahulu:
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Diagnosa medic pada saat MRS, pemeriksaan penunjang dan tindakan yang telah dilakukan,
mulai dari pasien MRS (UGD/POLI), sampai diambil kasus kelolaan.
Masalah atau DxMedis pada saat MRS:
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Tindakan yang telah dilakukan di poliklinik atau UGD

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Catatan Penanganan Kasus (dimulai saat pasien di rawat di ruang rawat sampai pengambilan
kasus)
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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)
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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): __________________________________
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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
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. 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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D. PEMERIKSAAN FISIK
(Chepalocaudal)
Keluhan yang dirasakan saat ini: __________________________________________
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Kesadaran:
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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 ANALISIS DATA KEPERAWATAN

No. Hari/ Data Masalah Etiologi

Tanggal

NURSING CARE PLAN

Hari/ Diagnosa Keperawatan NOC NIC

Tanggal

8
 CATATAN PERKEMBANGAN

Hari/ Diagnosa Keperawatan Implementasi Evaluasi

Tanggal

9
10
PENANGANAN KASUS (dimulai saat Anda mengambil sebagai kasus kelolaan,
sampai akhir praktik)

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