FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Tanggal MRS : Jam Masuk :

Tanggal Pengkajian : No. RM :
Jam Pengkajian : Diagnosa Masuk :

IDENTITAS
1. Nama Pasien :
2. Umur :
3. Suku/ Bangsa :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :
8. Sumber Biaya :

KELUHAN UTAMA
Keluhan utama: .....................................................................................................................................
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RIWAYAT PENYAKIT SEKARANG

Riwayat Penyakit Sekarang: ..................................................................................................................
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RIWAYAT PENYAKIT DAHULU

1. Pernah dirawat : ya tidak kapan :......... Diagnosa :..........
2. Riwayat penyakit kronik dan menular : ya tidak jenis :...................
Riwayat kontrol : .................................
Riwayat penggunaan obat : .................
3. Riwayat alergi :
Obat ya tidak jenis:...........
Makanan ya tidak jenis:...........
Lain-lain ya tidak jenis:...........
4. Riwayat operasi : ya tidak
- Kapan : .................
- Jenis operasi : .................
5. Lain-lain: ...........................................................................................................................................
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RIWAYAT PENYAKIT KELUARGA
ya tidak
- Jenis :...................
- Genogram

PERILAKU YANG MEMPENGARUHI KESEHATAN Masalah Keperawatan:

Perilaku sebelum sakit yang mempengaruhi kesehatan:
Alkohol ya tidak
Keterangan: ..............................................................................
Merokok ya tidak
Keterangan: ..............................................................................
Obat ya tidak
Keterangan: ..............................................................................
Olahraga ya tidak
Keterangan: ..............................................................................

OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda-tanda vital
0
S: C N: x/mnt TD: mmHg RR: x/mnt
Kesadaran: Compos Mentis Apatis Samnolen Sopor Koma

2. Sistem pernafasan
a. RR: x/menit
b. Keluhan: sesak nyeri waktu nafas orthopnea
Batuk: produktif tidak produktif
Sekret :............ Konsistensi :.....................
Warna:............ Bau :................................
c. Penggunaan otot bantu napas : .....................................................................................................
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d. PCH : ya tidak
e. Irama nafas : teratur tidak teratur
f. Pola nafas: Dispnoe Kusmaul Cheyne Stokes
g. Suara nafas: Vesikuler Bronko vesikuler Masalah Keperawatan :
Tracheal Bronkial
Ronki Wheezing
Crackles
h. Alat bantu nafas: ya tidak

Jenis:................................ Flow:.......................lpm
i. Penggunaan WSD:
- Jenis : .........................................................................................................................
- Jumlah cairan : .........................................................................................................................
- Undulasi : .........................................................................................................................
- Tekanan : .........................................................................................................................
 j. Tracheostomy : ya tidak
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k. Lain-lain
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3. Sistem kardio vaskuler Masalah Keperawatan:

a. TD: mmHg
b. N : x/mnt
c. HR : x/mnt
d. Keluhan nyeri dada: ya tidak
P : .............................................................
Q: .............................................................
R: .............................................................
S: ..............................................................
T: ............................................................
e. Irama jantung: reguler ireguler
f. Suara jantung: normal (S1/S2 tunggal) murmur
gallop lain-lain:
g. Ictus cordis:........................................
h. CRT:..........detik
i. Konjungtiva ananemis anemis
j. Akral: hangat kering merah pucat
Panas dingin
k. Sirkulasi perifer : normal menurun
l. JVP : ................................
m. CVP: ................................
n. CRT: ................................
o. ECG & Interprestasinya:
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p. Lain-lain:
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4. Sistem persyarafan
o
a. S : C
b. GCS: Masalah keperawatan:
c. Refleks fisiologis patella triceps biceps
d. Refleks patologis babinsky brudzinsky kernig
e. Keluhan pusing ya tidak
P : .............................................................
Q: .............................................................
R: .............................................................
S: ..............................................................
T: ..............................................................
f. Pemeriksaan saraf kranial:
N1 : normal tidak Ket: ...................................................................
N2 : normal tidak Ket: ...................................................................
N3 : normal tidak Ket: ...................................................................
N4 : normal tidak Ket: ...................................................................
N5 : normal tidak Ket: ...................................................................
 N6 : normal tidak Ket: ...................................................................
N7 : normal tidak Ket: ...................................................................
N8 : normal tidak Ket: ...................................................................
N9 : normal tidak Ket: ...................................................................
N10 : normal tidak Ket: ...................................................................
N11 : normal tidak Ket: ...................................................................
N12 : normal tidak Ket: ...................................................................

g. Pupil anisokor isokor Diameter :....

h. Istirahat/ tidur :............jam/hari
i. Lain-lain
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5. Sistem perkemihan Masalah Keperawatan:

a. Kebersihan genetalia: Bersih Kotor
b. Sekret: Ada Tidak
c. Ulkus: Ada Tidak
d. Kebersihan meatus uretra: Bersih Kotor
e. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
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f. Kemampuan berkemih:
Spontan Alat bantu, sebutkan:.........................
Jenis :...................................................................
Ukuran :...................................................................
Hari ke :...................................................................
g. Produksi urine:............ml/jam
Warna :..............
Bau :..............
h. Kandung kemih Membesar ya tidak
i. Nyeri tekan ya tidak
j. Intake cairan oral :...........cc/hari parenteral :............cc/hari
k. Balance cairan
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l. Lain-lain
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6. Sistem pencernaan
a. TB :.........cm BB :.........kg Masalah keperawatan:
b. IMT : Interpretasi :
c. LILA :
d. Sclera : anikterus ikterus
e. Mulut : bersih kotor berbau
f. Membran mukosa: lembab kering stomatitis
g. Tenggorokan:
sakit menelan kesulitan menelan
pembesaran tonsil nyeri tekan
h. Abdomen: tegang kembung ascites
i. Nyeri tekan: ya tidak
 j. Luka operasi: ya tidak
Tanggal operasi : ....................................................
Jenis operasi : ....................................................
Lokasi : ....................................................
Keadaan : ....................................................
Drain : ada tidak
- Jumlah : ..........................
- Warna : ..........................
- Kondisi area sekitar insersi : ..........................
k. Peristaltik :........x/menit
l. BAB :...............x/hari Terakhir tanggal :..........
m. Konsistensi : keras lunak cair lendir/ darah
n. Diet : padat lunak cair
o. Diet khusus :
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p. Nafsu makan: baik menurun Frekuensi :........x/hari
q. Porsi makan: habis tidak Keterangan:.......

r. Lain-lain:
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7. Sistem penglihatan
a. Pengkajian segmen anterior dan posterior : Masalah keperawatan:

OD OS
Visus

Palpebra

Conjungtiva

Kornea

Pupil

Iris

Lensa

TIO

b. Keluhan nyeri : ya tidak

P: ..............................................................
Q: .............................................................
R: .............................................................
S: ..............................................................
T: ..............................................................
c. Luka operasi : ya tidak
Tanggal operasi : .............................
Jenis operasi : .............................
Lokasi : .............................
Keadaan : .............................
d. Pemeriksaan penunjang lain :................
e. Lain-lain
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8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
OD OS Masalah keperawatan:
Aurcicula

Membran
Tympani

Rinne

Weber

b. Tes Audiometri:
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c. Keluhan nyeri: ya tidak
P: ..............................................................
Q: .............................................................
R: .............................................................
S: ..............................................................
T: ..............................................................
d. Luka operasi: ada tidak
Tanggal operasi : .............................
Jenis operasi : .............................
Lokasi : .............................
Keadaan : .............................
e. Alat bantu dengar : .............................
f. Lain-lain
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9. Sistem muskuloskeletal Masalah keperawatan:

a. Pergerakan sendi : ya terbatas
b. Kekuatan otot :

c. Kelainan ekstremitas : ya tidak

d. Kelainan tulang belakang : ya tidak
Ket : ……………. ............................................
e. Fraktur: ya tidak
Jenis : .............................................................
f. Traksi: ya tidak
- Jenis : ......................................
- Beban : ......................................
- Lama pemasangan : .....................................
g. Penggunaan spalk/ gips : ya tidak
h. Keluhan nyeri : ya tidak
P: ..............................................................
Q: .............................................................
R: .............................................................
S: ..............................................................
T: ..............................................................
i. Sirkulasi perifer : ....................................
j. Kompartemen syndrome: ya tidak
k. Kulit : ikterik sianosis kemerahan hiperpigmentasi
 l. Turgor : baik kurang jelek
m. Luka operasi : ada tidak
Tanggal operasi : ....................................
Jenis operasi : ....................................
Lokasi : ....................................
Keadaan : ....................................
Drain : ada tidak
- Jumlah : ...................
- Warna : ...................
- Kondisi area sekitar insersi : ...................
n. ROM : .............................................
o. Lain-lain :
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10. Sistem integumen

a. Penilaian risiko decubitus:
ASPEK YANG KRITERIA PENILAIAN
NILAI
DINILAI 1 2 3 4
PERSEPSI TERBATAS SANGAT KETERBATASAN TIDAK ADA
SENSORI SEPENUHNYA TERBATAS RINGAN GANGGUAN
TERUS
SANGAT
KELEMBABAN MENERUS KADANG2 BASAH JARANG BASAH
LEMBAB
BASAH
LEBIH SERING
AKTIVITAS BEDFAST CHAIRFAST KADANG2 JALAN
JALAN
IMMOBILE SANGAT KETERBATASAN TIDAK ADA
MOBILISASI
SEPENUHNYA TERBATAS RINGAN KETERBATASAN
SANGAT KEMUNGKINAN
NUTRISI ADEKUAT SANGAT BAIK
BURUK TIDAK ADEKUAT
TIDAK
GESEKAN & POTENSIAL
BERMASALAH MENIMBULKAN
PERGESERAN BERMASALAH
MASALAH
NOTE: Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien berisiko
mengalami dekubitus (pressure ulcers) TOTAL NILAI
(15 or 16 = low risk, 13 or 14 = moderate risk, 12 or less = high risk)

b. Warna : ........................................................
Masalah keperawatan:
c. Pitting edema : +/-
d. Ekskoriasis : ya tidak
e. Psoriasis : ya tidak
f. Pruritus : ya tidak
g. Urtikaria : ya tidak
h. Lain-lain :
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11. Sistem endokrin

Masalah keperawatan:
a. Pembesaran tyroid : ya tidak
b. Pembesaran kelenjar getah bening : ya tidak
c. Hipoglikemia : ya tidak
d. Hiperglikemia : ya tidak
e. Kondisi kaki DM :
- Luka gangren : ya tidak
- Lama luka : .................................
- Warna : .................................
- Luas luka : .................................
- Kedalaman : .................................
- Kulit kaki : .................................
- Kuku kaki : .................................
- Telapak kaki : .................................
- Jari kaki : .................................
 - Infeksi : ya tidak
- Riwayat luka sebelumnya : ya tidak
Jika ya :
- Tahun : ......................
- Jenis luka : ......................
- Lokasi : ......................
- Riwayat amputasi sebelumnya : ya tidak
Jika ya :
- Tahun : ......................
- Lokasi : ......................
f. Lain-lain
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PENGKAJIAN PSIKOSOSIAL
a. Persepsi klien terhadap penyakitnya : Masalah keperawatan:
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b. Ekspresi klien terhadap penyakitnya

murung/ diam gelisah tegang marah/ menangis
c. Reaksi saat interaksi kooperatif tidak kooperatif curiga
d. Gangguan konsep diri:
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e. Lain-lain:
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PERSONAL HYGIENE & KEBIASAAN

a. Kebersihan diri : Masalah keperawatan :
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b. Kemampuan klien dalam pemenuhan kebutuhan
- Mandi : dibantu seluruhnya dibantu sebagian mandiri
- Ganti pakaian :
dibantu seluruhnya dibantu sebagian mandiri
- Keramas : dibantu seluruhnya dibantu sebagian mandiri
- Sikat gigi : dibantu seluruhnya dibantu sebagian mandiri
- Memotong kuku :
dibantu seluruhnya dibantu sebagian mandiri
- Berhias : dibantu seluruhnya dibantu sebagian mandiri
- Makan : dibantu seluruhnya dibantu sebagian mandiri

PENGKAJIAN SPRITUAL
a. Kebiasaan beribadah Masalah keperawatan:
- Sebelum sakit sering kadang-kadang tidak pernah
- Selama sakit sering kadang-kadang tidak pernah

b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah :

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PEMERIKSAAN PENUNJANG (Laboratorium, Radiologi, EKG, USG, dll)
Tanggal :
Jam :
Pemeriksaan Hasil Satuan Nilai rujukan Kesimpulan
TERAPI

DATA TAMBAHAN LAIN:

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