FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH

Nama Preceptee :………………………………………..

NIM :………………………………………..
Ruangan :……………………………………….
Tanggal Pengkajian :…………………… Jam …………………

IDENTITAS

Nama Pasien :……………………..

Umur :……………………..
Jenis Kelamin :……………………..
Suku Bangsa :…………………….
Pekerjaan :…………………….
Pendidikan :…………………….
Alamat :……………………..
Tanggal MRS :…………………….
Diagnosa Medis :……………………..

KELUHAN UTAMA SAAT PENGKAJIAN :

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RIWAYAT KESEHATAN :
1. Riwayat Kesehatan/Penyakit sekarang :
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2. Riwayat Kesehatan/Penyakit dahulu :

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3. Riwayat Kesehatan/Penyakit keluarga :

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Genogram :
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POLA FUNGSI KESEHATAN :

1. Pola penatalaksanaan kesehatan / persepsi sehat
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Masalah Keperawatan :
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2. Pola Nutrisi– Metabolik

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Masalah Keperawatan :
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3. Pola Eliminasi
Eliminasi Alvi
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Eliminasi Uri
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Masalah Keperawatan :
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4. Pola Istirahat dan tidur

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Masalah Keperawatan :
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5. Pola Aktifitas - Latihan

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Masalah Keperawatan :
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6. Pola kognitif – perseptual – keadekuatan alat sensori

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Masalah Keperawatan :
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7. Pola persepsi dan konsep diri

Pola persepsi
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 Konsep diri
a. Gambaran diri
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b. Harga diri
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c. Ideal diri
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d. Peran diri
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e. Identitas diri
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Masalah Keperawatan :
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8. Pola Reproduksi Seksual

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Masalah Keperawatan :
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9. Pola hubungan peran

 Persepsi klien tantang pola hubungan
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Persepsi klien tentang peran dan tanggung jawab

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Masalah Keperawatan :
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10. Mekanisme Koping

Kemampuan mengendalian stress

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Sumber pendukung
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Masalah Keperawatan :
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11. Pola tata nilai dan kepercayaan

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Masalah Keperawatan :
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PEMERIKSAAN FISIK

Status kesehatan umum

Kesadaran :
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TTV : Suhu : ...............................................................................
TD : ...............................................................................
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Nadi : . ...............................................................................

PEMERIKSAAN HEAD TO TOE

1. Kepala dan Leher
a. Kepala
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b. Muka
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c. Mata
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 d. Telinga
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e. Hidung
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f. Mulut dan faring
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g. Leher
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2. Thorak
a. Inpeksi
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b. Palpasi
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c. Perkusi
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d. Auskultasi
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3. Abdomen
a. Inpeksi
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b. Palpasi
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c. Perkusi
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d. Auskultasi.
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4. Inguinal, genital dan Anus

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5. Integumen
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6. Muskuloskeletal neurologis
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7. Neurologis
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Refleks : Fisilogis

Dextra Sinistra Dextra Sinistra

Biceps Triceps
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Dextra Sinistra Dextra Sinistra

Knee Achiles
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Patologis

Dextra Sinistra Dextra Sinistra

Babinski Oppenheim
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Dextra Sinistra

Chadok
PEMERIKSAAN PENUNJANG

1. Pemeriksaan Laboratorium
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2. Pemeriksaan Radiologi
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3. Pemeriksaan Lain – lain

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4. Terapi dan Diet.

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DAFTAR MASALAH KEPERAWATAN

1……………………………………………………………………………………
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10……………………………………………………………………………………
Surabaya,
Preceptee

(……………………….)
ANALISA DATA

NO DATA ETIOLOGI/PENYEBAB MASALAH

1

Surabaya,
Preceptee

(……………………….)
NO DX KEPERAWATAN KRETERIA HASIL INTERVENSI RASIONAL
1 DS :

DO :

4
NO IMPLEMENTASI EVALUASI
1 S:
O:
A:
P:

2 S:
O:
A:
P:

3 S:
O:
A:
P:

4 S:
O:
A:
P:

Surabaya,
Preceptee

(……………………….)

DAFTAR PUSTAKA