FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

SEKOLAH TINGGI ILMU KESEHATAN BAHRUL U’LUM

PROGRAM STUDI DIII KEPERAWATAN

Nama Mahasiswa : …………………………..

N I M : ………………..................
Ruangan : ………………………......
Tanggal Pengkajian : …………………….......... Jam: ………

IDENTITAS KLIEN
Nama : ………………….. No. Reg. : ……………………….
Umur : ............. tahun Tgl. MRS : ……………………….
Jenis Kelamin : .............................. Diagnosa : ……………………….
Suku/Bangsa : …………………..
Agama : …………………..
Pekerjaan : …………………..
Pendidikan : …………………..
Alamat : ………………………………………………………………………………….
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I. RIWAYAT KEPERAWATAN (NURSING HISTORY)

I.1 Riwayat Sebelum Sakit:
Penyakit berat yang penah diderita : …………………………………………………….
Obat-obat yang biasa dikonsumsi : …………………………………………………….
Kebiasaan berobat : …………………………………………………….
Alergi : …………………………………………………….
Kebiasaan merokok/alkohol : …………………………………………………….

I.2 Riwayat Penyakit Sekarang

Keluhan utama :
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Riwayat keluhan utama : .....................................................................................................
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Upaya yang telah dilakukan:
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Terapi/operasi yang pernah dilakukan:
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 I.3 Riwayat Kesehatan Keluarga
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Genogram:

I.4 Riwayat Kesehatan Lingkungan

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II. Pemeriksaan Fisik
1. Keadaan Umum: ..............................................................................................................
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 Kesadaran: ..................................................................................................................
 Tanda-tanda vital: - Tekanan darah :……… mmHg - Suhu :………oC
- Nadi :……... x/meni - RR :……… x/menit
 Tinggi badan: ....................................cm Berat Badan:........................kg
2. Kepala & Leher
a. Kepala : ......................................................................................................................
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b. Mata :..........................................................................................................................
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c. Hidung :.......................................................................................................................
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d. Mulut & tenggorokan:
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e. Telinga:.......................................................................................................................
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f. Leher:..........................................................................................................................
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3. Thorak & Dada:
 Jantung
- Inspeksi:..................................................................................................................
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- Palpasi:...................................................................................................................
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- Perkusi:...................................................................................................................
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- Auskultasi:..............................................................................................................
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 Paru
- Inspeksi:..................................................................................................................
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- Palpasi:...................................................................................................................
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- Perkusi:...................................................................................................................
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- Auskultasi:..............................................................................................................
4. Payudara & Ketiak
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5. Punggung & Tulang Belakang
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6. Abdomen
 Inspeksi:......................................................................................................................
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 Palpasi:.......................................................................................................................
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 Perkusi:.......................................................................................................................
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 Auskultasi:...................................................................................................................
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7. Genetalia & Anus
 Inspeksi:......................................................................................................................
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 Palpasi:.......................................................................................................................
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8. Ekstermitas
 Atas:............................................................................................................................
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 Bawah:........................................................................................................................
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9. Sistem Neorologi
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10. Kulit & Kuku
 Kulit:..............................................................................................................................
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 Kuku: ...........................................................................................................................
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III. Pola Kesehatan

III.1 Pola Aktifitas-Latihan

Rumah Rumah Sakit
 Makan/minum .................................................... ....................................................
 Mandi .................................................... ....................................................
 Berpakaian/berdandan .................................................... ....................................................
 Toileting .................................................... ....................................................
 Mobilitas di tempat tidur .................................................... ....................................................
 Berpindah .................................................... ....................................................
  Berjalan .................................................... ....................................................
 Naik tangga .................................................... ....................................................

III.2 Pola Nutrisi Metabolik

Rumah Rumah Sakit
 Jenis diit/makanan .............................................. .................................................
 Frekuensi/pola .............................................. .................................................
 Porsi yg dihabiskan .............................................. .................................................
 Komposisi menu .............................................. .................................................
 Pantangan .............................................. .................................................
 Napsu makan .............................................. .................................................
 Fluktuasi BB 6 bln. terakhir .............................................. .................................................
 Jenis minuman .............................................. .................................................
 Frekuensi/pola minum .............................................. .................................................
 Gelas yg dihabiskan .............................................. .................................................
 Sukar menelan (padat/cair) .............................................. .................................................
 Pemakaian gigi palsu (area) .............................................. .................................................
 Riw. masalah penyembuhan luka .............................................. .................................................

III.3 Pola Eliminasi

Rumah Rumah Sakit
 BAB:
- Frekuensi/pola .................................................... .................................................
- Konsistensi .................................................... .................................................
- Warna & bau .................................................... .................................................
- Kesulitan .................................................... .................................................
- Upaya mengatasi .................................................... .................................................
 BAK:
- Frekuensi/pola .................................................... .................................................
- Konsistensi .................................................... .................................................
- Warna & bau .................................................... .................................................
- Kesulitan .................................................... .................................................
- Upaya mengatasi .................................................... .................................................

III.4 Pola Tidur-Istirahat

Rumah Rumah Sakit
 Tidur siang: .............................................. ....................................................
- Jam …s/d… ............................................. ..................................................
- Kenyamanan stlh. tidur ............................................. ..................................................
 Tidur malam: .............................................. ....................................................
- Jam …s/d… ............................................. ..................................................
- Kenyamanan stlh. tidur ............................................. ..................................................
- Kebiasaan sblm. tidur ............................................. ..................................................
 - Kesulitan ............................................. ..................................................
- Upaya mengatasi ............................................. ..................................................

III.5 Pola Kebersihan Diri

Rumah Rumah Sakit
 Mandi ................................................. .................................................
 Keramas ................................................. .................................................
 Gosok gigi ................................................. .................................................
 Ganti baju: ................................................. .................................................
 Memotong kuku: ................................................. .................................................
 Kesulitan ................................................. .................................................
 Upaya yg dilakukan ................................................. .................................................

III.6 PSIKO-SOSIAL-SPIRITUAL

 Sosial / interaksi :
Rumah: ................................................................................................................................
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Rumah Sakit : ......................................................................................................................
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 Konsep diri
Rumah: ................................................................................................................................
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 Spiritual
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Rumah Sakit : ......................................................................................................................
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PEMERIKSAAN PENUNJANG
Laboratorium :
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X Ray :
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USG :
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Lain-lain (sebutkan)
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TERAPI
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Tanda Tangan Mahasiswa

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NIM.