14

FORMAT PENGKAJIAN PBK

KEPERAWATAN MEDIKAL BEDAH I

Nama Mahasiswa : .....................................................

Tempat Praktek : .....................................................
Tanggal pengkajian : .....................................................

I. Identitas diri klien

Nama/inisial : ........................... Tgl masuk RS : ..............................
Umur :........................... Keluarga terdekat yang dapat
Jenis kelamin : ........................... segera dihubungi : ................
Pekerjaan : ………………….
Alamat : ............................................................................
Status Perkawinan : ...............................
Agama : ................................
Suku : ................................
Pendidikan : ................................
Dx medis : ................................
No. Register medis : .................................

II. Status Kesehatan Saat ini

1. Alasan kunjungan / keluhan utama : ............................................................................
......................................................................................................................................
2. Faktor pencetus : ..........................................................................................................
3. Lamanya keluhan : .......................................................................................................
4. Timbulnya keluhan : [ ] bertahap
: [ ] mendadak
5. Faktor yang
memperberat : .............................................................................................
6. Riwayat perjalanan penyakit : .....................................................................................

Catatan / Data tambahan : ………………………..........................................

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III. Riwayat kesehatan yang lalu

1. Penyakit yang pernah dialami
a. Kanak – kanak : .....................................................................................................
b. Kecelakaan :.......................................................................................................
c. Operasi : .................................................................................................................
2. Alergi : ………………………………………………………………………………
3. Imunisasi : …………………………………………………………………………..
4. Pola Kebiasaan Sehari-hari : ………………………………………………………..

a. Sebelum sakit
- Pola nutrisi
Frekwensi makan : ...................................................................................................
Jenis makanan : ..........................................................................................................
Makanan yang disukai : .............................................................................................
Makanan yang tak disukai : .......................................................................................
Makanan pantang : .................................................................................................
Nafsu makan : ............................................................................................................

- Pola minum
Jenis minuman : .......................................................................................................
Minuman yang disukai : ...........................................................................................
Minuman yang tak disukai : ......................................................................................
Minuman pantang : ...............................................................................................
Perubahan berat badan 3 bulan terakhir : bertambah/ tetap/ berkurang ............kg

- Pola eliminasi :
a. Buang air besar
Frekwensi : .............................. Penggunaan pencahar...............................
Waktu : pagi / siang / sore / malam
Warna : ..........................................
Konsistensi : ........................................
b. Buang air kecil
frekwensi : .............................................
Warna : ............................................
Bau : ............................................
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- Pola tidur dan istirahat

Waktu tidur (jam) : .....................................................................
Lama tidur / hari : ........................................................................
Kebiasaan saat tidur : ......................................................................
Kesulitan dalam hal tidur : ……………………………………………

- Pola aktivitas dan latihan

a. Kegiatan dalam pekerjaan : .............................................................................
b. Olah raga :
- Jenis : ..........................................................................................
- Frekwensi : ..........................................................................................
c. Kegaiatan diwaktu luang : .............................................................................
d. Kesulitan / keluhan dalam hal aktivitas dan latihan.....................................

- Personal Hygiene...............................................................................................

- Pola bekerja :………………………………………………………………….

b. Selama sakit
- Pola nutrisi
Frekwensi makan : .............................................................................
Jenis makanan : ...........................................................................................
Makanan yang disukai : ...............................................................................
Makanan yang tak disukai : ............................................................................
Makanan pantang : ................................................................................
Nafsu makan :.........................................................................................

- Pola minum
Jenis minuman : ...........................................................................................
Minuman yang disukai : ...............................................................................
Minuman yang tak disukai : ..........................................................................
Minuman pantang : .....................................................................................
Perubahan berat badan 3 bulan terakhir : : bertambah/ tetap/ berkurang ........kg
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- Pola eliminasi :
a. Buang air besar
Frekwensi : ............................ Penggunaan pencahar.................................
Waktu : pagi / siang / sore / malam
Warna : ..........................................
Konsistensi : ........................................
b. Buang air kecil
Frekwensi : .............................................
Warna : ............................................
Bau : ............................................
- Pola tidur dan istirahat
Waktu tidur (jam) : .......................................................................
Lama tidur / hari : .............................................................................
Kebiasaan saat tidur: .............................................................................
Kesulitan dalam hal tidur : ………………………………………….

- Pola aktivitas dan latihan

Kesulitan / keluhan dalam hal aktivitas ........................................................
- Personal Hygiene..........................................................................................

Catatan / Data tambahan........................................

VI. Aspek Psikososial

1. Pola pikir dan persepsi terhadap penyakitnya ;.....................................................

2. Konsep diri
Citra tubuh : .............................................................................

Harga diri : .............................................................................

Peran diri : .............................................................................

Ideal diri :..............................................................................

Identitas diri : .............................................................................

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3. Pertahanan koping
a. Pengambilan keputusan sendiri/ dibantu orang lain sebutkan : ……………
.....................................
b. Yang disukai tentang diri sendiri : ……....................................................
..................................................
c. Yang ingin dirubah dari kehidupan : ………………………….....................
............................................................
d. Yang dilakukan jika stres :
[ ] Pemecahan masalah
[ ] Makan
[ ] Tidur
[ ] Makan obat
[ ] Cari pertolongan
[ ] Lain –lain ( misal, marah, diam dll sebutkan)
4. Sistim nilai – kepercayaan
a. Siapa atau apa sumber
kekuatan : .......................................................... ...................................................
..
b. Apakah Tuhan, Agama, Kepercayaan penting untuk anda.........................
…………………………………......................
c. Kegiatan agama atau kepercayaan yang dilakukan (macam dan frekwensi)
sebutkan : ……………………………………………………………….
............................. ………………… ………. ................................ .........
d. Kegiatan agama atau kepercayaan yang ingin dilakukan selama dirumah sakit,
sebutkan : ..............................................................................
……………………………………...........................................
5. Hubungan / komunikasi
a. Bicara Bahasa utama : ....................................
[ ] jelas
[ ] relevan Bahasa Daerah : ...................................
[ ] mampu mengepresikan
[ ] mampu mengerti orang lain

b. Tempat tinggal
[ ] sendiri
[ ] bersama orang lain. Yaitu : .....................................................................
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c. Kehidupan keluarga
- Adat istiadat yang dianut : ..................................................................
- Pembuatan keputusan dalam keluarga : ........................................................
- Pola Komunikasi : .................................................................................
- Keuangan : [ ] memadai [ ] kurang
d. Kesulitan dalam keluarga
[ ] hubungan orang tua
[ ] hubungan sanak keluarga
[ ] hubungan perkawinan
5. Kebiasaan seksual
a. Gangguan hubungan seksual disebabkan kondisi sebagai berikut :
[ ] fertilitas [ ] menstruasi
[ ] libido [ ] kehamilan
[ ] ereksi [ ] alat kontrasepsi
b. Pemahaman terhadap fungsi seksual : ...........................................................

Catatan / Data tambahan........................................

VII. Pengkajian Fisik

1. Keadaan umum :........................................................................................
2. Tingkat kesadaran :..........................Nilai GCS: V:............. E......... M:............
3. Vital sigh : TD :...............mmhg, Respirasi : ......... x/m
Pols:................x/m, Temp:.....................x/m
4. Keluhan yang berhubungan :

5. Inspeksi/ palpasi/percusi/auskultasi
a. Rambut :.....................................................................................
b. Kepala :.......................................................................................
c. wajah ;........................................................................................
d. Mata : Uukuran pupil ............................. isokor .............................
Reaksi terhadap cahaya ..........................................................................
Akomudasi ............................................................................................
Bentuk ....................................................................................................
Konjungtiva ............................................................................................
Fungsi penglihatan :
Baik / kabur / tidak jelas .......................................................................
Tanda – tanda radang .............................................................................
Kaca mata ...............................................................................................
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e. Hidung :..................................................................................................................
Sinus ............................. Perdarahan ...............................................
f. Telinga :............................................................................................................
Serumen..............................Pendengaran...............................................
g. Mulut dan Tenggorok : Gigi geligi .............................................................
Kesulitan / gangguan bersuara ...............................................................
Kesulitan menelan .................................................................................
h. Leher :.................................................................................................
i. Thorax :.................................................................................................
Suara paru ...............................................................................
Pola nafas ............................. Batuk ...................................................
Sputum ................................. Nyeri ...................................................
Batuk darah ..........................................................................................
j. Abdomen:..........................................................................................................
k. Ext. Superior :.....................................................................................................
- Bisep
- Trisep
l. Ext. Inperior :...........................................................................................................
- Reflek patella
- Reflek achiles
m. Sirkulasi : ..........................................................................................
Distensi fena jugularis ..........................................................................
Suara Jantung .......................................................................................
Suara Jantung tambahan .......................................................................
Nyeri ................................ Udema ....................................................
Palpitasi ...........................Perubahan warna (kulit, kuku, bibir, dll)
Clubbing ...................... ...................................
n. Nutrisi : Jenis diet ............................ Nafsu makan ..............................
Rasa mual................................. Muntah ......................................
Intake cairan ..........................................................................................
o. Eliminasi :
Kostipasi .........................................................................................
Diare ......................................................................................................
(BAK) Incontenesia .............................................................................
Infeksi ...................................................................................................
Nematuri ................................................................................................
Kateter ...................................................................................................
Urine out – put .......................................................................................
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p. Reproduksi : Kehamilan ............................................................................

Buah dada ........................... Perdarahan .............................................
Keputihan ...............................................................................................
Pemeriksaan sendiri ...............................................................................
Prostat ....................................................................................................
Penggunaan kateter ...............................................................................
q. Muskulosskeletal : Nyeri ........................................................................
Kekakuan ...............................................................................................
Pola latihan gerak ..................................................................................
r. Kulit : Warna .................................. Integritas ..........................................
Turgor ...................................................................................................
Catatan / Data tambahan........................................

6. Pemeriksaan Penunjang

Data Laboratorium :

Rontgen :

Pemeriksaan Diagnostik lain :

7. Therapi medis ;
No Nama Obat Dosis Efek Ket
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Identifikasi data
a. Data subjektif
1...........................................
2...........................................
3............................................
4............................................
5...........................................
6...........................................
7...........................................
8............................................
9............................................
10..........................................

b. Data objektif
1...........................................
2............................................
3............................................
4............................................
5............................................
6............................................
7............................................
8............................................
9…………………………...
10………………………….
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ANALISA DATA

N DATA ETIOLOGI MASALAH

O
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Diagnosa Keperawatan

1.

2.

3.

4.

5.