RMAT PENGKAJIAN KEPERAWATAN

KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI S1 KEPERAWATAN

Ruangan :..............................Tgl.Pengkajian :....................................

Kamar : .............................. Waktu Pengkajian :...................................
Tgl. Masuk RS: ........................................ AutoAnamnese :

AlloAnamnese :
IDENTIFIKASI
KLIEN
NamaInitial : ...................................................................
Tempat/tgl.Lahir (umur) : ...................................................................
Jeniskelamin : Laki-laki Perempuan
Statusperkawinan : ...................................................................
Agama/Suku : ...................................................................
Warganegara : Indonesia Asing
Bahasayangdigunakan : Indonesia
  Asing ............................................
Pendidikan : ...............................................................
Pekerjaan : ...............................................................
AlamatRumah : ...............................................................
Alamat : ...............................................................
Hubungandengan klien : ...............................................................
DATAMEDIK
Dikirimoleh :UGD Dokterpraktek

DiagnosaMedik :

Saatmasuk :

SaatPengkajian :

KEADAANUMUM

KEADAAN SAKIT: Klien tampak sakit ringan / sedang / berat /tidak

tampak sakit.
Alasan: Tak bereaksi / baring lemah / duduk / aktif / gelisah / posisi
tubuh
................................................/ pucat / Cyanosis / sesak nafas /
Penggunaan alatmedik......................................................................
TANDA-TANDAVITAL:
Kesadaran:
Kualitatif: Composmentis Somnolens Coma
Apatis Soporocomatous.
Kuantitatif:
Skala Coma Glasgow: -ResponMotorik :...............
-Respon Bicara :...............
- Respon Membuka Mata:...............
+
Jumlah :...............
Kesimpulan: ............................................................................
Flapping Tremor/asterixis: Positif Negatif 2.
Tekanandarah:.....................................mmHg
 Kesimpulan :................................................................................
.................................................................................
Suhu:...........°C Oral Axillar Rectal
 Nadi:..........................x/menit
4. Pernafasan:Frekuensi...................x/menit
Irama: Teratur Kusmaull Cheynes-Stokes
Jenis: Dada Perut
 Lingkar Lengan Atas: .............cm 3.TinggiBadan:...................cm
Lipat Kulit Triceps : ............. cm 4.Berat badan.......................cm
Indeks MassaTubuh(IMT).............................kg/m²
Kesimpulan :......................................................................................................
Catatan :......................................................................................................
GENOGRAM:

PENGKAJIAN POLAKESEHATAN
KAJIAN PERSEPSI KESEHATAN –PEMELIHARAAN
KESEHATAN
 Sakit berat, dirawat, kecelakaan, operasi, gangguan kehamilan/persalinan,
abortus, transfusi, reaksi alergi.
Kapan Catatan
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Kapan Catatan
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 DataSubyektif
Keadaan sebelumsakit:

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Data Obyektif
Observasi:
Kulit kepala :.................................................................................
Kebersihankulit :.................................................................................
Higiene rongga mulut :.................................................................................
Kebersihan genitalia :.................................................................................
Kebersihananus :.................................................................................
Tanda/ScarVaksinasi :BCG Cacar
KAJIAN NUTRISIMETABOLIK
DataSubyektif
Keadaan sebelumsakit:

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Keadaan sejaksakit:
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DataObyektif
Observasi
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PemeriksaanFisik
Keadaan rambut.......................................................................................
Hidrasi kulit ...............................................................................................
Palpebrae ................................... Conjungtiva.........................................
Sclera...........................................................................................................
Hidung........................................................................................................
Rongga mulut ............................. Gusi....................................................
Gigi Geligi .................................. Gigi palsu............................................
Kemampuan mengunyah keras .................................................................
Lidah............................................ Tonsil..................................................
Pharing......................................................................................................
Kelenjar getah bening leher....................................................................
 Kelenjar parotis ............................ Kelenjar tyroid................................
Abdomen
Inspeksi: Bentuk...........................................................................
Bayangan vena.............................................................
Benjolan vena..............................................................
Auskultasi:Peristaltik........................x/menit
Palpasi : Tanda nyeri umum.........................................................
Massa ............................................................................
Hidrasikulit....................................................................
Nyeri tekan: R. Epigastrica TitikMc.Burney

R.Suprapubica R. IlliacaHepar

.................................................................................................. Lien
.....................................................................................................
Perkusi .................................................................................................
Ascites Negatif

Positif, Lingkar perut ............ /............../...............cm

Kelenjar limfe inguinal...........................................................................
Kulit:
Spidernaevi: Negatif Positif
Uremicfrost : Negatif Positif
oEdema : Negatif Positif, Lokasi:.......................

Icteric : Negatif Positif

oTanda radang ..........................................................................................
Lesi:...........................................................................................................

Pemeriksaandiagnostik
Laboratorium:
Lain-lain
Terapi:

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KAJIAN POLAELIMINASI
DataSubyektif
Keadaan sebelumsakit:
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Keadaan sejaksakit:
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DataObyektif
Observasi
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PemeriksaanFisik
Peristaltikusus:.....................................x/menit
Palpasi Suprapubica:kandungkemih Penuh Kosong
Nyeri ketukginjal:Kiri Negatif Positif
Kanan Negatif Positif
Mulut urethra:............................................................................................
Anus:

 Peradangan : Negatif Positif

 Fissura : Negatif Positif
 Hemoroid : Negatif Positif
 Prolapsusrecti : Negatif Positif
  Masa tumor :Negatif Positif
Pemeriksaandiagnostik
Laboratorium:
Lain-lain
Terapi:
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KAJIAN POLA AKTIVITAS DANLATIHAN
DataSubyektif
Keadaan sebelumsakit:
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Keadaan sejaksakit:
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DataObyektif
Observasi
Mobilisasi ditempattidur 
 Ambulasi: mandiri / tongkat / kursi roda / tempattidur
Postur tubuh ..........................................................................................
Gaya jalan............................................................................................
Anggota gerak yang cacat.....................................................................
Fiksasi..................................................................................................
Tracheostomie........................................................................................
Pemeriksaanfisik
J V P: ..........cmH2O. Kesimpulan ....................................................
Perfusi pembuluh perifer kuku:.........................................................
Thorax danPernafasan
oInspeksi: Bentuk thorax:..........................................................
Stridor: Negatif Positif
Dyspnea d’ Effort: Negatif Positif
Sianosis: Negatif Positif
Palpasi: VocalFremitus
Perkusi: Sonor Redup Pekak
Batas paru hepar:....................................................
Kesimpulan:...........................................................
oAuskultasi: Suara Nafas ............................................................
Suara Ucapan...........................................................
Suara Tambahan......................................................
Jantung
oInspeksi: Ictus cordis ............................................................
Klien menggunakan alat pacu jantung Negatif

Positif

oPalpasi: Ictus cordis:.............................................................

Thrill: Negatif Positif

oPerkusi: Batas atas jantung......................................................

Batas kanan jantung: ….............................................
Batas kiri jantung : ...................................................
oAuskultasi: Bunyi jantung II A:................................................
Bunyi jantung II P:.................................................
Bunyi jantung IT:..................................................
Bunyi jantung I M: ................................................
Bunyi jantung III Irama Gallop: Negatif Positif
Murmur: Negatif Positif, Tempat: ...................
 HR:.......................x/menit.
BruitAorta: Negatif Positif

A.Renalis: Negatif Positif

A. Femoralis: Negatif Positif

Lengan danTungkai
oAtrofiotot: Negatif Positif, Tempat:...................................
o Rentang gerak:..................................................................................
- Mati sendi:.....................................................................................
- Kaku sendi: ....................................................................................

Uji kekuatan otot:Kiri

Kanan

o Reflex Fisiologik:.............................................................................
Reflex Patologik:Babinski,Kiri Negatif Positif
Kanan Negatif Positif

ClubingJari-jari Negatif Positif

VaricesTungkai Negatif Positif
Columna Vertebralis
o Inspeksi: Kelainan bentuk..............................................................
Palpasi: Nyeri tekan Negatif Positif
o N III – IV – VI :............................................................................
N VIII Romberg Test: Negatif Positif
o N XI :...............................................................................................
 o Kaku kuduk|:.....................................................................................
PemeriksaanDiagnostik
Laboratorium
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Terapi

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KAJIAN POLA TIDUR DANISTIRAHAT
DataSubyektif
Keadaan sebelumsakit:
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Keadaan sejaksakit:
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DataObyektif
Observasi

Expresi wajah mengantuk :  Negatif  Positif

Banyak menguap :  Negatif  Positif
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KAJIAN POLA PERSEPSIKOGNITIF

DataSubyektif
Keadaan sebelumsakit:
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DataObyektif
Observasi
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 PemeriksaanFisik
Penglihatan
o Cornea ............................................................
o Visus :...........................................................
o Pupil :...........................................................
o LensaMata :...........................................................
o Tekanan Intra Ocular(TIO) :...........................................................
Pendengaran
o Pina : ...........................................................................
o Canalis :...........................................................................
o Membran Tympani:...........................................................................
o TesPendengaran :...........................................................................
Pengenalan rasa posisi pada gerakan lengan dantungkai
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N I :.............................................................................
NII :.............................................................................
NV Sensorik :.......................................................................
NVIISensorik :.......................................................................
NVIIIPendengaran :.......................................................................
TesRomberg :......................................................................
PemeriksaanDiagnostik
Laboratorium
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Terapi
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KAJIAN POLA PERSEPSI DAN KONSEPDIRI
DataSubyektif
Keadaan sebelumsakit:
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Keadaan sejaksakit:
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DataObyektif
Observasi
Kontakmata :...................................................................
Rentangperhatian :...................................................................
Suara dancarabicara :...................................................................
Posturtubuh :...................................................................

PemeriksaanFisik
Kelainan bawaan yang nyata :...................................................................
Abdomen:Bentuk :...................................................................
Bayangan vena:...................................................................
Bayanganmassa:...................................................................
Kulit:Lesikulit :...................................................................

Penggunaanprotesa :  Hidung  Payudara

KAJIAN POLA PERAN DAN HUBUNGAN DENGANSESAMA
DataSubyektif
Keadaan sebelumsakit:
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DataObyektif
Observasi
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KAJIAN POLA REPRODUKSI -SEKSUALITAS

DataSubyektif
Keadaan sebelumsakit:
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DataObyektif
Observasi
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PemeriksaanFisik
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PemeriksaanDiagnostik

Laboratorium:
Lain-lain

Terapi:
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J. KAJIAN MEKANISME KOPING DAN TOLERANSI TERHADAP
STRES

DataSubyektif
Keadaan sebelumsakit:
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DataObyektif
Observasi

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PemeriksaanFisik
Tekanandarah: Berbaring.............................................mmHg
Duduk :................................mmHg
Berdiri....................................mmHg

KesimpulanHipotensiOrtostatik: Negatif Positif

HR:.....................................x/menit
 Kulit:Keringat
dingin:...............................................................................
Basah:...........................................................................

Terapi

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K. KAJIAN POLA SISTEM NILAI KEPERCAYAAN

DataSubyektif
Keadaan sebelumsakit:

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 DataObyektif
Observasi
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