PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI PROFESI NERS

STIKES dr. SOEBANDI JEMBER
Nama Mahasiswa : Tempat Praktik :
NIM : Tgl. Praktik :

A. IDENTITAS DIRI KLIEN

Tanggal/jam MRS :.....................................................
No. Register :.....................................................
Diagnosa Medis :.....................................................
Tgl/jam pengkajian :.....................................................
Nama Pasien : …………………………………. Suami/istri/ orang tua
Usia : ………………………………….
Nama :........................
Jenis Kelamin : ………………………………….
Agama : …………………………………. Pekerjaan :.......................

Suku/Bangsa :...................................................... Alamat :.......................

Bahasa :......................................................
Status : ………………………………….
Penanggung Jawab
Pendidikan :......................................................
Pekerjaan : …………………………………. Nama :......................
Alamat : ………………………………….
Alamat :......................

B. KELUHAN UTAMA SAAT MASUK RUMAH SAKIT:

..............................................................................................................................

..............................................................................................................................

..............................................................................................................................

C. Riwayat Alergi Obat : ..........................................................................................

..............................................................................................................................
..............................................................................................................................
1
D. Nyeri (Vas Scale) :

Durasi Nyeri :

Ringan: 1-3, Sedang: 4-6, Berat: 7-10

E. RIWAYAT PENYAKIT SEKARANG

..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
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F. RIWAYAT PENYAKIT DAHULU

..............................................................................................................................
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..............................................................................................................................
..............................................................................................................................
..............................................................................................................................

2
G. RESIKO JATUH (Morse Scale)
Resiko Jatuh (Morse Scale) √ (Cheklist) Skor
pada kotak skor
Riwayat Jatuh yang baru atau dalam 3 Tidak 0=
bulan terakhir Ya 25=
Diagnosis medis sekunder >1 Tidak 15=
Ya 0=
Alat bantu jalan Bed rest 0=
Penompang tongkat 15=
Furnitur 30=
Memakai terapi heparin lock/iv Tidak 0=
Ya 20=
Cara berjalan/ Berpindah Normal/bedrest/imobilisasi 0=
Lemah 10=
Terganggu 20=
Status mental Orientasi sesuai kemampuan 0=

Lupa keterbatasan 15==

Kesimpulan : 0-24 (tidak berisiko), >24-45 (risiko sedang), >45 (risiko tinggi)
Skor Total: ....................

H. PENGKAJIAN KEPERAWATAN
1. Persepsi dan pemeliharaan kesehatan (Pengetahuan tentang penyakit/
perawatan; obat yang biasa dikonsumsi, faktor risiko tentang penyakit,
seperti: riwayat keluarga, kebiasaan, dll.; perlindungan kesehatan;
kebiasaan dalam menangani sakit, seperti: pilihan pengobatan; kebutuhan
akan edukasi kesehatan/ discharge planning)
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
2. Pola Nutrisi dan Metabolismenya
Program diit RS :
Intake makanan (Pengkajiam nutrisi ABCD/ skrining nutrisi; faktor
spesifik dalam memilih makanan, seperti: budaya, agama, ekonomi; faktor
yang mempengaruhi ingesti makanan, seperti: nafsu makan, kenyamanan,
kesehatan gigi dan mulut, alergi, nyeri, mual, muntah, pantangan
makanan):
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
Intake cairan :

........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................

3. Pola eliminasi
a. Buang Air Besar (frekuensi, warna, jumlah, konsistensi,
ketidaknyamanan, kontrol saat defekasi, apakah ada perubahan
khusus)
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
b. Buang Air Kecil (frekuensi, warna, jumlah, bau, ketidaknyamanan,
kontrol saat defekasi, apakah ada perubahan khusus, nokturia)
..................................................................................................................
..................................................................................................................
..................................................................................................................
 ..................................................................................................................
..................................................................................................................

c. Balance Cairan
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
4. Pola Aktivitas dan latihan
Kemampuan Perawatan diri 0 1 2 3 4
Makan dan minum
Mandi
Toileting
Berpakaian
Mobilitas ditempat tidur
Berpindah
Ambulansi/ROM
Keterangan : 0: Mandiri, 1 : alat bantu, 2 : dibantu orang lain, 3: dibantu
orang lain dan alat, 4: tergantung total
a. Skor Pengkajian Fungsional ADL (BARTHEL INDEX):
b. Skor Risiko Jatuh (MORSE):
c. Skor Risiko Dekubitus (BRADEN SCALE):
d. Fungsi Respiratory:
..................................................................................................................
..................................................................................................................
..................................................................................................................
e. Fungsi Cardiovascular:
..................................................................................................................
..................................................................................................................
..................................................................................................................
 5. Pola Tidur dan Istirahat (lama tidur, gangguan tidur; penggunaan obat bantu
tidur; faktor terkait, seperti nyeri, kenyamanan lingkungan, suhu):
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
.........................................................................................................................
6. Pola Perceptual (penglihatan; pendengaran; pengecap; sensasi; pembau;
penggunaan alat bantu; nyeri dan kenyamanan):
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
.........................................................................................................................
7. Pola persepsi diri (pandangan klien tentang sakitnya; kecemasan; konsep
diri):
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
8. Pola Seksualitas dan Reproduksi (masalah seksual; fertilitas, libido,
menstruasi, kontrasepsi, dll.):
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
.............................................................................................................................
9. Pola Peran-hubungan (perubahan peran, komunikasi, hubungan dengan orang
lain, kemampuan keuangan, significant others):

...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
..............................................................................................................................
10. Pola Managemen Koping-Stress (stress saat ini; koping; perubahan terbesar
dalam hidup pada akhir-akhir ini/ kehilangan, dll):
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
11. Sistem Nilai dan Keyakinan (budaya terkait kesehatan; pandangan klien
tentang agama; kegiatan agama, dll.):
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................

I. PEMERIKSAAN FISIK
1. Kelulahan yang dirasakan saat ini:
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................

2. Pemeriksaan Umum (TTV Dasar)

a. Kesadaran : ……………………………
b. GCS : ……………………………
c. Suhu....................................................................OC
 d. Nadi.....................................................................x/menit
e. Tekanan Darah....................................................mmHg
f. RR.......................................................................x/menit
g. BB/ TB: kg/ cm

3. Pemeriksaan Kepala
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
4. Pemeriksaan Leher
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
5. Pemeriksaan Thoraks
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................

6. Pemeriksaan Abdomen
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
 7. Pemeriksaan Kelamin dan Anus
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................

8. Ekstremitas:
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................

9. Pemeriksaan Neurologi
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................
.......................................................................................................................

J. HASIL PEMERIKSAAN PENUNJANG

1. Laboratorium
......................................................................................................................
......................................................................................................................
......................................................................................................................
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......................................................................................................................
 ......................................................................................................................
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......................................................................................................................

2. Foto Rongen/USG/ECG/dll
......................................................................................................................
......................................................................................................................
......................................................................................................................

K. PENATALAKSANAAN DAN TERAPI

..............................................................................................................................
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..............................................................................................................................
.............................................................................................................................

.......................................................................................................................

............, ………………………21
Pemeriksa,

(…………………………………………)
 ANALISA DATA
TGL/ Data Masalah Penyebab
JAM
DAFTAR DIAGNOSA KEPERAWATAN BERDASARKAN URUTAN
PRIORITAS
NO PRIORITAS DIAGNOSA KEPERAWATAN
1.

2.

3.

4.

Dst
 INTERVENSI KEPERAWATAN
DIAGNOSA
KEPERAWATAN NOC DAN INDIKATOR
URAIAN AKTIVITAS RENCANA
NO TANGGAL DITEGAKKAN / SERTA SKOR AWAL DAN SKOR
TINDAKAN (NIC)
KODE DIAGNOSA TARGET
KEPERAWATAN

14
 IMPLEMENTASI & EVALUASI KEPERAWATAN
EVALUASI
DIAGNOSA
(PERBANDINGAN SKOR AKHIR
KEPERAWATAN
TERHADAP SKOR AWAL DAN SKOR
NO DITEGAKKAN /KODE IMPLEMENTASI
TARGET)
DIAGNOSA
KEPERAWATAN
 Lampiran 10. Resume Keperawatan Medikal Bedah

RESUME ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Pasien :
No. RM :
Dx. Medis :
Rumusan Diagnosa Intervensi
Pengkajian Fokus NOC NIC Implementasi Evaluasi
Keperawatan
Lampiran 11. Format Log Book Mahasiswa

LOG BOOK MAHASISWA PROGRAM STUDI NERS

PROGRAM STUDI S1 KEPERAWATAN
STIKES dr. SOEBANDI

Nama :
NIM :
Ruang :
Paraf Paraf
No. Hari/tanggal Kegiatan
Mahasiswa Pembimbing

17
 PENGKAJIAN PASIEN PERIOPERATIF (KAMAR OPERASI)
PROGRAM STUDI PROFESI NERS
STIKES dr. SOEBANDI JEMBER
Nama Mahasiswa : Tempat Praktik :
NIM : Tgl. Praktik :

A. Biodata
Identitas Pasien Identitas Penanggung Jawab Pasien
1. Nama Pasien :............................................. 1.Nama Pasien ;.......................................
2. Usia :............................................. 2.Usia ;.......................................
3. Jenis Kelamin :............................................. 3.Jenis Kelamin ;.......................................
4. Agama :............................................ 4.Agama ;.......................................
5. Pendidikan :............................................ 5.Pendidikan ;.......................................
6. Pekerjaan :............................................ 6.Pekerjaan ;.......................................
7. Status :............................................ 7.Status ;.......................................
8. Alamat :............................................. 8.Alamat ;.......................................
9. Suku Bangsa :............................................. 9.No.Hp ;.......................................
10. No.Hp :............................................. 10. Hubungan ;.......................................
11. No Register :............................................. dengan Pasien
12. Diagnosa Medis :.............................................

B. Keluhan Umum
1. Keluhan Utama :........................................................................................................

:........................................................................................................

:........................................................................................................

2. Riwayat Penyakit :........................................................................................................

Sekarang :........................................................................................................

:........................................................................................................

3. Riwayat Penyakit :........................................................................................................

Dahulu :........................................................................................................

:........................................................................................................
4. Riwayat Alergi Obat : ........................................................................................

5. Nyeri (Vas Scale) :

 Durasi Nyeri :

Ringan: 1-3, Sedang: 4-6, Berat: 7-10

6. Resiko Jatuh (Morse Scale)

Resiko Jatuh (Morse Scale) √ (Cheklist) Skor

pada kotak skor
Riwayat Jatuh yang baru atau dalam 3 Tidak 0=
bulan terakhir Ya 25=
Diagnosis medis sekunder >1 Tidak 15=
Ya 0=
Alat bantu jalan Bed rest 0=
Penompang tongkat 15=
Furnitur 30=
Memakai terapi heparin lock/iv Tidak 0=
 Ya 20=
Cara berjalan/ Berpindah Normal/bedrest/imobilisasi 0=
Lemah 10=
Terganggu 20=
Status mental Orientasi sesuai kemampuan 0=

Lupa keterbatasan 15==

Kesimpulan : 0-24 (tidak berisiko), >24-45 (risiko sedang), >45 (risiko tinggi)
Skor Total: ....................

C. Pre Operasi
Kondisi Umum
 Keadaan Umum : Baik/ Cukup/ Lemah
 GCS :
 Kesadaran : Compos Mentis/
Samnolen/
Delirium/Apatis/Koma
Status Jalan nafas : Paten/ Obtruksi parsial/ Obstruksi Total
 Trauma saluran nafas : Ada/ Tidak ada
 Benda Asing : Ada/ Tidak ada

Status Breathing
 Pernafasan :Spontan/ Dyspneu/ Gagal nafas
 Frekuensi : Reguler/ Irreguler
 Simetrisitas : Simetris/ Tidak simetris
 Suara Nafas : Vesikuler/ Ronchi/ Wheezing
 Suara Nafas :........................................................................................................
 Abnormal Lainya :........................................................................................................

Status Sirkulasi
 Tekanan Darah : mmHg Turgor Kulit : detik
 Nadi : x/menit CRT : detik
 Irama : Reguler/ Irreguler Akral : Hangat/ Dingin
 Kualitas : Kuat/ Lemah Diaforesis : Ada/ Tidak ada
 Palpitasi : Ada/ Tidak ada Kelembaban :
Mukosa
 Sianosis : Ada/ tidak ada Konfungtiva : Merah muda/
Hipermia/
Pucat
 Suhu tubuh : o
c Oedema : Ada/ Tidak ada

Informasi Pre Operasi

 Rencana tindakan :........................................................................................................
operasi
 Status skiren area : Sudah & bersih/ Sudah Status puasa : Puasa/ tidak puasa
Tapi belum bersih/
Belum adekuat
 Infus : Terpasang/ Belum Bising usus : Adekuat/ Tidak
adekuat
 Jika terpasang infus : Terpasang/ Belum NGT : Terpasang/ Tidak
terpasang
(ukuran abocath) :
 Jenis cairan infus : Kateter : Terpasang/ Tidak
terpasang
masuk
 Jumlah cairan yang : Produksi urine.................................cc
sudah masuk (rata-rata/ jam)
 Persedian transfusi : Tersedia/ Tidak tersedia
 Jenis transfusi : PRC/ WB/ FFP/ lainya
 Jumlah kolf transfusi : kolf

Kesiapan Status Premedikasi

 Antibiotik : Status Alergi : Alergi/ tidak ada
 Masuk jam : Jika alergi :
(sebutkan)
 Obat lainya : Rencana anastesi: Per Informasi lainya
D. Intra (Durante) Operasi
 Waktu mulai operasi :
 Waktu selesai operasi :

Status Anastesi Status Operatif

 Jenis Anastesi : General/ Regional/ Persiapan alat :
Operasi
 Jenis obat + dosis :

 Waktu mulai anastesi :

 Jumlah cairan yang masuk : Persipan bahan :
 Jumlah transfusi yang : habis pakai
Masuk (dan jenisnya) :

Observasi Durante Operasi

 Jam :
 GCS :
 Kesadaran : Composmentis/ Persiapan bahan :
Somnolen/ Penunjang
Delirium/ Apatis/
Koma
 Tekanan darah : mmHg
 Nadi : x/menit
 Frekuensi pernafasan :
 Suhu : oC

 Jam :
 GCS :
 Kesadaran : Composmentis/ Persiapan bahan :
Somnolen/ Penunjang
Delirium/ Apatis/
Koma
 Tekanan darah : mmHg
 Nadi : x/menit
 Frekuensi pernafasan :
 Suhu : o
C

 Laporan Operasi
 Cairan yang masuk : cc
 Jenis :
 Jumlah pendarahan : cc
 Jumlah kassa yang : buah
yang terpakai
 Status peralatan yang : Lengkap/ tidak lengkap
Dipakai
 Jenis jahitan/ jumlah :

E. Post Operasi (Recovery)

 Kondisi Umum
 GCS :
 Kesadaran : Composmentis/ Produksi urine : cc
Somnolen/
Delirium/ Apatis/
Koma
 Tekanan darah : mmHg Respon sensoris:Baik/ Cukup/ Kurang
 Nadi : x/menit Respon motoris : Baik/ Cukup/ Kurang
 Frekuensi pernafasan :
 Suhu aksila : o
C
 Irama :
 Spontanitas : Spontan/ Tidak spontan
 Simetrisitas : Simetris/ tidak simetris
 Suara nafas : Vesikuler/ Ronckhi/ Wheezing/ Lain-lain

Discharge Planning
Alderette Score (Terlmpir)
 ANALISA DATA
Pre Operasi

TGL/ Data Masalah Penyebab

JAM
 ANALISA DATA
Intra Operasi

TGL/ Data Masalah Penyebab

JAM
 ANALISA DATA
Post Operasi

TGL/ Data Masalah Penyebab

JAM
DAFTAR DIAGNOSA KEPERAWATAN BERDASARKAN URUTAN
PRIORITAS
NO PRIORITAS DIAGNOSA KEPERAWATAN
1.

2.

3.

4.

Dst
 INTERVENSI KEPERAWATAN
DIAGNOSA
KEPERAWATAN NOC DAN INDIKATOR
URAIAN AKTIVITAS RENCANA
NO TANGGAL DITEGAKKAN / SERTA SKOR AWAL DAN SKOR
TINDAKAN (NIC)
KODE DIAGNOSA TARGET
KEPERAWATAN

29
 IMPLEMENTASI & EVALUASI KEPERAWATAN
EVALUASI
DIAGNOSA
(PERBANDINGAN SKOR AKHIR
KEPERAWATAN
TERHADAP SKOR AWAL DAN SKOR
NO DITEGAKKAN /KODE IMPLEMENTASI
TARGET)
DIAGNOSA
KEPERAWATAN
 PENGKAJIAN PASIEN DI RUANG HEMODIALISA
PROGRAM STUDI PROFESI NERS
STIKES dr. SOEBANDI JEMBER

Nama Mahasiswa : Tempat Praktik :

NIM : Tgl. Praktik :

A. IDENTITAS
Nama : ...........................................................................................
Umur : ...........................................................................................
Status : ...........................................................................................
Agama : ...........................................................................................
Tanggal masuk : ...........................................................................................
Tanggal pengkajian : ...........................................................................................
Sumber informasi : ...........................................................................................

B. PENGKAJIAN KEPERAWATAN
1. Keluhan Utama : ..........................................................................................
: ..........................................................................................
2. Diagnosa Medis :
3. Dialiasis ke :
4. BB Kering :

Interval dengan HD HbsAg Negatif, Positif

sebelumnya
Sifat HD Akut, Kronis,
Preparation
Golongan Darah A, B, O, AB

5. Riwayat Alergi obat :

6. Nyeri (Vas Scale) :

31
 Durasi Nyeri : Akut/ Kronik

Ringan: 1-3, Sedang: 4-6, Berat: 7-10

7. Riwayat Penyakit Sekarang : ...................................................................................

: ...................................................................................
: ...................................................................................
8. Riwayat Penyakit dahulu : ...................................................................................
: ...................................................................................

9. Resiko Jatuh
Resiko Jatuh (Morse Scale) √ (Cheklist) Skor
pada kotak skor
Riwayat Jatuh yang baru atau dalam 3 bulan Tidak 0=
terakhir Ya 25=
Diagnosis medis sekunder >1 Tidak 15=
Ya 0=
Alat bantu jalan Bed rest 0=
Penompang tongkat 15=
Furnitur 30=
Memakai terapi heparin lock/iv Tidak 0=
Ya 20=
Cara berjalan/ Berpindah Normal/bedrest/imobilisasi 0=
Lemah 10=
Terganggu 20=
Status mental Orientasi sesuai kemampuan 0=
 Lupa keterbatasan 15==
Kesimpulan : 0-24 (tidak berisiko), >24-45 (risiko sedang), >45 (risiko tinggi)
Skor Total: ....................

10. Pemeriksaan Fisik

Keadaan umum:
TD : mmHg
P : x/menit
N : x/menit
O
S : C
BB/ TB: kg/ cm
Kepala:

Leher:

Thorak:
Abdomen:

Inguinal:

Ekstremitas:

11. Pemeriksaan Laboratorium

C. PERSIAPAN
Mesin Dialisa Dializer
Model Normal/ tidak Model
Monitor Normal/ tidak Tes Volume
Konduktivitas Re Use Ya/ Tidak, Ke
Dialisat Acetat/ Bicarbonat

D. PUNKSI
 Arteri :
 Vena :
 AV Shunt :
 Lama tindakan :
Pelaksana (Tulis Nama Penyulit
Dokter Jenis Penanganan
Perawat Sukar
Operasi
Plebitis
Hematoma
Infeksi
Mudah

E. DATA
i. Pre HD
TD Anemis, Ronchi, Ascites, Edema
N Lain-lain:
RR
S HB
BB BUN
 BB Post HD Creatinin
Kenaikan BB

ii. Durante HD
Jam Mulai Jam Selesai
QB QD
Intake Output
Priming Muntah
Heparinasi Urin
Regional
Heparinasi TMP
Continue
Dosis Awal Ultra Filtrasi
Dalam PZ
Tranfusi/ Infus
Darah
Albumin
Nabic

 Lama HD :

 TMP :

 Balance :

iii. Post HD
TD Anemis, Ronchi, Ascites, Edema
N Lain-lain:
RR
S HB
BB BUN
BB Post HD Creatinin
Kenaikan BB
 ANALISIS DATA KEPERAWATAN

Pre Hemodialisa
NO DATA MASALAH ETIOLOGI
Intra Hemodialisa

Persiapan Perawat

Persiapan Alat dan Ruang

Alat steril:

Alat tidak steril:

Bahan medis habis pakai:

Persiapan Pasien

Prosedur Hemodialisa
Analisa data selama hemodialisa
NO DATA MASALAH ETIOLOGI
Post Hemodialisa
Persiapan Perawat

Persiapan Alat dan Ruang

Alat steril:

Alat tidak steril:

Bahan medis habis pakai:

Ending mesin HD
Analisis data post hemodialisa
NO DATA MASALAH ETIOLOGI