Sekolah Tinggi Ilmu Kesehatan Stella Maris

Jl. MAIPA NO.19

MAKASSAR

KAJIAN KEPERAWATAN

Nama Mahasiswa Yang Mengkaji: NIM:

Unit : …………………………… Autoanamnese: ………………………

Kamar : …………………………… Alloanamnese : ………………………
Tanggal masuk RS : ……………………………
Tanggal pengkajian : …………………………....

I. IDENTIFIKASI
A. PASIEN
Nama initial : …………………………………………………………………........
Umur : …………………………………………………………………........
Jenis kelamin : ………………………………………………………………………
Status perkawinan : ………………………………………………………………………
Jumlah anak : ………………………………………………………………………
Agama/ suku : ………………………………………………………………………
Warga negara : ………………………………………………………………………
Bahasa yang digunakan : ……………………………………………………………….........
Pendidikan : ………………………………………………………………………
Pekerjaan : ………………………………………………………………………
Alamat rumah :
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B. PENANGGUNG JAWAB
Nama : …………………………………………………………………. …..
Umur : ………………………………………………………………………
Alamat : ………………………………………………………………………
Hubungan dengan pasien : …………………………………………………………………..

II. DATA MEDIK

Diagnosa medik
Saat masuk : ……………………………………………………………………...
Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 1
 Saat pengkajian : ……………………………………………………………………...
III. KEADAAN UMUM
A. KEADAAN SAKIT
Pasien tampak sakit ringan/ sedang / berat / tidak tampak sakit
Alasan:
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B. TANDA-TANDA VITAL
1. Kesadaran (kualitatif): …………………………………………………………………
Skala koma Glasgow (kuantitatif)
a) Respon motorik : …………………………..
b) Respon bicara : …………………………..
c) Respon membuka mata : ………………………….
Jumlah:
Kesimpulan : ………………………………………………………………………...
2. Tekanan darah :……………………..mmHg
MAP :………………………..mmHg
Kesimpulan : …………………………………………………………………………….
3. Suhu :………..0C di Oral Axilla Rectal
4. Pernapasan: ……….x/menit
Irama : Teratur Bradipnea Takipnea Kusmaul Cheynes-stokes
Jenis : Dada Perut
5. Nadi : ………..x/menit
Irama : Teratur Bradikardi Takikardi
Kuat Lemah
C. PENGUKURAN
1. Lingkar lengan atas : …………….cm
2. Tinggi badan : …………….cm
3. Berat badan : …………….kg
4. IMT (Indeks Massa Tubuh : …………...
Kesimpulan : …………………………………………………………………………….

Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 2

 D. GENOGRAM

IV. PENGKAJIAN POLA KESEHATAN

A. POLA PERSEPSI KESEHATAN DAN PEMELIHARAAN KESEHATAN
1. Keadaan sebelum sakit:
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2. Riwayat penyakit saat ini :
a) Keluhan utama :
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b) Riwayat keluhan utama :
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3. Riwayat penyakit yang pernah dialami :
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Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 3

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4. Riwayat kesehatan keluarga :
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5. Pemeriksaan fisik :
a) Kebersihan rambut : ...............................................................................................
b) Kulit kepala : ...............................................................................................
c) Kebersihan kulit : ...............................................................................................
d) Higiene rongga mulut : ...............................................................................................
e) Kebersihan genetalia : ...............................................................................................
f) Kebersihan anus : ...............................................................................................

B. POLA NUTRISI DAN METABOLIK

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :
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Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 4

 4. Pemeriksaan fisik :
a) Keadaan rambut : ................................................................................................
b) Hidrasi kulit : ................................................................................................
c) Palpebra/conjungtiva : ................................................................................................
d) Sclera : ................................................................................................
e) Hidung : ................................................................................................
f) Rongga mulut : ............................................ gusi :.........................................
g) Gigi : ............................................ gigi palsu :................................
h) Kemampuan mengunyah keras : .................................................................................
i) Lidah : ................................................................................................
j) Pharing : ................................................................................................
k) Kelenjar getah bening : ...............................................................................................
l) Kelenjar parotis : ...............................................................................................
m) Abdomen :
 Inspeksi : ………………………………………………………………………
 Auskultasi : ………………………………………………………………………
 Palpasi : ………………………………………………………………………
 Perkusi : ………………………………………………………………………
n) Kulit :
 Edema : Positif Negatif
 Icterik : Positif Negatif
 Tanda-tanda radang : ………………………………………………………….....
o) Lesi : …………………………………………………………………………………

C. POLA ELIMINASI
1. Keadaan sebelum sakit :
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Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 5

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2. Keadaan sejak sakit :

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3. Observasi :
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4. Pemeriksaan fisik :
a) Peristaltik usus : …………….x/menit
b) Palpasi kandung kemih : Penuh Kosong
c) Nyeri ketuk ginjal : Positif Negatif
d) Mulut uretra : ………………………………………………………………………...
e) Anus :
 Peradangan : ………………………………………………………………
 Hemoroid : ………………………………………………………………
 Fistula : ………………………………………………………………

D. POLA AKTIVITAS DAN LATIHAN

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :

Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 6

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3. Observasi :
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a) Aktivitas harian :
 Makan : ……. 0 : mandiri
 Mandi : ……. 1 : bantuan dengan alat
2 : bantuan orang
 Pakaian : ……. 3 : bantuan alat dan orang
 Kerapihan : ……. 4 : bantuan penuh

 Buang air besar : …….

 Buang air kecil : …….
 Mobilisasi di tempat tidur : …….
b) Postur tubuh : ………………………………………………………………………
c) Gaya jalan : ………………………………………………………………………
d) Anggota gerak yang cacat : ……………………………………………………….....
e) Fiksasi: : ………………………………………………………………………
f) Tracheostomi : ………………………………………………………………………
4. Pemeriksaan fisik
a) Tekanan darah
Berbaring : ………………..mmHg
Duduk : ………………..mmHg
Berdiri : ………………..mmHg
Kesimpulan : Hipotensi ortostatik : Positif Negatif
b) HR : …………………x/menit
c) Kulit :
Keringat dingin : ………………………………………………………
Basah : ………………………………………………………
d) JVP : ……………………..cmH2O
Kesimpulan : ………………………………………………………………………...

Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 7

 e) Perfusi pembuluh kapiler kuku : …………………………………………………….
f) Thorax dan pernapasan
 Inspeksi:
Bentuk thorax : ………………………………………………………………
Retraksi interkostal : …………………………………………………………
Sianosis : ………………………………………………………………
Stridor : ………………………………………………………………
 Palpasi :
Vocal premitus: ……………………………………………………………...
Krepitasi : ………………………………………………………………
 Perkusi :
Sonor Redup Pekak
Lokasi : …………………………………………………………………………
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 Auskultasi :
Suara napas : ……………………………………………………………..
Suara ucapan : ……………………………………………………………..
Suara tambahan : ………………………………………………………….....
g) Jantung
 Inspeksi :
Ictus cordis : ………………………………………………………………....
 Palpasi :
Ictus cordis : ………………………………………………………………....
 Perkusi :
Batas atas jantung : ………………………………………………………
Batas bawah jantung : ………………………………………………………
Batas kanan jantung : ………………………………………………………
Batas kiri jantung : ………………………………………………………
 Auskultasi :
Bunyi jantung II A : ………………………………………………………
Bunyi jantung II P : ………………………………………………………
Bunyi jantung I T : ………………………………………………………
Bunyi jantung I M : ………………………………………………………

Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 8

 Bunyi jantung III irama gallop : ……………………………………………..
Murmur : ………………………………………………………………
Bruit : Aorta : ………………………………………………………
A.Renalis : ………………………………………………………
A. Femoralis : ………………………………………………………

h) Lengan dan tungkai

 Atrofi otot : Positif Negatif
 Rentang gerak : ………………………………………………………………
Kaku sendi : ………………………………………………………………
Nyeri sendi : ………………………………………………………………
Fraktur : ………………………………………………………………
Parese : ………………………………………………………………
Paralisis : ………………………………………………………………
 Uji kekuatan otot
Kanan Kiri
Tangan

Kaki
Keterangan :
Nilai 5 : kekuatan penuh
Nilai 4 : kekuatan kurang dibandingkan sisi yang lain
Nilai 3 : mampu menahan tegak tapi tidak mampu melawan tekanan
Nilai 2 : mampu menahan gaya gravitasi tapi dengan sentuhan akan jatuh
Nilai 1 : tampak kontraksi otot, ada sedikit gerakan
Nilai 0 : tidak ada kontraksi otot, tidak mampu bergerak
 Refleks fisiologi : ………………………………………………………………..
 Refleks patologi : ………………………………………………………………..
Babinski, Kiri : Positif Negatif
Kanan : Positif Negatif
 Clubing jari-jari : ………………………………………………………………
 Varises tungkai : ………………………………………………………………
i) Columna vetebralis:

Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 9

  Inspeksi : Lordosis Kiposis Skoliosis
 Palpasi : ………………………………………………………………………
Kaku kuduk : ………………………………………………………………………

E. POLA TIDUR DAN ISTIRAHAT

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :
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Ekspresi wajah mengantuk : Positif Negatif
Banyak menguap : Positif Negatif
Palpebra inferior berwarna gelap : Positif Negatif

F. POLA PERSEPSI KOGNITIF

1. Keadaan sebelum sakit :
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Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 10

 2. Keadaan sejak sakit :
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3. Observasi :
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4. Pemeriksaan fisik :
a) Penglihatan
 Kornea : ………………………………………………………………………
 Pupil : ………………………………………………………………………
 Lensa mata : ……………………………………………………………………..
 Tekanan intra okuler (TIO) : ………………………………………………….....
b) Pendengaran
 Pina : ………………………………………………………………………
 Kanalis : ………………………………………………………………………
 Membran timpani : ………………………………………………………………
c) Pengenalan rasa pada gerakan lengan dan tungkai
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G. POLA PERSEPSI DAN KONSEP DIRI

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 11

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3. Observasi :
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a) Kontak mata : ………………………………………………………………

b) Rentang perhatian : ………………………………………………………………
c) Suara dan cara bicara : ………………………………………………………………
d) Postur tubuh : ………………………………………………………………
4. Pemeriksaan fisik :
a) Kelainan bawaan yang nyata : ………………………………………………………
b) Bentuk/postur tubuh : ………………………………………………………
c) Kulit : ………………………………………………………

H. POLA PERAN DAN HUBUNGAN DENGAN SESAMA

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :
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I. POLA REPRODUKSI DAN SEKSUALITAS

Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 12

 1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :
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4. Pemeriksaan fisik :
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J. POLA MEKANISME KOPING DAN TOLERANSI TERHADAP STRES

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :

Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 13

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K. POLA SISTEM NILAI KEPERCAYAAN

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :
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Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 14

V. UJI SARAF KRANIAL
A. N I : …………………………………………………………………………………………..
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B. N II : ………………………………………………………………………………………....
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C. N III, IV, VI : ……………………………………………………………………………......
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D. N V :
Sensorik : ..…………………………………………………………………………………...
Motorik : ..…………………………………………………………………………………...
E. N VII :
Sensorik : …..………………………………………………………………………………...
Motorik : …..………………………………………………………………………………...
F. N VIII :
Vestibularis : ….……………………………………………………………………………..
Akustikus : …..……………………………………………………………………………..
G. N IX : ……………………………………………………………………………………..….
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H. N X : ………………………………………………………………………………………....
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I. N XI : ………………………………………………………………………………………...
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J. N XII : ……………………………………………………………………………………….
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Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 15

VI. PEMERIKSAAN PENUNJANG

Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 16

VII. TERAPI

Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 17

 Tanda Tangan Mahasiswa Yang Mengkaji

( )

Pengkajian Keperawatan Medikal Bedah STIK Stella Maris 18