Visi Akper Bina Insani Sakti

“Menghasilkan perawat berkompeten yang mampu bersaing dibidang keperawatan gawat darurat di provinsi Jambi tahun 2020”

FORMAT PENGKAJIAN
KEPERAWATAN MEDIKAL BEDAH
AKPER BINA INSANI SAKTI SUNGAI PENUH

NAMA MAHASISWA :
NIM :
RUANGAN :

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I. BIODATA
A. Identitas Pasien
Nama : ....................................................................
Umur : ....................................................................
Jenis Kelamin : .....................................................................
Status Perkawinan : ......................................................................
Pendidikan : ......................................................................
Pekerjaan : ......................................................................
Alamat : ......................................................................
Tanggal masuk RS/ jam : ......................................................................
No. Register : ......................................................................
Ruangan/Kamar : ......................................................................
Golongan Darah : ......................................................................
Tanggal Pengkajian/jam : ......................................................................
Diagnosa Medis : ......................................................................
B. Identitas Penanggung Jawab
Nama : .......................................................................
Hubungan dg Pasien : .......................................................................
Pekerjaan : ......................................................................
Alamat : ......................................................................
II. KELUHAN UTAMA
............................................................................................................................................
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III. RIWAYAT KESEHATAN
A. Sekarang
.......................................................................................................................................
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Keluhan utama saat di data
a. Provocative/palliative
.........................................................................................................................
........................................................................................................................
b. Quality
.........................................................................................................................
.........................................................................................................................
c. Region (Lokasi)
.........................................................................................................................
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Visi Akper Bina Insani Sakti
“Menghasilkan perawat berkompeten yang mampu bersaing dibidang keperawatan gawat darurat di provinsi Jambi tahun 2020”

d. Severity (Mengganggu Aktivitas)

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

e. Time (Waktu)
.........................................................................................................................
........................................................................................................................
B. Yang Lalu
Penyakit yang pernah dialami
.......................................................................................................................................
.......................................................................................................................................
Tindakan medis / Pengobatan yang dilakukan
.......................................................................................................................................
.......................................................................................................................................
Pernah dirawat / dioperasi
.......................................................................................................................................
.......................................................................................................................................
Lamanya dirawat
.......................................................................................................................................
.......................................................................................................................................
Alergi
.......................................................................................................................................
......................................................................................................................................
IV. RIWAYAT KESEHATAN KELUARGA
Orang Tua
.........................................................................................................................................
.........................................................................................................................................
Saudara Kandung
.........................................................................................................................................
.........................................................................................................................................
Penyakit keturunan yang ada
.........................................................................................................................................
.........................................................................................................................................
Anggota keluarga yang meninggal
.........................................................................................................................................
.........................................................................................................................................
Penyebab meninggal
.........................................................................................................................................
.........................................................................................................................................
Genogram

V. Riwayat / Keadaan psikososial

A. Bahasa yang digunakan
...................................................................................................................................
...................................................................................................................................
B. Persepsi pasien tentang penyakitnya
Visi Akper Bina Insani Sakti
“Menghasilkan perawat berkompeten yang mampu bersaing dibidang keperawatan gawat darurat di provinsi Jambi tahun 2020”

...................................................................................................................................
...................................................................................................................................
C. Konsep diri
1. Body image: ...................................................................................................
2. Ideal diri : .......................................................................................................
3. Harga diri : ....................................................................................................
4. Peran diri : .....................................................................................................
5. Personal identity :. .........................................................................................
D. Keadaan emosi
...................................................................................................................................
E. Perhatian terhadap orang lain / lawan bicara
...................................................................................................................................
F. Hubungan dengan keluarga
..................................................................................................................................
G. Hubungan dengan orang lain
..................................................................................................................................
H. Kegemaran
..................................................................................................................................
I. Daya adaptasi
..................................................................................................................................
J. Mekanisme pertahanan diri
................................................................................................................................

VI. PEMERIKSAAN FISIK

A. Keadaan Umum :
B. Tanda-tanda vital
TD : RR :
Suhu : BB :
Nadi : TB :
C. Pemeriksaan kepala dan leher
1. Kepala dan rambut
a. Kepala
Ubun-ubun : ........................................................................
Kulit kepala : ........................................................................
b. Rambut
Penyebaran rambut : .........................................................................
Bau : .........................................................................
Warna rambut : .........................................................................
Tekstur rambut
: ..........................................................................
c. Wajah
Warna kulit : ..........................................................................
Kesimetrisan : .........................................................................
Ekspresi wajah : .........................................................................
d. Mata
Kelengkapan
....................................................................................................................
Posisi dan kesejajaran mata
....................................................................................................................
Palpebra
Visi Akper Bina Insani Sakti
“Menghasilkan perawat berkompeten yang mampu bersaing dibidang keperawatan gawat darurat di provinsi Jambi tahun 2020”

....................................................................................................................
Konjungtiva dan sclera
....................................................................................................................
Pupil
....................................................................................................................

e. Hidung
Tulang hidung dan posisi septum nasal
....................................................................................................................
Lubang hidung dan mukosa hidung
....................................................................................................................
Cuping hidung
....................................................................................................................
f. Telinga
Daun telinga : ............................................................................
Lubang telinga : ............................................................................
Gendang telinga : ............................................................................
Ketajaman pendengaran : .........................................................................
g. Mulut dan faring
Bibir : ............................................................................
Gigi dan gusi : .............................................................................
Mukosa oral : .............................................................................
Orofaring : ............................................................................
h. Leher
Posisi trakea : ............................................................................
Thyroid : ............................................................................
Suara : ............................................................................
Kelenjar limfe : ............................................................................

D. Pemeriksaan integumen
Kebersihan : ............................................................................
Warna : ............................................................................
Turgor : ............................................................................
Kelainan pada kulit : ............................................................................
Kuku : ............................................................................

E. Pemeriksaan payudara dan axila

Ukuran dan bentuk payudara : ............................................................................
Warna payudara dan areola : ............................................................................
Kelainan pada payudara : ............................................................................
Axila : ............................................................................

F. Pemeriksaan thorax
1. Inspeksi thorax
 Bentuk thorax : ................................................................
 Frekuensi pernafasan : ................................................................
 Tanda kesulitan bernafas : .................................................................
2. Pemeriksaan paru
Palpasi getaran suara : ................................................................
Perkusi : ...............................................................
Visi Akper Bina Insani Sakti
“Menghasilkan perawat berkompeten yang mampu bersaing dibidang keperawatan gawat darurat di provinsi Jambi tahun 2020”

Auskultasi
Suara nafas : .................................................................
Suara ucapan : ................................................................
Suara tambahan : .................................................................
3. Pemeriksaan jantung
Inspeksi : .............................................................................
Palpasi
Pulsasi : .............................................................................
Ictus cordis : .............................................................................
Perkusi
Batas jantung : .............................................................................
Auskultasi
Bunyi jantung I : ............................................................................
Bunyi jantung II : ............................................................................
Mur-mur : ............................................................................
Frekuensi : ............................................................................

G. Pemeriksaan abdomen
a. Inspeksi
 Bentuk abdomen : ............................................................................
 Benjolan : ............................................................................
 Bayangan pembuluh darah :..................................................................
b. Auskultasi
 Peristaltik usus :..............................................................................
c. Palpasi
 Nyeri : ............................................................................
 Benjolan : ............................................................................
 Tanda acites : ............................................................................
 Hepar : ............................................................................
 Limfe : ............................................................................
d. Perkusi
 Suara abdomen : .............................................................................
 Pemeriksaan acites : .............................................................................
H. Pemeriksaan kelamin
1. Genetalia
 Rambut pubis : ............................................................................
 Lubang uretra :..............................................................................
 Kelainan pada genetalia eksterna dan daerah inguinal
....................................................................................................................
2. Anus dan perineum
 Lubang anus :..............................................................................
 Kelainan pada anus : .............................................................................
 Perinium :..............................................................................

I. Pemeriksaan Muskuloskletal
Kesimetrisan otot : .........................................................................................
Pemeriksaan edema : ........................................................................................
Kekuatan otot : ........................................................................................
Kelainan : ....................................................................................................
Visi Akper Bina Insani Sakti
“Menghasilkan perawat berkompeten yang mampu bersaing dibidang keperawatan gawat darurat di provinsi Jambi tahun 2020”

J. Pemeriksaan Neurology
1. Tingkat kesadaran : .............................................................................
GCS : ............................. (.............................................................................)
E : ........ (......................................................................................................)
M : .........(......................................................................................................)
V : .........(......................................................................................................)
2. Meningeal sign
kaku kuduk :.........................................................................................
kernig : .........................................................................................
buzinskyI-IV : .........................................................................................
3. Status mental
a. Kondisi emosi
....................................................................................................................
........................................................................................................
b. Orientasi orang, waktu, dan tempat
....................................................................................................................
........................................................................................................
c. Proses pikir
....................................................................................................................
........................................................................................................
d. Motivasi
....................................................................................................................
........................................................................................................
e. Bahasa
..............................................................................................................
4. Nervus cranialis
a. Olfaktorius (N I)
....................................................................................................................
........................................................................................................
b. Opticus (N II)
....................................................................................................................
........................................................................................................
c. Okulomotorius (N III), Trochlearis (N IV), Abdusen (N VI)
....................................................................................................................
........................................................................................................
d. Trigeminus (N V)
....................................................................................................................
........................................................................................................
e. Fasialis (N VII)
....................................................................................................................
........................................................................................................
f. Festibulocochlearis (N VIII)
....................................................................................................................
........................................................................................................
g. Glosopharingeus (N IX)
....................................................................................................................
........................................................................................................
h. Asesorius (N XI)
....................................................................................................................
........................................................................................................
Visi Akper Bina Insani Sakti
“Menghasilkan perawat berkompeten yang mampu bersaing dibidang keperawatan gawat darurat di provinsi Jambi tahun 2020”

i. Hipoglossus (N XII)
....................................................................................................................
........................................................................................................
5. Fungsi motorik
a. Cara berjalan : ......................................................................
b. Romberg test : ......................................................................
c. Test jari hidung : ......................................................................
d. Pronasi supinasi test : ......................................................................
6. Fungsi sensori
a. Identifikasi sentuhan ringan
..............................................................................................................
b. Test tajam tumpul : ......................................................................
c. Test panas dingin : ......................................................................
d. Streognosis test : ......................................................................
e. Gaphestesia : ......................................................................
f. Topognosis test : ......................................................................
7. Refleks
a. Refleks bisep : ......................................................................
b. Refleks trisep : ......................................................................
c. Refleks brachioradialis : ..........................................................
d. Refleks patella : ..........................................................
e. Refleks tendon achiles : ..........................................................

VII. Pola kebiasaan sehari-hari

No Kegiatan Sebelum masuk RS Setelah masuk RS

1 Pola tidur
Waktu tidur ................................. .................................
Waktu bangun ................................. .................................
Rata-rata lama tidur/ jam ................................. .................................
Yang mempermudah tidur ................................. .................................
Yang mempermudah bangun ................................. ..................................
Kualitas tidur .................................. .................................
2
Pola eliminasi
a. BAB ................................. ................................
Pola BAB ................................. ................................
Penggunaan laktasik ................................. .................................
Karakter feses ................................. .................................
BAB terakhir ................................. .................................
Riwayat perdarahan ................................. .................................
Diare
b. BAK .................................. .................................
Pola BAK ................................. .................................
Inkontinensia .................................. .................................
Karakter urin ................................. .................................
Retensi .................................. .................................
Nyeri ................................. .................................
Riwayat penyakit ginjal ................................. .................................
Penggunaan diuretik .................................. ..................................
Volume cairan( / 8 jam) .................................. .................................
3
 Visi Akper Bina Insani Sakti
“Menghasilkan perawat berkompeten yang mampu bersaing dibidang keperawatan gawat darurat di provinsi Jambi tahun 2020”

Penggunaan alat bantu ( ................................ .................................

cateter/ pispot ) .................................. ..................................
Pola makan dan minum .................................. .................................
a. Pola Makan .................................. .................................
Diet tipe .................................. .................................
Jumlah makanan/hari .................................. .................................
Pola diet .................................. .................................
Kehilangan selera makan .................................. .................................
Mual/muntah
Intoleransi makanan .................................. .................................
BB .................................. .................................
TB .................................. .................................
Waktu pemberian ................................. .................................
Jumlah dan jenis makanan ................................. ................................
b. Pola cairan
Waktu pemberian cairan .................................. .................................
Jumlah cairan : .................................. .................................
- Peroral
................................. .................................
- Parenteral (Infus/injeksi)
c. Masalah makan/ minum ................................. .................................
Kesulitan mengunyah
Kesulitan menelan .................................. ..................................
4
Tidak dapat makan sendiri .................................. .................................
Upaya mengatasi masalah ................................. .................................
5 Alergi makana. Minuman. ................................. .................................
................................. .................................
4. Kegiatan dan aktivitas ................................. .................................

Personal Hygiene ................................. ..................................

Mandi ................................... ..................................
Cuci rambut .................................. ....................................
Potong kuku ..................................... ...................................
Oral hygiene

VIII. Hasil pemeriksaan Doagnostik

 Diagnosa medis : ......................................................................
 Pemeriksaan diagnostik (tanggal/hari/bulan/tahun)
Laboratorium
....................................................................................................................
....................................................................................................................
Rontgen
....................................................................................................................
....................................................................................................................
ECG
....................................................................................................................
....................................................................................................................
USG
....................................................................................................................
....................................................................................................................
Lain-lain
Visi Akper Bina Insani Sakti
“Menghasilkan perawat berkompeten yang mampu bersaing dibidang keperawatan gawat darurat di provinsi Jambi tahun 2020”

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

Penatalaksanaan terapi (tanggal/bulan/tahun)

Dosis Rute
No Nama Obat Pemberian Efek terapi Efek samping
(mg)

ANALISA DATA

No Symptom Etiologi Problem

DIAGNOSA KEPERAWATAN

1. ............................................................................................................................................
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2. ............................................................................................................................................
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3. ............................................................................................................................................
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RENCANA KEPERAWATAN

No Hari/Tanggal Diagnosa NOC Rencana Keperawatan

/Jam NIC Aktivitas
Visi Akper Bina Insani Sakti
“Menghasilkan perawat berkompeten yang mampu bersaing dibidang keperawatan gawat darurat di provinsi Jambi tahun 2020”
Visi Akper Bina Insani Sakti
“Menghasilkan perawat berkompeten yang mampu bersaing dibidang keperawatan gawat darurat di provinsi Jambi tahun
2020”

IMPLEMENTASI

No No. Diagnosa Hari/Tanggal/jam Implementasi Dan Hasil Paraf

EVALUASI

No No. Diagnosa Hari/Tanggal/jam Evaluasi Paraf

S ( subjektif) :

O ( Objektif) :

A ( Analisa) :

P ( Planning) :