U N I V E R S I T A S B O N D O W O S O

PR OGR A M STUD I DI I I KEPER A WA TA N

Terakreditasi LAM-PTKes No.0071/LAM PTKes/Akr/Dip/II/2019
Jl. Diponegoro No.247 Tlp/Fax. (0332) 427660 Bondowoso

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama mahasiswa : ........................................

NIM : …………………………….
Tgl/jam pengkajian : ........................................
Diagnosa medis : ........................................
Tgl/jam MRS : ........................................
No. RM : ........................................
Ruangan/kelas : ........................................
No.kamar : .............................................

I. IDENTITAS
1. Nama : .....................................................................................................................
2. Umur : .....................................................................................................................
3. Jenis kelamin : .....................................................................................................................
4. Status : .....................................................................................................................
5. Agama : .....................................................................................................................
6. Suku/bangsa : .....................................................................................................................
7. Bahasa : .....................................................................................................................
8. Pendidikan : .....................................................................................................................
9. Pekerjaan : .....................................................................................................................
10. Alamat dan no. Telp: .....................................................................................................................
11. Penanggung jawab : .....................................................................................................................

II. RIWAYAT SAKIT DAN KESEHATAN

1. Keluhan utama :
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2. Riwayat penyakit sekarang :
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3. Riwayat penyakit dahulu :
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4. Riwayat kesehatan keluarga :
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5. Susunan Keluarga (Genogram) :

6. Riwayat alergi :
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III. POLA FUNGSI KESEHATAN
1. Persepsi Terhadap Kesehatan (Keyakinan Terhadap Kesehatan & Sakitnya)
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2. Pola Aktivitas Dan Latihan
a. Kemampuan perawatan diri
SMRS MRS
Aktivitas
0 1 2 3 4 0 1 2 3 4
Mandi
Berpakaian/berdandan
Eliminasi/toileting
Mobilitas di tempat tidur
Berpindah
Berjalan
Naik tangga
Berbelanja
Memasak
Pemeliharaan rumah
Skor 0 = mandiri 3 = dibantu orang lain & alat
1 = alat bantu 4 = tergantung/tidak mampu
2 = dibantu orang lain
Alat bantu : ( ) tidak ( ) kruk ( ) tongkat
( ) pispot disamping tempat tidur ( ) kursi roda
b. Kebersihan diri
Di rumah Di rumah sakit
Mandi : ........................ Mandi : ........................
/hr /hr
Gosok gigi : ........................ Gosok gigi : ........................
/hr /hr
Keramas : .................... Keramas : ....................
/mgg /mgg
Potong kuku : .................... Potong kuku : ....................
/mgg /mgg
c. Aktivitas sehari-hari

d. Rekreasi
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e. Olahraga : ( ) tidak ( ) ya
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3. Pola Istirahat Dan Tidur
Di rumah Waktu tidur : Siang ............-.........
 Malam ..........-......... Waktu tidur : Siang ............-..............
Jumlah jam tidur : .................................. Malam ...........-.............
Di rumah sakit Jumlah jam tidur : ..................................
Masalah di RS : ( ) tidak ada ( ) terbangun dini ( ) mimpi buruk
( ) insomnia ( ) Lainnya, ...............................
4. Pola Nutrisi – Metabolik
a. Pola makan
Di rumah Di rumah sakit
Frekuensi : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Porsi : ......................... Porsi : ..................................
Pantangan : ......................... Diit khusus : ..................................
Makanan disukai : .........................
Nafsu makan di RS : ( ) normal ( ) bertambah ( ) berkurang
( ) mual ( ) muntah, .............. cc ( ) stomatitis
Kesulitan menelan : ( ) tidak ( ) ya
Gigi palsu : ( ) tidak ( ) ya
NG tube : ( ) tidak ( ) ya
b. Pola minum
Di rumah Di rumah sakit
Frekuensi : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Jumlah : ......................... Jumlah : ..................................
Pantangan : .........................
Minuman disukai : .........................

5. Pola Eliminasi
a. Buang air besar
Di rumah Di rumah sakit
Frekuensi : .................................. Frekuensi : ..................................
Konsistensi : .................................. Konsistensi : ..................................
Warna : .................................. Warna : ( ) kuning
( ) bercampur darah
( ) lainnya, ..............
Masalah di RS : ( ) konstipasi ( ) diare ( ) inkontinensia
Kolostomi : ( ) tidak ( ) ya

b. Buang air kecil

Di rumah
Frekuensi : ..................................
Konsistensi : ..................................
Warna : ..................................

Di rumah sakit
Frekuensi : ..................................
Konsistensi : ..................................
Warna : ..................................
 Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria
( ) retensi ( ) inkontinensia
Kolostomi : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari
6. Pola Kognitif Perseptual
Berbicara : ( ) normal ( ) gagap ( ) bicara tak jelas
Bahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya, ....................................
Kemampuan membaca : ( ) bisa ( ) tidak
Tingkat ansietas : ( ) ringan ( ) sedang ( ) berat ( ) panik
Sebab, ...................................................................................................
Kemampuan interaksi : ( ) sesuai ( ) tidak, ...................................................................
Vertigo : ( ) tidak ( ) ya
Nyeri : ( ) tidak ( ) ya
Bila ya, P : .................................................................................................................................
Q : .................................................................................................................................
R : .................................................................................................................................
S : .................................................................................................................................
T : .................................................................................................................................
7. Pola Konsep Diri
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8. Pola Koping
Masalah utama selama MRS (penyakit, biaya, perawatan diri)
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Kehilangan perubahan yang terjadi sebelumnya
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Kemampuan adaptasi
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9. Pola Seksual – Reproduksi
Menstruasi terakhir : .....................................................................................................................
Masalah menstruasi : .....................................................................................................................
Pap smear terakhir : .....................................................................................................................
Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidak
Masalah seksual yang berhubungan dengan penyakit : ...............................................................
 10. Pola Peran – Hubungan
Pekerjaan : ......................................................................................................
Kualitas bekerja : ......................................................................................................
Hubungan dengan orang lain : ......................................................................................................
Sistem pendukung : ( ) pasangan ( ) tetangga/teman ( ) tidak ada
( ) lainnya, .................................................................................
Masalah keluarga mengenai perawatan di RS : .............................................................................

11. Pola Nilai – Kepercayaan

Agama : ................................................................................................
Pelaksanaan ibadah : ................................................................................................
Pantangan agama : ( ) tidak ( ) ya, ................................................................
Meminta kunjungan rohaniawan : ( ) tidak ( ) ya

IV. PEMERIKSAAN FISIK

1. Keadaan umum :
2. Tanda-Tanda Vital
a. Suhu : ................... °C lokasi : ......................
b. Nadi : ................... /menit irama : ...................... pulsasi : ......................
c. Tekanan darah : ................... mmHg lokasi : ......................
d. Frekuensi nafas : ................... /menit irama : ......................
e. Tinggi badan : ................... cm
f. Berat badan : SMRS ................... kg MRS .................... kg

3. Kepala
I :...................................................................................................................................................
P :..................................................................................................................................................

4. Mata
I :...................................................................................................................................................
P :..................................................................................................................................................

5. Telinga
I :...................................................................................................................................................
P :..................................................................................................................................................

6. Hidung
I :...................................................................................................................................................
P :..................................................................................................................................................
7. Mulut
I :...................................................................................................................................................
P:...................................................................................................................................................

8. Leher
I ;...................................................................................................................................................
P :..................................................................................................................................................

9. Dada:
Jantung:
I :...................................................................................................................................................
P :..................................................................................................................................................
P :..................................................................................................................................................
A :..................................................................................................................................................

Paru:
I :...................................................................................................................................................
P :..................................................................................................................................................
P :..................................................................................................................................................
A :..................................................................................................................................................

10. Abdomen
I :...................................................................................................................................................
A :..................................................................................................................................................
P :..................................................................................................................................................
P :..................................................................................................................................................

11. Urogenital
I :...................................................................................................................................................
P :..................................................................................................................................................

12. Ekstremitas
I :...................................................................................................................................................
P :..................................................................................................................................................
P :..................................................................................................................................................

13. Kulit dan kuku

I :...................................................................................................................................................
P :..................................................................................................................................................
 14. Keadaan lokal
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V. PEMERIKSAAN PENUNJANG
1. Laboratorium
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2. Photo
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3. Lain-lain
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VI. TERAPI
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Bondowoso, ………………... 2022

Mahasiswa

( )
 ANALISA DATA

Nama Klien : ..................... Ruangan/kamar : ..............................

Umur : ..................... No. RM : ..............................
TGL/JAM DATA ETIOLOGI MASALAH

DIAGNOSA KEPERAWATAN BERDASARKAN URUTAN PRIORITAS

Nama Klien : ..................... Ruangan/kamar : ..............................
Umur : ..................... No. RM : ..............................
NO TGL/JAM DIAGNOSA KEPERAWATAN (SDKI) PARAF
 RENCANA TINDAKAN KEPERAWATAN

TGL/ DIAGNOSA TUJUAN DAN RENCANA TINDAKAN (SIKI) RASIONAL PARAF

JAM KEPERAWATAN KRITERIA HASIL (SLKI)
 IMPLEMENTASI

NO. DX KEP TANGGAL / JAM IMPLEMENTASI PARAF

 EVALUASI

NO. DX KEP TANGGAL / JAM EVALUASI PARAF