KEMENTERIAN KESEHATAN RI

DIREKTORAT JENDERAL TENAGA KESEHATAN

POLITEKNIK KESEHATAN ACEH
PROGRAM STUDI KEPERAWATAN MEULABOH
Jln.Keperawatan No. 25 Suak Ribee Email: prodikepmeulaboh@gmail.com
Telp. (0655) 7005889 – 700589 Kode Pos : 23653. Fax.0655-7552397

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Pengkajian Tgl. : 13 september 2022 Jam : 20.30

MRS Tanggal : 12 september 2022 No. RM : 120076
Diagnosa Masuk : kolik abdomen Hari Rawat Ke : Ke 2
Ruangan/kelas : Kelas 3

A. IDENTITAS PASIEN
Nama : Ny.L Penanggung jawab biaya
Usia : 27 Nama : Adi Muklis
Jenis kelamin : Perempuan Alamat : Punge
Suku /Bangsa : Indonesia Hub. Keluarga : Abang Kandung
Agama : Islam Telepon : 08116830333
Pendidikan : S1 sikologi
Status perkawinan : Belum Menikah
Pekerjaan : Guru SD
Alamat : Lampeneurut

B. RIWAYAT PENYAKIT SEKARANG

1. Keluhan Utama : nyeri perut
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2. Riwayat Penyakit Sekarang :
C. Pasien mengatakan sejak 2 hari yang lalu nyeri perut disertai
mual,muntah,menggigil,pusing,tidak nafsu makan,diare,badan lemas,sulit tidur,nyeri muncul
secara tiba-tiba seperti ditusuk-tusuk dan terasa panas,skala nyeri4.Td:130/115
mmhg,RR.20x/I,n.94x/I,S.36,3 Oc
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D. RIWAYAT PENYAKIT DAHULU

1. Pernah di rawat ya, jenis : Sakit lambung............ tidak

2. Riwayat Penyakit Kronik dan Menular ya, jenis : ....................... tidak

3. Riwayat Penyakit Alergi ya, jenis : ....................... tidak

4. Riwayat Operasi ya, jenis : ....................... tidak

- Kapan : ...............................
- Jenis Operasi : ...............................
5. Lain-lain :
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E. RIWAYAT PENYAKIT KELUARGA

ya : ........................................ tidak

GENOGRAM

F. PERILAKU YANG MEMPENGARUHI KESEHATAN

Perilaku sebelum sakit yang mempengaruhi kesehatan
Alkohol ya tidak
Keterangan ..................................................................................................................................
Merokok ya tidak
Keterangan ...................................................................................................................................
Obat ya tidak
Keterangan ...................................................................................................................................

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 Olahraga ya tidak
Keterangan ...................................................................................................................................
G. OBSERVASI DAN PEMERIKSAAN FISIK
1. Tanda-tanda vital
Kesadaran Compos mentis Apatis Somnolen Sopor Koma
S : 36,3 c O
N :94 x/i TD : 115 mmhg RR : 20x/i
MASALAH KEPERAWATAN :
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2. Sistem Pernafasan
a. RR : 20x/i...............................
b. Keluhan : Sesak Nyeri waktu sesak Orthopnea
Batuk Produktif Tidak Produktif
Sekret : .................... Konsistensi : .......................
Warna : ................... Bau : ....................................
c. Pola nafas irama:  Teratur  Tidak teratur
d. Jenis  Dispnoe  Kusmaul  Ceyne Stokes Lain-lain:
Pernafasan cuping hidung ada tidak
Septum nasi simetris tidak simetris
Lain-lain :
e. Bentuk dada simetris asimetris barrel chest
Funnel chest Pigeons chest
f. Suara napas vesiculer ronchi D/S wheezing D/S rales D/S
g. Alat bantu nafas Ya Tidak
Jenis .........................Flow ................Lpm
h. Penggunaan WSD :
- Jenis : .........................................................................................................................
- Jumlah Cairan : ..............................................................................................................
- Undulasi : ......................................................................................................................
- Tekanan : ......................................................................................................................
i. Trakeostomy Ya Tidak
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j. Lain-lain :
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MASALAH KEPERAWATAN :
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3. Sistem Kardiovakuler
a. TD :130/115 mmhg
b. N : 94x/i
c. HR :
d. Keluhan nyeri dada ya tidak
P : .....................................................................................
Q : .....................................................................................
R : .....................................................................................
S : .....................................................................................
T : .....................................................................................
e. CRT : ...............
f. Konjungtiva pucat ya tidak
g. Bunyi jantung:  Normal  Murmur  Gallop lain-lain

h. Irama jantung:  Reguler  Ireguler S1/S2 tunggal  Ya  Tidak

i. Akral:  Hangat  Panas  Dingin kering  Dingin basah

j. Siklus perifer Normal Menurun

k. JVP : ..........................
l. CVP : ..........................
m. CTR : ..........................
n. ECG & Interpretasinya :
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Lain-
lain : ........................................................................................................................................
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MASALAH KEPERAWATAN :
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4. Sistem Persarafan
a. Kesadaran composmentis apatis somnolen sopor koma
GCS :
b. Pupil isokor anisokor
c. Sclera Anikterus Ikterus
d. Konjungtiva Ananemis Anemis
e. Istirahat/Tidur : sulit tidur.................................................
f. IVD : ......................................................
g. EVD : ......................................................
h. ICP : ......................................................
i. Nyeri tidak ya, skala nyeri : lokasi :
j. Refleks fisiologis:  patella  triceps  biceps lain-lain:

k. Refleks patologis:  babinsky  budzinsky  kernig lain-lain

l. Keluhan Pusing O ya O Tidak

P : .....................................................................................
Q : .....................................................................................
R : .....................................................................................
S : .....................................................................................
T : .....................................................................................
m. Pemeriksaan saraf kranial
N1 Normal Tidak Ket : ..................................................
N2 Normal Tidak Ket : ...................................................
N3 Normal Tidak Ket : ...................................................
N4 Normal Tidak Ket : ...................................................
N5 Normal Tidak Ket : ........................................... …..
N6 Normal Tidak Ket : ..................................................
N7 Normal Tidak Ket : ..................................................
N8 Normal Tidak Ket : ...................................................
N9 Normal Tidak Ket : ..................................................
N10 Normal Tidak Ket : ...................................................
N11 Normal Tidak Ket : .................................................
N12 Normal Tidak Ket : ..................................................

MASALAH KEPERAWATAN :

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 Tidak ada masalah keperawatan
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5. Sistem Perkemihan (B4)
a. Kebersihan genetalia : Bersih Kotor
b. Sekret : Ada Tidak
c. Ulkus : Ada Tidak
d. Kebersihan Meatus uretera : Bersih Kotor
e. Keluhan Kencing Ada Tidak
Bila ada jelaskan :
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f. Kemampuan berkemih
Spontan Alat bantu, sebutkan : ...............................................................
Jenis : ....................................................................................
Ukuran : ....................................................................................
Hari Ke: ...................................................................................
g. Produksi urine : ...........................ml/jam
Warnah : ...............................
Bau : ...............................
h. Kandung kemih : Membesar Ya
Tidak
i. Nyeri Tekan : Ya
Tidak
j. Intake Cairan : Oral :................cc/hari
Parenteral : ..............cc/hari
k. Balance Cairan
: ..............................................................................................................
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o. Lain-lain : ..................................................................................................................................
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MASALAH KEPERAWATAN :
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6. Sistem Pencernaan
a. TB : 157............. cm BB : 46..............kg
b. IMT : ............. Interpretasi : ....................................
MASALAH KEPERAWATAN :
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c. Mulut : Bersih Kotor

d. Mukosa mulut : Lembab Kering Merah stomatitis
e. Tenggorokan Nyeri telan Sulit menelan
Pembesaran Tonsil Nyeri Tekan
f. Abdomen Supel Tegang nyeri tekan, lokasi :perut
Luka operasi Jejas lokasi :
Pembesaran hepar ya tidak
Pembesaran lien ya tidak
Ascites ya tidak
Drain Ada Tidak
- Jumlah : ......................
- Warna : ......................
- Kondisi area sekitar insersi : .....................................
Mual ya tidak
Muntah ya tidak
Terpasang NGT ya tidak
Bising usus :..........x/mnt
g. BAB :........x/hr, konsistensi : lunak cair lendir/darah
konstipasi inkontinensia kolostomi
h. Diet padat lunak cair

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 Diet Khusus : ......................................................................................................................
Nafsu Makan Baik Menurun
Frekuensi :...............x/hari jumlah:............... jenis : .......................
Lain –lain : ..........................................................................................................................
MASALAH KEPERAWATAN :
Defisit nutrisi
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7. Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
OD CS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO

b. Keluhan nyeri Ya Tidak

P : ..................................................................
Q : ..................................................................
R : ..................................................................
S : ..................................................................
T : ..................................................................
c. Luka opreasi Ada Tidak
Tanggal operasi : ........................
Jenis Operasi : ........................
Lokasi : ........................
Keadaan : ........................
d. Pemeriksaan penunjang lain
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 e. Lain ..................................................................................................................
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MASALAH KEPERAWATAN :
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8. Sistem pendengaran
a. Pengkajian segmen dan posterior
OD OS
Aurcicula
MAE
Membran Tympani
Rinne
Webber
Swabach

b. Tes audiometri
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c. Keluhan nyeri Ya Tidak
P : ..................................................................
Q : ..................................................................
R : ..................................................................
S : ..................................................................
T : ..................................................................
d. Luka opreasi Ada Tidak
Tanggal operasi : ........................
Jenis Operasi : ........................
Lokasi : ........................
Keadaan : ........................
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 e. Alat bantu dengar : .......................................................
f. Lain-
lain. ..................................................................................................................................
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MASALAH KEPERAWATAN
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9. Sistem Muskuloskeletal dan Integumen (B6)

1. Keluhan Utama
1.1. Persendian
1.1.1. Nyeri
Keluhan nyeri :
P : ..................................................................
Q : ..................................................................
R : ..................................................................
S : ..................................................................
T : ..................................................................
1.1.2. Kekauan
a. Apakah terjadinya pagi hari Ya Tidak
b. Apakah terjadi Setelah istirahar Ya Tidak

1.1.3. Pembengkakan, panas dan kemerahan pada sendi

a. Pembengkakan Ya Tidak
b. Kemerahan Ya Tidak
c. Panas/nyeri Ya Tidak
1.1.4. Keterbatasan gerak Ya Tidak

1.1.5. Kekuatan otot

a. Pergerakan sendi bebas terbatas

b. Kelainan ekstremitas ya tidak
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c. Kelainan ekstremitas ya tidak
d. Traksi/spalk/gips ya tidak
- Jenis : ............................................
- Beban : ............................................
- Lama pemasangan : ...........................................
e. Penggunaan spalk/gips ya tidak
f. Keluhan nyeri : ya tidak
P : ..................................................................
Q : ..................................................................
R : ..................................................................
S : ..................................................................
T : ..................................................................

g. Sirkulasi perifer : ...........................................

h. Kompartemen sindrom ya tidak
i. Kulit ikterik sianosis kemerahan hiperpigmentasi
j. Akral hangat panas dingin kering basah
k. Turgor baik kurang jelek
l. Odema:  Ada  Tidak ada Lokasi

m. Luka operasi : jenis : bersih kotor luas : ...............

n. Tanggal operasi : ..................
o. Jenis operasi : ..................
p. Lokasi : ..................
q. Keadaan : ..................
r. Drain : Ada Tidak
s. Jumlah : ...................................................
t. Warna : ...................................................
u. Kondisi area sekitar insersi : ......................................
v. ROM : ..................................................
w. POD : ..................................................
x. Cardial Sign : ..................................................
Lain-lain : ...............................................................................................................
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MASALAH KEPERAWATAN :
Intoleransi aktivitas
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10. Sistem Integumen

a. Penilaian risiko decubitus :
Aspek yang KRITERIA YANG DINILAI NILAI
dinilai 1 3 3 4
PERSEPSI TERBATAS SANGAT KETERBATASAN TIDAK ADA
SENSORI SEPENUHNYA TERBATAS RINGAN GANGGUAN 4
TERUS
SANGAT KADANG-
KELEMBABAN MENERUS
LEMBAB KADANG BASAH
JARANG BASAH 3
BASAH

KADANG- LEBIH SERING

AKTIVITAS BEDFAST CHAIRFAST
KADANG JALAN JALAN 3
IMMOBILE SANGAT KETERBATASAN TIDAK ADA
MOBILISASI
SEPENUHNYA TERBATAS RINGAN KETERBATASAN 3
KEMUNGKINAN
NUTRISI
SANGAT
TIDAK ADEKUAT SANGAT BAIK 3
BURUK
ADEKUAT

TIDAK
GESEKAN & POTENSIAL
BERMASALAH MENIMBULKAN 3
PERGESERAN BERMASALAH
MASALAH
NOTE : Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien
beresiko mengalami dekubitus (Pressure ulcers) TOTAL NILAI 19
(15 or 16 =low risk, 13 or 14 = moderate risk, 12 or less= high risk)

b. Warna : ...........................................................
c. Pitting edema : +/- grade : .............................
d. Ekskoriasis : ya tidak
e. Psoriasis : ya tidak
f. Urtikaria : ya tidak
g. Lain-
lain : ............................................................................................................................
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MASALAH KEPERAWATAN
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11. Sistem Endokrin
a. Pembesaran kelenjar tyroid ya tidak
b. Pembesaran kelenjar getah bening ya tidak
c. Hiperglikemia  Ya  Tidak
d. Hipoglikemia  Ya  Tidak
e. Kondisi kaki DM :
- Luka gangrene  Ya  Tidak

- Jenis Luka : .....................................................

- Lama luka
- Warna
- Luas Luka
- Kedalaman
- Kulit Kaki
- Kuku kaki
- Telapak kaki
- Jari kaki
- Infeksi
: .....................................................
: .....................................................
: .....................................................
: .....................................................
: ..............................................
: ..............................................
: ..............................................
: ..............................................
:  Ya  Tidak

- Riwayat luka sebelumnya :  Ya  Tidak

- Tahun : ..................................................
- Jenis Luka : ..................................................
- Lokasi : ..................................................
- Riwayat amputansi sebelumnya :  Ya  Tidak
Jika Ya
- Tahun : ..........................
- Lokasi : .........................
- Lain-lain : .....................................................................................................
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MASALAH KEPERAWATAN :
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H. PENGKAJIAN PSIKOSOSIAL
1. Persepsi klien terhadap penyakitnya
cobaan Tuhan hukuman lainnya
2. Ekspresi klien terhadap penyakitnya
murung gelisah tegang marah/menangis
3. Reaksi saat interaksi kooperatif tak kooperatif curiga
4. Gangguan konsep diri ya tidak

MASALAH KEPERAWATAN :
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I. PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah
- Sebelum sakit sering kadang-kadang tidak pernah
- Selama sakit sering kadang-kadang tidak pernah
b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah :
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MASALAH KEPERAWATAN :
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J. PERSONAL HYGIEN
a. Kebersihan diri :
Pasien tampak bersih
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b. Kemampuan klien dalam pemenuhan kebutuhan :
- Mandi : Dibantu seluruhnya dibantu sebagian mandiri
- Ganti pakaian : Dibantu seluruhnya dibantu sebagian mandiri
- Keramas : Dibantu seluruhnya dibantu sebagian mandiri
- Sikat gigi : Dibantu seluruhnya dibantu sebagian mandiri
- Memotong kuku: Dibantu seluruhnya dibantu sebagian mandiri

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 - Berhias : Dibantu seluruhnya dibantu sebagian mandiri
- Makan : Dibantu seluruhnya dibantu sebagian mandiri
MASALAH KEPERAWATAN :
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K. PEMERIKSAAN PENUNJANG (Laboratorium, radiologi, EKG, USG)
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L. TERAPI
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Meulaboh ,............................2022
Perawat

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