FORMAT PENGKAJIAN RUANG BEDAH

PROGRAM PROFESI NERS FAKULTAS ILMU KESEHATAN

UNIVERSITAS MUHAMMADIYAH GORONTALO

No. RM :
Tanggal :
Tempat :
I. DATA UMUM
1. Identitas Klien
Nama : Umur :
Tempat / Tanggal Lahir : Jenis Kelamin :L/P
Agama : Suku :
Pendidikan : Dx. Medis :
Alamat : Telepon :
Tanggal masuk RS : Ruangan :
Golongan Darah : Sumber info :

2. Identitas Keluarga (terutama satu rumah)

No. Nama Umur (thn) Hubungan Status Kesehatan

1
2
3
4

Genogram
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 1

 Simbol Genogram :
: Laki-laki : Cerai : Berpisah
: Perempuan : Kembar Non identik : Abortus
X : Meninggal Dunia : Kembar Identik : Diadopsi
: Klien - - - - : Hidup bersama : Lahir Mati

II. RIWAYAT KESEHATAN SAAT INI

1. Diagnosa Medis :
2. Keluhan Utama :
3. Keluhan Saat Ini :
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4. Riwayat Keluhan Saat Ini :
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5. Riwayat penyakit sekarang :
Tanggal Awitan :
Sifat Awitan : Bertahap/tiba-tiba
Karakteritik :
a. Lokasi :
b. Yang Memperberat :
c. Yang Meringankan :
6. Penyakit atau Tindakan Operasi sebelumnya :
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 2

 7. Riwayat Obat-obatan :
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III. RIWAYAT KESEHATAN MASA LALU

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IV. RIWAYAT PSIKO-SOSIO-SPIRITUAL

1. Riwayat psikososial
a. Tempat tinggal :
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b. Lingkungan rumah :
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c. Hubungan antar anggota keluarga :
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2. Riwayat spiritual
a. Support system :
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b. Kegiatan keagamaan :
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3. Riwayat hospitalisasi
a. Pemahaman keluarga tentang sakit dan rawat inap di rumah sakit :
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 3

 b. Pemahaman pasien tentang sakit dan rawat inap :
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V. KEBUTUHAN DASAR / POLA KEBIASAAN SEHARI-HARI

1. Nutrisi
Sebelum sakit :
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Saat sakit :
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2. Istirahat / tidur
Sebelum Sakit :
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Saat sakit :
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3. Eliminasi fekal / BAB
Sebelum Sakit :
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Saat sakit :
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 4

 4. Eliminasi urine / BAK
Sebelum Sakit :
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Saat sakit :
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5. Aktivitas dan Latihan
Sebelum Sakit :
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Saat sakit :
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6. Personal hygiene
Sebelum Sakit :
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Saat sakit :
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7. Aktivitas sehari-hari
Sebelum Sakit :
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Saat sakit :
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 5

VI. PEMERIKSAAN FISIK
Hari , tanggal 2022, pukul
1. Keadaan umum
a. Kesadaran :
b. Penampilan dihubungkan dengan usia :
c. Ekspresi wajah :
d. Kebersihan secara umum :
e. Tanda-tanda vital :
1. Tekanan Darah : mmHg
2. Frekuensi Nadi : kali/menit
3. Frekuensi Suhu : 0
C
4. Frekuensi Pernapasan : kali/menit
5. SPO2 : %
f. Berat Badan : Kg
g. Tinggi Badan : cm
h. IMT : Kg/m2
i. BBI : Kg
2. Head to toe
a. Kulit / integument :
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b. Kepala dan rambut :
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c. Kuku :
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d. Mata / penglihatan :
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 6

 e. Hidung / penghiduan :
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f. Telinga / pendengaran :
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g. Mulut dan gigi :
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h. Leher :
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i. Dada :
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j. Abdomen :
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k. Perineum dan genitalia :
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l. Ekstremitas atas dan bawah :
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 7

 3. Pemeriksaan diagnostik (meliputi tanggal dan hasil pemeriksaan) meliputi
Pemeriksaan Laboratorium, Foto Rontgen, Data Tambahan

Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 8

 4. Penatalaksanaan medis (Uraian sesuai dengan anjuran medis) meliputi Obat-obatan
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 9

VII. IDENTIFIKASI DATA
1. Keluhan (Data Subjektif)
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2. Data objektif
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 10

XI. KLASIFIKASI/PENGELOMPOKKAN DATA BERDASARKAN
GANGGUAN KEBUTUHAN
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 11

XII. ANALISA DATA BERDASARKAN PATOFISIOLOGI DAN
PENYIMPANGAN KDM

Penyakit (Diagnosa Medis) Klien :

Respon utama :
Penyimpangan KDM :
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 12

XIII. DAFTAR MASALAH KEPERAWATAN
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 13
XIV. RUMUSAN INTERVENSI KEPERAWATAN
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Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 14
Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 15
Stase Keperawatan Dasar Ns XV FIKES UMGO pg. 16
XV. RUMUSAN INTERVENSI KEPERAWATAN
Inisial Pasien :
No. RM :
Ruangan :

NO Diagnosa Keperawatan Luaran Keperawatan Intervensi

DX Keperawatan
 Diagnosa Keperawatan : Setelah dilakukan Label Intervensi
(Label Dx aktual b.d Penyebab d.d intervensi keperawatan Utama/Pendukung
Tanda/Gelaja) selama …….. , maka  Definisi
[Label luaran]  Tindakan
(Label Dx Risiko d.d Faktor Risiko) [Ekspektasi] dengan (Obeservasi,
kriteria hasil: Terapeutik, Edukasi,
 Kategori/Sub Kategori - Kriteria 1 (hasil) Kolaborasi)
- Kriteria 2 (hasil)
 Definisi
- Kriteria 3 (hasil)
 Gejala dan Tanda Mayor (DO, DS)-
> Dx Aktual
 Gejala dan Tanda Minor (DO, DS)-
> Dx Aktual
 Faktor Risiko -> Dx Risiko
 Kondisi Klinis Terkait

XVI. IMPLEMENTASI DAN EVALUASI

N WAKTU IMPLEMENTASI EVALUASI

O (TGL/JAM)
DX
1. Implementasi …… S:
Hasil : O:
A:
P:

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