PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Ruang rawat :
No. Rawat :
1. Identitas Pasien
Nama/umur : Agama :
Pendidikan : Bahasa yg digunakan :
Pekerjaan : Status Perkawinan : M/S/D/J
Tanggal MRS : Tgl & Jam pengambilan data:
Diagnosa Medis :

2. Riwayat kesehatan :
a. Riwayat kesehatan sekarang :
 Keluhan utama :
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 Riwayat keluhan utama
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b. Riwayat kesehatan yang lalu & riwayat kesehatan keluarga :
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c. Genogram (tiga generasi) JIKA DIPERLUKAN

3. Pemeriksaan fisik/biologis
 Keadaan umum :
 TTV : TD………….mmHg Suhu………..°C
Nadi……….X/I P……………X/i
 BB sebelum/setelah sakit : …………/…………Kg TB…………cm
 Kesadaran :
 Kepala : ..............................................................................................................
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 Leher : ..............................................................................................................
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 Dada : ..............................................................................................................
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 Abdomen : ..............................................................................................................
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 Genital : ..............................................................................................................
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 Integument : ..............................................................................................................
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 Ekstremitas : ..............................................................................................................
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4. Pola kebiasaan Klien

 Nutrisi :
Kegiatan Sebelum Sakit Saat Sakit
Jenis Makanan :

Frekuensi Makan :
 Makanan Pantangan :

Kebiasaan Sebelum Makan :

Diet :
Masalah Lainnya

 Eliminasi urine :
Kegiatan Sebelum Sakit Saat Sakit
Frekuensi
Warna
Bau
Jumlah Urine
Masalah Lainnya

 Eliminasi fecal :
Kegiatan Sebelum Sakit Saat Sakit
Frekuensi
Warna
Bau
Konsistensi
Penggunaan Obat Pencahar
Masalah Lainnya

 Balance Cairan
Kegiatan Selama 24 Jam
Masukan Cairan

Air metabolisme

Haluaran Cairan
 Frekuensi

Jenis Cairan

IWL (1 Hari)

Total
Balance

 Aktivitas :
Kegiatan Sebelum Sakit Saat Sakit
Aktivitas Ringan

Aktivitas Berat

Frekuensi

Masalah Lainnya

PENGKAJIAN STATUS FUNGSIONAL

(BARTHEL INDEKS)

NO FUNGSI SKOR KETERANGAN

0 Tidak terkendali/tidak terukur (perlu
Mengendalikan rangsang buang air besar pencahar)
1
(BAB) 1 Kadang-kadang tidak terkendali
2 (1 x seminggu)
Skor
0 Tidak terkendali/pakai kateter
1 Kadang-kadang tidang terkendali
2 Mengendalikan rangsang berkemih
(hanya 1x/24 jam)
2 Mandiri
Skor
0 Perlu pertolongan orang lain
Membersihkan diri (mandi, basuh muka, 1 Mandiri
3
sisir rambut,sikat gigi)

Skor
4 Penggunaan kloset, masuk dan keluar 0 Tergantung pertolongan orang lain
(melepaskan, memakai celana, 1 Perlu pertolongan pada beberapa
membersihkan, menyiram) kegiatan, tetapi dapat mengerjakan
 sendirih beberapa kegiatan orang lain
2 Mandiri
Skor
0 Tidak mampu
1 Perlu pertolongan memotong
5 Makan
makanan
2 Mandiri
Skor
Tidak mampu
0
Perlu banyak bantuan untuk bisa
1
6 Berubah posisi dari berbaring ke duduk duduk (2 orang)bantuan minimal 1
orang
2
Mandiri
Skor
0 Tidak mampu
1 Bisa pindah dengan kursi roda
7 Berpindah/berjalan
2 Berjalan dengan bantuan 1 orang
3 Mandiri
Skor
0 Tergantung pada orang lain
1 Sebagian dibantu (Misal mengancing
8 Memakai Baju
baju)
2 Mandiri
Skor
0 Tidak mampu
9 Naik turun tangga 1 Butuh pertolongan
2 Mandiri
Skor
0 Tergantung orang lain
10 Mandi 1 Mandi

Skor
Total Skor

Keterangan :
20 : Mandiri
12-19 : Ketergantungan ringan
9-11 : Ketergantungan sedang
5-8 : Ketergantungan berat
0-4 : Ketergantungan total

 Istirahan dan tidur :

Kegiatan Sebelum Sakit Saat Sakit
Tidur Siang (Jumlah dlm jam)
 Tidur Malam (Jumlah dlm jam)

Gangguan Tidur

Kebiasaan sebelum tidur

Masalah Lainnya

 Kebiasaan lainnya : merokok kafein alcohol obat

Lain-lain…....

5. Data psikologis, sosiologis, seksual dan spiritual :

 Psikologis : t.a.k gelisah takut sedih rendah diri
Hiperaktif acuh tak acuh/apatis marah
Mudah tersinggung lain-lain……
 Sosiologis : t.a.k menarik diri komunikasi inkoheren
 Seksua : t.a.k ↓libido impotensia lain-lain............
 Spiritual : t.a.k perlu dibantu dalam beribadah lain2.........

6. Data Penunjang ( EKG, EEG, Laboratorium, pemeriksaan radiologi dan lain-lain) :

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 7. Terapi Medis

No No. Nama Obat Dosis & Cara Pemberian Manfaat/Cara Kerja

8. Rumusan Masalah Berdasarkan Prioritas Masalah (Minimal 3 Diagnosa

Keperawatan)
1.
2.
3.
4.
5.
9. Analisa Data

No Symptom Etiologi Problem

10. Intervensi Keperawatan

No. Diagnosa Keperawatan Tujuan & Kriteria Hasil Intervensi (NIC)

No
Diagnosa Keperawatan Tujuan & Kriteria Hasil Intervensi (NIC)
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No
Diagnosa Keperawatan Tujuan & Kriteria Hasil Intervensi (NIC)
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Ruangan : Nama Pasien : Hari/tanggal :
No
Implementasi Catatan perkembangan/Evaluasi
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Ruangan : Nama Pasien : Hari/tanggal :
No. Implementasi Catatan perkembangan/Evaluasi
Ruangan : Nama Pasien : Hari/tanggal :
No. Implementasi Catatan perkembangan/Evaluasi