FORMAT PENGKAJIAN

1. Identitas Klien
Nama :..........................................................
Tanggal Masuk RS :........................................................../Jam :.............WIB
Tanggal Pengkajian :........................................................../Jam :.............WIB
Jenis Kelamin :..........................................................
Umur :..........................................................
Status Perkawinan :.............................................................
Agama :..........................................................
Pendidikan :..........................................................
Pekerjaan :..........................................................
Alamat :..........................................................
Ruangan/Kamar :..........................................................
Diagnosa Medis :..........................................................

2. Riwayat Kesehatan
Keluhan utama :.....................................................................
................................................................................................................................................
Riwayat Penyakit Dahulu
 Penyakit yang pernah dialami :.....................................................................
....................................................................................................................................
 Pengobatan/Tindakan yang dilakukan :.....................................................................
....................................................................................................................................
 Riwayat operasi : ....................................................................
....................................................................................................................................
 Lamanya dirawat :.....................................................................
....................................................................................................................................
 Alergi : ....................................................................
....................................................................................................................................
 Imunisasi : ....................................................................
....................................................................................................................................
....................................................................................................................................

3. Riwayat Kesehatan Keluarga

Orang tua :...............................................................................................................................
................................................................................................................................................
Saudara kandung : ....................................................................
................................................................................................................................................
Penyakit keturunan yang ada :.....................................................................
................................................................................................................................................
Anggota keluarga yang meninggal :.....................................................................
................................................................................................................................................
Penyebab meninggal : ....................................................................
................................................................................................................................................
Genogram (Dituliskan dalam 3 generasi ke atas) : .................................................................
................................................................................................................................................

Panduan Praktik Klinik Keperawatan Medikal Bedah Kep. Unja 1

4. Pemeriksaan fisik
BB : .....................................
TB : .....................................
Tanda-Tanda Vital
 Nadi : .....................................
 RR : .....................................
 Suhu : .....................................
 Tekanan darah : .....................................
Nyeri

 P (Provokatif/paliatif) : ..................................
 Q (Quality) : .....................................
 R (Regio) : .....................................
 S (Scale) : .....................................
 T (Time) : .....................................
Pemeriksaan Head to Toe
a. Kepala dan rambut
 Bentuk : .....................................................
 Ukuran : .....................................................
 Posisi : .....................................................
 Keadaaan rambut : .....................................................
 Kebersihan : .....................................................

b. Mata/penglihatan
 Bentuk : .....................................................
 Sklera : .....................................................
 Konjungtiva : .....................................................
 Posisi : .....................................................
 Ketajaman penglihatan :......................................................
 Reflek cahaya : .....................................................
 Muka : .....................................................
 Pemakaian alat bantu : .....................................................

c. Hidung/Penciuman
 Bentuk dan posisi : .....................................................
 Peradangan : .....................................................
 Perdarahan : .....................................................
 Polip/sumbatan : .....................................................
 Fungsi penciuman : .....................................................
 Pada hidung terpasang O2 : .....................................................

d. Telinga/Pendengaran
 Bentuk dan posisi : .....................................................
 Peradangan : .....................................................
 Perdarahan : .....................................................
 Cairan : .....................................................
 Fungsi pendengaran : .....................................................
 Pemakaian alat bantu :......................................................

e. Mulut dan Gigi

Panduan Praktik Klinik Keperawatan Medikal Bedah Kep. Unja 2
  Bibir : .....................................................
 Mukosa gusi : .....................................................
 Lidah : .....................................................
 Tonsil/faring : .....................................................
 Peradangan : .....................................................
 Perdarahan : .....................................................
 Kebersihan : .....................................................
 Bau :......................................................
 Fungsi pengecapan : .....................................................
 Kemampuan berbicara : .....................................................
 Kemampuan menelan :......................................................

f. Integumen
 Warna : .....................................................
 Turgor : .....................................................
 Kebersihan : .....................................................
 Kelainan pada kulit : .....................................................

g. Leher
 Kelenjar getah bening
 Kelenjar typoid
 Vena jugularis
 Kekakuan
: .....................................................
: .....................................................
: .....................................................
: .....................................................

h. Thorax/dada
 Inspeksi : .....................................................
 Auskultasi : .....................................................
 Palpasi : .....................................................
 Perkusi : .....................................................
 Nyeri dada : .....................................................
 Produksi sputum : .....................................................
 Irama pernapasan : .....................................................
 Inspeksi jantung : .....................................................
 Palpasi (ictus cordis) : .....................................................
 Perkusi (Batas jantung) :......................................................
 Auskultasi : .....................................................
Irama jantung : .....................................................
Bunyi jantung : .....................................................
i. Abdomen
 Inspesksi : .....................................................
 Auskultasi : .....................................................
 Perkusi : .....................................................
 Palpasi
Nyeri tekan : .....................................................
Benjolan/massa : .....................................................
Asites : .....................................................
Hepar : .....................................................
Lien : .....................................................
Ginjal : .....................................................
Titik Mc. Burney : .....................................................
j. Perineum dan Genitalia

Panduan Praktik Klinik Keperawatan Medikal Bedah Kep. Unja 3

  Kebersihan perineum : .....................................................
 Peradangan .......................................................
 Perdarahan .......................................................
 Pembesaran kelenjar : .....................................................
 Hemoroid .......................................................
 Alat genitalia .......................................................
 Lain-lain .......................................................
k. Ekstremitas atas
 Bentuk dan kekuatan otot : .....................................................
 Rentang gerak : .....................................................
 Reflex patologis : .....................................................
 Lain-Lain : .....................................................
l. Ekstremitas bawah
 Bentuk dan kekuatan otot : .....................................................
 Rentang gerak : .....................................................
 Lain-Lain : .....................................................

m. Neurologis
 Tingkat kesadaran : .....................................................
 GCS : .....................................................

n. Pemeriksaan status mental

 Kondisi emosi/perasaan : .........................................................................
.......................................................................................................................
 Proses berpikir : .........................................................................
.......................................................................................................................
 Motivasi : .........................................................................
.......................................................................................................................
 Persepsi : .........................................................................
.......................................................................................................................
 Bahasa : .........................................................................
.......................................................................................................................

5. Pola Kebiasaan Sehari-Hari

No Pola Sebelum Sakit Ketika Sakit
(1) (2) (3) (4)
1 a. Makanan
 Diet
 Komposisi
 Frekuensi
 Makanan yang disukai
 Selera makan
 Makanan pantangan
b. Minum
 Jenis
 Jumlah per hari
 Minuman yang disukai
 Minuman pantangan
2 Tidur
 Kebiasaan tidur siang
 Kebiasaan tidur malam
 Kesulitan tidur

Panduan Praktik Klinik Keperawatan Medikal Bedah Kep. Unja 4

 No Pola Sebelum Sakit Ketika Sakit
(1) (2) (3) (4)
 Cara mengatasainya
3 a. Eliminasi BAK
 Frekuensi
 Jumlah
 Warna
 Bau
 Kelainan
 Lain-Lain
b. Eliminasi BAB
 Frekuensi
 Jumlah
 Warna
 Konsistensi
 Bau
 Kelainan
 Lain-Lain
c. Personal higiene
 Kebiasaan mandi
 Pemeliharaan gigi dan mulut
 Pemeliharaan rambut
 Pemeliharaan kuku
 Masalah dalam melaksanakan
personal higiene

6. Riwayat Psikososial
Bahasa yang digunakan : ....................................................................
Persepsi Pasien tentang penyakitnya : ....................................................................
Konsep diri : ....................................................................
......................................................................
Keadaan emosi : ....................................................................
Perhatian terhadap orang lain/lawan bicara : ....................................................................
Hubungan dengan keluarga : ....................................................................
Hubungan dengan saudara : ....................................................................
Hubungan dengan orang lain : ....................................................................
Kegemaran : ....................................................................
: ....................................................................
Daya adaptasi : ....................................................................
Mekanisme pertahanan diri : ....................................................................

7. Spiritual
Pola ibadah : ....................................................................
......................................................................
Keyakinan tentang kesehatan : ....................................................................

8. Hasil Pemeriksaan Penunjang dan Diagnostik

a. Pemeriksaan diagnostik/penunjang medis
 Laboratorium : ....................................................................
 Rontgen : ....................................................................
 EKG : ....................................................................
 USG : ....................................................................

Panduan Praktik Klinik Keperawatan Medikal Bedah Kep. Unja 5

  Lain-lain :.....................................................................
b. Penatalaksanaan/terapi :.....................................................................

9. Intervensi Keperawatan :.....................................................................

................................................................................................................................................
10. Implementasi :.....................................................................
................................................................................................................................................
11. Evaluasi :.....................................................................
................................................................................................................................................
Jambi, 2023
Mahasiswa yang Mengkaji,

Nama:
NIM:

Panduan Praktik Klinik Keperawatan Medikal Bedah Kep. Unja 6

 FORMAT LAPORAN ASUHAN KEPERAWATAN

Askep pasien dengan......

Di ruang : ........................................................................................
RS : ........................................................................................
1. Pengkajian dan Analisis data
A. Identitas Klien
B. Riwayat Kesehatan
C. Riwayat Kesehatan Keluarga
D. Pemeriksaan Fisik
E. Pola Kebiasaan Sehari-Hari
F. Riwayat Psikososial
G. Spiritual
H. Hasil Pemeriksaan Penunjang dan Diagnostik
I. Terapi
J. Analisis Data
Analisa Data

No Data Etiologi Masalah

2. Diagnosa Keperawatan

1. ....................................................................................................................................
2. ....................................................................................................................................
3. ....................................................................................................................................
4. ....................................................................................................................................
5. ....................................................................................................................................

3. Rencana/Intervensi Keperawatan

Rencana/Intervensi Keperawatan
Nama Pasien :
Ruang :

No Diagnosa Keperawatan Intervensi

Panduan Praktik Klinik Keperawatan Medikal Bedah Kep. Unja 7

4. Implementasi Keperawatan

Implementasi
Nama Pasien :
Ruang :
No Dx.Kep Tgl/Jam Implementasi Evaluasi/Respon Paraf
Klien

5. Catatan Perkembangan (Evaluasi)

Catatan Perkembangan
No Waktu Respon Perkembangan (SOAP) Paraf
(tgl/Jam)

Panduan Praktik Klinik Keperawatan Medikal Bedah Kep. Unja 8