Nama :

NIM :
Ruangan :

FORMAT PENGKAJIAN
KEPERAWATAN MEDIKAL BEDAH
PROGRAM STUDI PENDIDIKAN PROFESI NERS UNRI

A. INFORMASI UMUM
Nama : .................................................................................
Umur : ................................................................................
Tanggal lahir : .................................................................................
Jenis kelamin : .................................................................................
Suku bangsa : .................................................................................
Tanggal masuk : .................................................................................
Tanggal pengakajian : .................................................................................
Dari/rujukan : .................................................................................
Diagnosa medik : .................................................................................
Nomor Medical Record : .................................................................................

B. KELUHAN UTAMA
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C. RIWAYAT KESEHATAN SEBELUMNYA
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D. RIWAYAT KESEHATAN KELUARGA DAN GENOGRAM
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Genogram:

E. PEMERIKSAAN FISIK
Tanda-Tanda Vital:
TD :.........................................................
Suhu : .........................................................
Nadi : .........................................................
Pernapasan : .........................................................
Tinggi badan : .........................................................
Berat badan : .........................................................
GCS : .........................................................

I. Kepala
1. Rambut : panjang/ pendek/ tanpa rambut/ kotor/ mudah rontok/ gatal-gatal
Lain-lain :..................................................................................................................
Masalah keperawatan :..............................................................................................
2. Mata: ikterik/midriasis/pakai kaca mata/contact lens/gangguan penglihatan
Lain-lain :..................................................................................................................
Masalah keperawatan :..............................................................................................
3. Hidung: perdarahan/ sinusitis/ gangguan penciuman/ malformasi/ terpasang NGT
Lain-lain :..................................................................................................................
Masalah keperawatan :..............................................................................................
 4. Mulut: kotor/ bau/ terpasang ETT/ gudel/ perdarahan/ lidah kotor/ gangguan
pengecapan
Lain-lain :..................................................................................................................
Masalah keperawatan :..............................................................................................
5. Gigi: gigi palsu/ kotor/ terpasang kawat gigi/ karies/ tak ada gigi
Lain-lain :..................................................................................................................
Masalah keperawatan :..............................................................................................
6. Telinga: perdarahan/ terpasang alat bantu dengar/ infeksi/ gangguan pendengaran
Lain-lain :..................................................................................................................
Masalah keperawatan :..............................................................................................

II. Leher: Pemebesaran KGB/ kaku kuduk/ terpasang trakeostomi

JVP:................................................................................................................................
Lain-lain:........................................................................................................................
Masalah keperawatan:....................................................................................................

III. Dada
Inspeksi:.........................................................................................................................
Palpasi:...........................................................................................................................
Perkusi:...........................................................................................................................
Auskultasi:......................................................................................................................
Masalah keperawatan:....................................................................................................
IV. Tangan: utuh/ luka/ lecet/ sianosis/ caplarry ferill/ clubbing finger/ dingin/ fraktur/
edema
Lain-lain:........................................................................................................................
Masalah keperawatan:....................................................................................................
V. Abdomen
Inspeksi:.........................................................................................................................
Palpasi:...........................................................................................................................
Perkusi:...........................................................................................................................
Auskultasi:......................................................................................................................
Masalah keperawatan:....................................................................................................
 VI. Genitalia: perdarahan/ terpasang kateter/ trauma/ malformasi/ mentruasi/ infeksi
Lain-lain:........................................................................................................................
Masalah keperawatan:....................................................................................................
VII. Kaki: fraktur/ edema/ malformasi/ luka/ infeksi/ keganasan/ sianosis/ dingin
Lain-lain:........................................................................................................................
Masalah keperawatan:....................................................................................................
VIII. Punggung: lordosis/ kifosis/ skoliosis/ luka/ dekubitus/ infeksi
Lain-lain:........................................................................................................................
Masalah keperawatan:....................................................................................................

Hasil pemeriksaan laboratorium dan diagnostik:

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Medikasi/ obat-obatan yang diberikan saat ini:
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Diagnosa keperawatan:
1. ...........................................................................................................................................
2. ...........................................................................................................................................
3. ...........................................................................................................................................
4. ...........................................................................................................................................
5. ...........................................................................................................................................
Pekanbaru, ....................................

Mahasiswa........................
 FORMAT
RENCANA ASUHAN KEPERAWATAN
Nama pasien : Nama Mahasiswa:
Ruang :
No. RM : NIM:

NO DIAGNOSA TUJUAN/ SASARAN INTERVENSI RASIONAL

KEPERAWATAN
 CATATAN PERKEMBANGAN
(Catatan perkembangan dibuat setiap hari)

NO DIAGNOSA IMPLEMENTASI EVALUASI (SOAP) TTD

KEPERAWATAN