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
1. Tanda-Tanda Vital:
TD : .........................................................
Suhu : .........................................................
Nadi : .........................................................
Pernapasan : .........................................................
Tinggi badan : .........................................................
Berat badan : .........................................................
GCS : .........................................................

2. Pemeriksaan Head to Toe

a. 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 :........................................................................................
b. Leher: Pemebesaran KGB/ kaku kuduk/ terpasang trakeostomi
JVP:...........................................................................................................................
Lain-lain:...................................................................................................................
Masalah keperawatan:...............................................................................................
c. Dada
Inspeksi : …................................................................................................
Palpasi : …................................................................................................
Perkusi : …................................................................................................
Auskultasi : …................................................................................................
MK : …................................................................................................
d. Punggung: lordosis/ kifosis/ skoliosis/ luka/ dekubitus/ infeksi
Lain-lain:..................................................................................................................
Masalah keperawatan:..............................................................................................
e. Abdomen
Inspeksi : …................................................................................................
Palpasi : …................................................................................................
Perkusi : …................................................................................................
Auskultasi : …................................................................................................
MK : …................................................................................................
f. Genitalia: perdarahan/ terpasang kateter/ trauma/ malformasi/ mentruasi/ infeksi
Lain-lain:...................................................................................................................
Masalah keperawatan:..............................................................................................
g. Tangan: utuh/ luka/ lecet/ sianosis/ caplarry ferill/ clubbing finger/ dingin/
fraktur/ edema
Lain-lain:..................................................................................................................
Masalah keperawatan:..............................................................................................
h. Kaki: fraktur/ edema/ malformasi/ luka/ infeksi/ keganasan/ sianosis/ dingin
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: Dinda Daisya Putri

 ANALISA DATA

MASALAH
NO DATA PENUNJANG ETIOLOGI
KEPERAWATAN
 FORMAT RENCANA ASUHAN KEPERAWATAN

Nama pasien :
Nama Mahasiswa :
Ruang :
No. RM : NIM :

DIAGNOSA
NO TUJUAN/ SASARAN INTERVENSI
KEPERAWATAN
 DIAGNOSA
NO TUJUAN/ SASARAN INTERVENSI
KEPERAWATAN
 CATATAN PERKEMBANGAN

DIAGNOSA
NO IMPLEMENTASI EVALUASI (SOAP) TTD
KEPERAWATAN
 DIAGNOSA
NO IMPLEMENTASI EVALUASI (SOAP) TTD
KEPERAWATAN