UNIVERSITAS KATOLIK MUSI CHARITAS

FAKULTAS ILMU KESEHATAN

Kampus Burlian : Jalan Kolonel H. Burlian Lr. Suka Senang KM.7
Palembang 30152

Phone (0711) 412806, Fax. ( 0711) 415780 Email : prodi_perawat@ukmc.ac.id

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

PENGKAJIAN KEPERAWATAN BERDASARKAN POLA GORDON
(Format Bisa diganti dengan format sesuai dengan kondisi Pasien)
Nama Mahasiswa yang Mengkaji : ....................................NIM :....................................
Program Studi : ....................................Tingkat / Semester : ……………...............

Unit : ........................ Tgl/ Waktu Pengkajian: .............................................

Ruang / Kamar : ........................ Anamnese : Auto Anamnese
Tgl Masuk RS : ........................ : Allo Anamnese

A. IDENTIFIKASI
I. KLIEN
Nama Initial : .............................................
Tempat / Tgl Lahir ( umur ) : .............................................
Jenis Kelamin : .............................................
Status Perkawinan : .............................................
Jumlah Anak : .............................................
Agama / Suku : .............................................
Warga Negara : WNI WNA : ........................

Bahasa yang digunakan : Indonesia Daerah : ........................

Pendidikan : .............................................
Pekerjaan : .............................................
Alamat Rumah : .............................................

II. PENANGGUNG JAWAB

Nama : .............................................
Alamat : .............................................
Hubungan dengan klien : .............................................
III. DATA MEDIK
Dikirim oleh : UGD ( namanya ) Dokter Praktek ( namanya )
Diagnosa Medik : .............................................
 Saat Masuk :

 Saat Pengkajian :

B. KEADAAN UMUM
I. KEADAAN SAKIT : Klien tampak sakit rimgam / sedang / berat / tampak tidak sakit
Alasan : Tak bereaksi / baring lemah / duduk / aktif / gelisah / posisi tubuh .................. /
Pucat / cyanosis / sesak nafas / penggunaan alat medik .....................................
Lain – lain ...........................................................................................................
.............................................................................................................................
 a. Riwayat Kesehatan
1) Keluhan Utama :
.................................................................................................................
2) Riwayat Kesehatan Sekarang :
.................................................................................................................
................................................................................................................
.................................................................................................................
.................................................................................................................
3) Riwayat Kesehatan Masa Lalu :
.................................................................................................................
.................................................................................................................
II. TANDA – TANDA VITAL
1. Kesadaran :
a. Kualitatif : Compos Mentis Somnolens Coma
Apatis Soporocomatous

b. Kualitatif :
Skala Coma Glasgow : > Respon Motorik : ............ Jumlah
> Respon Bicara : ............
> Respon Membuka Mata : .............
Kesimpulan : ................................................
Flapping Tremor / Asterixis : ................................................
2. Tekanan Darah : ................................................mm Hg
MAP : ................................................mm Hg
3. Kesimpulan : ................................................
4. Suhu : . . . ◦C, Axilar Rectal Oral

5. Pernafasan : Frekwensi ......................... x / menit

Irama : Teratur Kusmauli Cheynes – Stokes

Jenis : Dada Perut

PENGUKURAN
Tinggi Badan : .............................................
Berat Badan : .............................................
IMT : .............................................
Kesimpulan : .............................................
Catatan : .............................................

III. GENOGRAM : ( 3 generasi / keturunan )

C. PENGKAJIAN POLA KESEHATAN
I. PERSEPSI KESEHATAN – PEMELIHARAN KESEHATAN

Riwayat Penyakit yang Pernah Dialami :

(Sakit berat dirawat kecelakaan, operasi, gangguan kehamilan /persalinan, abortus, transfusi, reaksi alergi)
Penyakit Waktu Catatan

a. Data Subyektif
1. Keadaan sebelum sakit
:..........................................................................................................................
:..........................................................................................................................
:..........................................................................................................................
2. Keadaan sejak sakit
:..........................................................................................................................
:..........................................................................................................................
:..........................................................................................................................
b. Data Obyektif
Observasi
 Kebersihan rambut : .............................................................................
 Kuli kepala : .............................................................................
 Kebersihan kulit : .............................................................................
 Kebersihan mulut : .............................................................................
 Kebersihan genitalia : .............................................................................
 Kebersihan anus : .............................................................................
 Scar Vaksinasi BCG : Ada Tidak

II. NUTRISI DAN METABOLIK

a. Data Subyektif
1. Keadaan sebelum sakit :
........................................................................................................................
........................................................................................................................
2. Keadaan sejak sakit :
........................................................................................................................
........................................................................................................................
b. Data Obyektif
1. Observasi
........................................................................................................................
........................................................................................................................
2. Pemeriksaan Fisik
 Rambut : ...............................................................
 Hidrasi kulit : ...............................................................
 Palpebrae : ...............................................................
 Conjungtiva : ...............................................................
 Hidung : ...............................................................
 Mukosa Hidung : ...............................................................
: ...............................................................
 Rongga mulut
: ...............................................................
 Gigi Geligi
: ...............................................................
 Gigi palsu : ...............................................................
  Kemampuan mengunyah : ...............................................................
 Lidah : ...............................................................
 Tonsil : ...............................................................
 Pharing : ...............................................................
 Kelenjar getah bening : ...............................................................
 Kelenjar Parotis : ...............................................................
: ...............................................................
 Kelenjar Thyroid

 Abdomen
 Inspeksi
Bentuk :..............................................................................
Bayangan : .............................................................................
 Auskultasi
Peristaltik : ....x / menit
 Palpasi : Tanda nyeri umum .............................................
Massa :..............................................................................
Hidrasi kulit : .............................................................................
Nyeri Tekan : Regio Epigastrica Regio Iliaca
Titik Mc Burney R. Suprapubica
 Hepar : ...........................................................................
 Lien : ………………………………………………...
 Kelenjar Limfe Inguinal : ……………………………………..
 Perkusi
Acites : Negatif Positif
Lingkar perut : …………../…………../......................................
Kulit :
 Spider Naevi Negatif Positif
 Uremic Frost Negatif Positif
 Edema Negatif Positif
 Icteric Negatif Positif
 Tanda-tanda radang : ………………………………………
 Lain- lain ……………………………………………………

3. Pemeriksaan Diagnostik ( hasil pemeriksaan )

 Laboratorium  Lain - lain

4. Terapi ( obat – obatan yang berhubungan dengan pola ini, nama & dosisnya )
...........................................................................................................................
...........................................................................................................................
III. POLA ELIMINASI
a. Data Subyektif
1. Keadaan sebelum sakit :
.....................................................................................................................
.....................................................................................................................
2. Keadaan sejak sakit :
.....................................................................................................................
.....................................................................................................................
b. Data Obyektif
1. Observasi
.....................................................................................................................
.....................................................................................................................
 2. Pemeriksaan Fisik
 Palpasi surapubik : Kandung kemih Penuh Kosong
 Nyeri ketuk ginjal :
 Kiri : Negatif Positif
 Kanan : Negatif Positif
 Mulut Urethra :
 Anus :
 Peradangan : Negatif Positif
 Fisura : Negatif Positif
 Hemoroid : Negatif Positif
 Prolapsus Recti : Negatif Positif

3. Pemeriksaan Diagnostik ( hasil pemeriksaan )

 Laboratorium  Lain - lain

4. Terapi ( obat – obatan yang berhubungan dengan pola ini, nama & dosis )
.....................................................................................................................
.....................................................................................................................

IV. POLA AKTIVITAS DAN LATIHAN

a. Data Subyektif
1. Keadaan sebelum sakit :
..................................................................................................................
..................................................................................................................
2. Keadaan sejak sakit :
..................................................................................................................
..................................................................................................................

b. Data Obyektif
1. Observasi
 Aktivitas Harian
 Makan
 Mandi 0 : Mandiri
 Berpakaian 1 : Bantuan dengan alat
 Kerapian 2. Bantuan orang
 Buang air besar 3. Bantuan orang dan alat
 Buang air kecil 4. Bantuan penuh
 Mobilisasi ditempat tidur
 Ambulansi
 Postur tubuh : ……………………...........................................
 Gaya jalan : …………………...............................................
 Anggota gerak yang cacat:…………….............................................
 Fikasasi : …………………...............................................
 Tracheostomie : ……………........................................................
2. Pemeriksaan Fisik
 JVP : .............................cmH2O. Kesimpulan : ...............................
 Perfusi pembuluh perifer kuku : .......................................................
 Thorax dan Pernafasan
 Inspeksi :Bentuk Thorak : ......................................................
Stridor : Negatif Positif
Dyspnea d’effort : Negatif Positif
Sianosis : Negatif Positif
  Palpasi : Vokal Fremitus : ..........................
 Perkusi Pekak: Sonor Redup
Batas Paru hepar : ......................................................
Kesimpulan:
 Auskultasi:Suara Nafas : .............................................
Suara Ucapan : .............................................
Suara Tambahan : .............................................
 Jantung
 Inspeksi: Ictus Cordis : ......................................................
Klien menggunakan alat pacu jantung Ya Tidak
 Palpasi : Ictus Cordis...................................:
Thrill : Negarif Positif
 Perkusi : Batas atas Jantung : ...................
Batas kanan Jantung : ..............................................
Batas kiri Jantung : ..............................................
 Auskultasi : Bunyi Jantung HA : ...............................................
Bunyi Jantung HP : ................................................
Bunyi Jantung IT : ...............................................
Bunyi Jantung IM : ...............................................
Bunyi Jantung III Irama Gallop : Negatif
Positif
Murmur : Negatif
Positif : Tempat : .....................
Grade : .....................
HR : ..............................................x / menit
Bruit Aorta Negatif Positif
A. Renalis Negatif Positif
A. Femoralis Negatif Positif
 Lengan dan Tungkai
 Atrofi otot : Negatif Positif, Tempat.....................
 Rentang gerak :
Mati Sendi : .........................................................................
Kaku Sendi : .........................................................................
 Uji kekuatan otot : Kiri
1 2 3 4 5
Kanan 1 2 3 4 5
 Reflex Fisiologik : .....................................................................
 Reflex Patologik : Babinski, Kiri Negatif Positif
Kanan Negatif Positif

 Clubing Jari – jari : Negatif Positif

 Varices Tungkai : Negatif Positif
 Columna Vertebralis
 Inspeksi ditemukan kelainan bentuk
Tidak ditemukan kelainan bentuk

 Palpasi : Nyeri tekan : Negatif Positif

N. III – IV – VI : ................................................................................
N. VIII Rombeng Test : Negatif Positif
tidak dipaksa, alasan ........................
N. XI : ....................................................................................
Kaku duduk : ....................................................................................

3. Pemeriksaan Diagnostik ( hsil pemeriksaan )

 Laboratorium  Lain - lain
 4. Terapi ( obat – obatan yang berhubungan dengan pola ini, nama & dosisnya )
..................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................

V. POLA TIDUR DAN ISTIRAHAT

a. Data Subyaktif
1. Keadaan sebelum sakit
..................................................................................................................
..................................................................................................................
2. Keadaan sejak sakit
..................................................................................................................
..................................................................................................................

b. Data Obyektif
1. Observasi
Expresi wajah mengantuk : Negatif Positif
Banyak menguap : Negatif Positif
Palpebrae Inferior berwarna gelap : Negatif Positif
2. Terapi
..................................................................................................................
..................................................................................................................
VI. POLA PERSEPSI KOGNITIF – PERSEPTUAL
a. Data Subyektif
1. Keadaan sebelum sakit
..................................................................................................................
..................................................................................................................
2. Keadaan sejak sakit
..................................................................................................................
..................................................................................................................
Data Obyektif
1. Observasi
..................................................................................................................
..................................................................................................................
2. Pemeriksaan Fisik
 Penglihatan
 Cornea : ................................................
 Visus : ................................................
 Pupil : ................................................
 Lensa Mata : ................................................
 TIO ( Tekanan Intra Ocular ) : ................................................
 Pendengaran
 Pina : ................................................
 Canalis : ................................................
 Membran Tympani : ................................................
 Tes Pendengaran : ................................................
 Pengenalan rasa posisi pada gerakan lengan dan tungkai :
............................................................................................................
 NI : ..............................................................
 N II : ..............................................................
 N V Sensorik : ..............................................................
  N VII Sensorik : ..............................................................

 N VIII Pendengaran : ..............................................................

 Tes Romberng : ..............................................................

3. Pemeriksaan Diagnostik ( hasil pemeriksaan )

 Laboratorium  Lain - lain

4. Terapi ( obat – obatan yang berhubungan dengan pola ini, nama & dosisnya )
..................................................................................................................
..................................................................................................................
VII. POLA PERSEPSI DIRI / KONSEP DIRI
a. Data Subyektif
1. Keadaan sebelum sakit
..................................................................................................................
..................................................................................................................
2. Keadaan sejak sakit
..................................................................................................................
..................................................................................................................
b. Data Obyektif
1. Observasi
 Kontak mata saat bicara : .........................................................
 Rentang perhatian : .........................................................
 Suara dan cara bicara : .........................................................
 Postur tubuh : .........................................................
2. Pemeriksaan Fisik
 Kelainan bawaan yang nyata : .........................................................
 Abdomen : Bentuk : .........................................................
Bayangan vena : .........................................................
Benjolan massa : .........................................................
 Kulit : Lesi kulit : .........................................................
 Penggunaan protesa : Hidung Payudara
Lengan Tungkai

VIII. POLA PERAN DAN HUBUNGAN DENGAN SESAMA

a. Data Subyektif
1. Keadaan sebelum sakit
..................................................................................................................
..................................................................................................................
2. Keadaan sejak sakit
..................................................................................................................
..................................................................................................................
Data Obyektif
1. Observasi
..................................................................................................................
..................................................................................................................
2. Pemeriksaan Fisik
..................................................................................................................
..................................................................................................................
IX. POLA REPRODUKSI – SEKSUALITAS
a. Data Subyektif
1. Keadaan sebelum sakit
..................................................................................................................
2. Keadaan sejak sakit
..................................................................................................................
 b. Data Obyektif
1. Observasi
..................................................................................................................
2. Pemeriksaan Fisik
..................................................................................................................
Pemeriksaan Diagnostik ( hasil pemeriksaan )
 Laboratorium  Lain - lain

3. Terapi
..................................................................................................................
..................................................................................................................
X. MEKANISME KOPING DAN TOLERANSI TERHADAP
STRESS
a. Data Subyektif
1. Keadaan sebelum sakit
..................................................................................................................
..................................................................................................................
Keadaan sejak sakit
..................................................................................................................
..................................................................................................................
Data Obyektif
1. Observasi
..................................................................................................................
..................................................................................................................
Pemeriksaan Fisik
 Tekanan Darah : Berbaring : ..........................................mmHg
Duduk : ..........................................mmHg
Berdiri : ..........................................mmHg
Kesimpulan:Hipotensi Ortostatik : Negatif Positif
 HR : x / menit
 Kulit : Keringat dingin : .................................................
Keringat Basah : ...................................................
2. Terapi ( obat – obatan yang berhubungan dengan pola ini, nama & dosisnya )
..................................................................................................................
..................................................................................................................
XI. POLA SISTEM NILAI KEPERCAYAAN / KEYAKINAN
a. Data Subyektif
1. Keadaan sebelum sakit
...............................................................................................................
...............................................................................................................
2. Keadaan sejak sakit
...............................................................................................................
...............................................................................................................
b. Data Obyektif
Observasi
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................

Preceptor Preceptee
 (................................................) (.................................................)

DATA PENUNJANG

Nama Pasien (inisial) :.................................... Tgl MRS/ Tgl Pengkajian :.........................../ .......................
Usia/ JK :......th/ (P/L) Diagnosa Medik :....................................................

Tuliskan Data penunjang lengkap dari pasien masuk pertama kali sampai saat ini, tuliskan juga waktu
pemeriksaan (Tanggal dan Waktu) serta interpretasinya!

1. Hasil Laboratorium
Tanggal/ Hasil Nilai
No Jam Jenis Pemeriksaan Abnormal Normal Satuan Normal
Pemeriksaan

2. Hasil USG, RO, ECG, Scan dll...

No Tanggal Jenis Pemeriksaan Deskripsi Hasil Interpretasi/ Kesimpulan
 ANALISA DATA
Nama Pasien (inisial) :.................................... Tgl MRS/ Tgl Pengkajian :.........................../ .......................
Usia/ JK :......th/ (P/L) Diagnosa Medik :....................................................

(Tuliskan semua data yang abnormal dan rumuskan semua masalah keperawatan )
Data Subyektif Data Obyektif
No (PF dan Penunjang) MasalahKeperawatan
Etiologi
Data Subyektif Data Obyektif (Uraikan patoflow masalah)

Palembang, .................., 20....

Mahasiswa, Perceptor Pengkaji
Nama dan Paraf Nama dan Paraf Perceptor Klinik Nama dan TTD
Perceptor Pendidikan Mahasiswa

(..................................................) (..................................................) (..................................................)

 DIAGNOSIS KEPERAWATAN
Nama Pasien (inisial) :.................................... Tgl MRS/ Tgl Pengkajian :.........................../ .......................
Usia/ JK :......th/ (P/L) Diagnosa Medik :....................................................
No DIAGNOSIS KEPERAWATAN
(Urutkan berdasarkan prioritas masalah,tuliskan minimal 3 teratas)

INTERVENSI KEPERAWATAN

Nama Pasien (inisial) :.................................. Tgl MRS/ Tgl Pengkajian :......................./ .......................
Usia/ JK :...............th/ (P/L) Diagnosa Medik :................................................

(Urutkan Sesuai prioritas masalah di atas)

Rencana Keperawatan (NIC)
Masalah NO Keperawatan
Out Came Intervensi
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Nama Pasien :..................................... Tgl MRS/ Tgl :............................/ .......................

(inisial) Pengkajian
Usia/ JK :........................th/ (P/L) Diagnosa Medik :.....................................................

No Implementasi Evaluasi
MK Tgl/ Jam Mandiri/ Kolaboratif Paraf Tgl/Jam Mandiri/ Kolaboratif Paraf
 CATATAN PERKEMBANGAN PASIEN
TERINTEGRASI

Nama Pasien (inisial) :.................................. Tgl MRS/ Tgl Pengkajian :....................../ .......................
Usia/ JK :...................th/ (P/L) Diagnosa Medik :...............................................
(Tuliskan selama 3 hari perawatan)
Hasil Pemeriksaan, Analisis, dan
Rencana Penatalaksanaan
Nama
Tgl/ S = (Subyektif)
Profesi Instruksi & PJ
Jam O= (Obyektif)
Paraf
A = (Asesmen)
P = (Planning)
 PENGOBATAN YANG DIBERIKAN

Nama Pasien (inisial) :.................................. Tgl MRS/ Tgl Pengkajian :........................../ .......................
Usia/ JK :....................th/ (P/L) Diagnosa Medik :.....................................................

1. Nama Obat
Dosis
2. Isi Obat
No pasien Mekanisme dan Fungsi Efek Samping
3. Golongan
(Rute)
4. Dosis umum

1..…….………………………
2..…………………………….
3..…………………………….
4………………………………
Catatan:
Biasanya obat-obat bisa diberikan dan dihentikan, berilah catatan khusus bila:
Obat telah dihentikan (tulis nama obat dan alasan)

Obat sebelumnya tidak diberikan, tetapi saat ini mendapat resep baru (Tulis nama obat dan alasan