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FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH
PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS GADJAH MADA
Nama Mahasiswa : ______________________

Ruangan

Waktu Praktik

Pembimbing : ___________________

: ______________________

: ___________________

1. IDENTITAS DIRI KLIEN
Nama

: ____________________________________________________ ___

Umur

: _____________________________________________________

Jenis Kelamin

: ____________________________________________________ ___

Alamat

: ____________________________________________________ ___

Status Perkawinan

: ____________________________________________________ ___

Agama

: ____________________________________________________ ___

Suku Bangsa

: ____________________________________________________ ___

Pendidikan

: ____________________________________________________ ___

Pekerjaan

: ____________________________________________________ ___

Lama Bekerja

: ____________________________________________________ ___

Dx Medis

: ____________________________________________________ ___

Tanggal MRS

: ____________________________________________________ ___

No RM

: ____________________________________________________ ___

Tanggal Pengkajian

: ____________________________________________________ ___

Jam Pengkajian

: ____________________________________________________ ___

Sumber Informasi

: ____________________________________________________ ___

2. RIWAYAT PENYAKIT
Keluhan utama saat masuk RS:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Riwayat Penyakit Sekarang:
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___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Riwayat Penyakit Dahulu: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Diagnosa medik pada saat MRS. Masalah atau Dx Medis pada saat MRS: ___________________________________________________________________________ ___________________________________________________________________________ Tindakan yang telah dilakukan di poliklinik atau UGD ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 2 . mulai dari pasien MRS (UGD/POLI). sampai diambil kasus kelolaan. pemeriksaan penunjang dan tindakan yang telah dilakukan.

faktor risiko tentang penyakit. PENGKAJIAN KEPERAWATAN 1. kebutuhan akan edukasi kesehatan/ discharge planning) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3 .Catatan Penanganan Kasus (dimulai saat pasien di rawat di ruang rawat sampai pengambilan kasus) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ C. seperti: pilihan pengobatan. kebiasaan. obat yang biasa dikonsumsi.. Persepsi dan pemeliharaan kesehatan (Pengetahuan tentang penyakit/ perawatan. seperti: riwayat keluarga. perlindungan kesehatan. kebiasaan dalam menangani sakit. dll.

Pola Nutrisi/Metabolik Program diit RS : ______________________________________________________ Intake makanan (Pengkajiam nutrisi ABCD/ skrining nutrisi. apakah ada perubahan khusus) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ b. ketidaknyamanan. konsistensi. Buang Air Besar (frekuensi. apakah ada perubahan khusus. seperti: budaya. seperti: nafsu makan. kesehatan gigi dan mulut.2. mual. nyeri. muntah. kontrol saat defekasi. ketidaknyamanan. kenyamanan. Buang Air Kecil (frekuensi. ekonomi. warna. agama. Balance Cairan 4 . nokturia) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ c. faktor spesifik dalam memilih makanan. alergi. faktor yang mempengaruhi ingesti makanan. kontrol saat defekasi. jumlah. jumlah. warna. Pola Eliminasi a. pantangan makanan): __________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Intake cairan : ______________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ___________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 3. bau.

Pola Aktivitas dan latihan Kemampuan Perawatan diri 0 1 2 3 4 Makan dan minum Mandi Toileting Berpakaian Mobilitas ditempat tidur Berpindah Ambulansi/ROM Keterangan : 0: Mandiri. Skor Pengkajian Fungsional ADL (BARTHEL INDEX): Skor Risiko Jatuh (MORSE): Skor Risiko Dekubitus (BRADEN SCALE): Fungsi Respiratory: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ e. 4: tergantung total a.__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 4. b. Fungsi Muskuloskeletal: __________________________________________________________________ __________________________________________________________________ 5 . 1 : alat bantu. d. 3: dibantu orang lain dan alat. 2 : dibantu orang lain. Fungsi Cardiovascular: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ f. Fungsi Neurologis: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ g. c.

Pola Peran-hubungan (perubahan peran. pembau. sensasi. kenyamanan lingkungan. Pola Perceptual (penglihatan. Pola persepsi diri (pandangan klien tentang sakitnya. penggunaan alat bantu. menstruasi. pendengaran. penggunaan obat bantu tidur. fertilitas. Pola Seksualitas dan Reproduksi (masalah seksual.__________________________________________________________________ __________________________________________________________________ 5. dll. seperti nyeri. kontrasepsi. Pola Tidur dan Istirahat (lama tidur. kemampuan keuangan. libido. pengecap.): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 9. hubungan dengan orang lain. suhu): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 6. nyeri dan kenyamanan): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 7. komunikasi. konsep diri): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 8. gangguan tidur. faktor terkait. kecemasan. significant others): _____________________________________________________________________ _____________________________________________________________________ 6 .

Pola Managemen Koping-Stress (stress saat ini.): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ D. dll): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 11. perubahan terbesar dalam hidup pada akhir-akhir ini/ kehilangan. Sistem Nilai dan Keyakinan (budaya terkait kesehatan. koping. PEMERIKSAAN FISIK (Chepalocaudal) Keluhan yang dirasakan saat ini: _____________________________________________ _____________________________________________________________________ _____________________________________________________________________ Kesadaran: Keadaan umum : TD : ____________ mmHg P : ____________ x/menit N : ____________ x/menit S : ____________ OC 7 . pandangan klien tentang agama. dll._____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 10. kegiatan agama.

sampai akhir praktik) 8 . PENANGANAN KASUS (dimulai saat Anda mengambil sebagai kasus kelolaan.BB/ TB: _________ kg/ __________ cm Kepala: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Leher: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Thorak: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Abdomen: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Inguinal: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Ekstremitas: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ E.

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