SEKOLAH TINGGI ILMU KESEHATAN NAHDLATUL ULAMA TUBAN

PROGRAM STUDI S1 KEPERAWATAN

JL. LETDA SECIPTO NO. 211 TUBAN TELP. 0356-325789 FAX. 333237 Email : STIKES-NU@Yahoo.Co.Id

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Pengkajian tgl.
MRS tanggal
Diagnosa Masuk
Ruangan/kelas

:
:
:
:

Jam
No. RM
Hari Rawat Ke

:
:
:

A. IDENTITAS PASIEN
Nama
:
Penanggung jawab biaya :
Usia
:
Nama
:
Jenis kelamin :
Alamat
:
Suku /Bangsa :
Hub. Keluarga
:
Agama
:
Telepon
:
Pendidikan :
Status perkawinan
Pekerjaan
:
Alamat
:
B. RIWAYAT PENYAKIT SEKARANG
1. Keluhan Utama : .......................................................................................................................
2. Riwayat Penyakit Sekarang : ....................................................................................................
...................................................................................................................................................
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C. RIWAYAT PENYAKIT DAHULU
1. Pernah di rawat
ya, jenis : .......................
tidak
2. Riwayat Penyakit Kronik dan Menular
ya, jenis : .......................
tidak
3. Riwayat Penyakit Alergi
ya, jenis : .......................
tidak
4. Riwayat Operasi
ya, jenis : .......................
tidak
- Kapan
: ...............................
- Jenis Operasi
: ...............................
5. Lain-lain :
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D. RIWAYAT PENYAKIT KELUARGA
ya : ........................................
GENOGRAM

tidak

E. PERILAKU YANG MEMPENGARUHI KESEHATAN

Perilaku sebelum sakit yang mempengaruhi kesehatan
Alkohol
ya
tidak
Keterangan ..........................................................................................................
Merokok
ya
tidak
Keterangan ..........................................................................................................
Obat
ya
tidak
Keterangan ..........................................................................................................
Olahraga
ya
tidak
Keterangan ..........................................................................................................
F. OBSERVASI DAN PEMERIKSAAN FISIK
1. Tanda-tanda vital
Kesadaran
Compos mentis
Apatis
Somnolen
Sopor
Koma
S :
N:
TD :
RR :
MASALAH KEPERAWATAN :
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2. Sistem Pernafasan
a. RR : ...............................
b. Keluhan :
Sesak
Nyeri waktu sesak
Orthopnea
Batuk
Produktif
Tidak Produktif
Sekret : ....................
Konsistensi : .......................
Warna : ...................
Bau : ....................................
c. Pola nafas
irama:
Teratur
Tidak teratur
d. Jenis
Dispnoe
Kusmaul Ceyne Stokes
Lain-lain:
Pernafasan cuping hidung
ada
tidak
Septum nasi
simetris
tidak simetris
Lain-lain :
e. Bentuk dada
simetris
asimetris
barrel chest
Funnel chest
Pigeons chest
f. Suara napas
vesiculer
ronchi D/S wheezing D/S
rales D/S
g. Alat bantu nafas
Ya
Tidak
Jenis .........................Flow ................Lpm
h. Penggunaan WSD :
- Jenis : ....................................................................................................................
- Jumlah Cairan : .........................................................................................................
- Undulasi : .................................................................................................................
- Tekanan : .................................................................................................................
i. Trakeostomy
Ya
Tidak
................................................................................................................................................
................................................................................................................................................
j. Lain-lain :
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MASALAH KEPERAWATAN :
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3. Sistem Kardiovakuler
a. TD :
b. N :
c. HR :
d. Keluhan nyeri dada
ya
tidak
P : .....................................................................................
Q : .....................................................................................
R : .....................................................................................
S : .....................................................................................
T : .....................................................................................
e. CRT : ...............
f. Konjungtiva pucat
ya
tidak
g. Bunyi jantung: Normal Murmur
Gallop
lain-lain
h. Irama jantung: Reguler Ireguler
S1/S2 tunggal
Ya Tidak
i. Akral:
Hangat Panas
Dingin kering Dingin basah
j. Siklus perifer
Normal
Menurun
k. JVP : ..........................
l. CVP : ..........................
m. CTR : ..........................
n. ECG & Interpretasinya :
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Lain-lain :
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MASALAH KEPERAWATAN :
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4. Sistem Persarafan
a. Kesadaran
composmentis
apatis
somnolen
GCS :
b. Pupil
isokor
anisokor
c. Sclera
Anikterus
Ikterus
d. Konjungtiva
Ananemis
Anemis
e. Istirahat/Tidur : .................................................
f. IVD
: ......................................................
g. EVD
: ......................................................
h. ICP
: ......................................................
i. Nyeri
tidak
ya, skala nyeri :
lokasi :
j. Refleks fisiologis: patella triceps
biceps
k. Refleks patologis: babinsky budzinsky
kernig
l. Keluhan Pusing
O ya
O Tidak
P : .....................................................................................
Q : .....................................................................................
R : .....................................................................................
S : .....................................................................................
T : .....................................................................................

sopor

lain-lain:
lain-lain

koma

m. Pemeriksaan saraf kranial

N1
Normal
N2
Normal
N3
Normal
N4
Normal
N5
Normal
N6
Normal
N7
Normal
N8
Normal
N9
Normal
N10
Normal
N11
Normal
N12
Normal

Tidak
Tidak
Tidak
Tidak
Tidak
Tidak
Tidak
Tidak
Tidak
Tidak
Tidak
Tidak

Ket : ........................................................
Ket : ........................................................
Ket : ........................................................
Ket : ........................................................
Ket : ........................................................
Ket : ........................................................
Ket : ........................................................
Ket : ........................................................
Ket : ........................................................
Ket : ........................................................
Ket : ........................................................
Ket : ........................................................

MASALAH KEPERAWATAN :
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5. Sistem Perkemihan (B4)
a. Kebersihan genetalia :
Bersih
Kotor
b. Sekret :
Ada
Tidak
c. Ulkus :
Ada
Tidak
d. Kebersihan Meatus uretera :
Bersih
Kotor
e. Keluhan Kencing
Ada
Tidak
Bila ada jelaskan :
....................................................................................................................................................
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f. Kemampuan berkemih
Spontan
Alat bantu, sebutkan : ...................................................................
Jenis : ........................................................................................
Ukuran : ........................................................................................
Hari Ke: ........................................................................................
g. Produksi urine : ...........................ml/jam
Warnah : ...............................
Bau
: ...............................
h. Kandung kemih
:
Membesar
Ya
Tidak
i. Nyeri Tekan
:
Ya
Tidak
j. Intake Cairan
:
Oral :....................cc/hari
Parenteral :
..............cc/hari
k. Balance Cairan
: ..................................................................................................................
....................................................................................................................................................
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o. Lain-lain : .....................................................................................................................................
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MASALAH KEPERAWATAN :
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6. Sistem Pencernaan
a. TB
: ............. cm
BB : ..............kg
b. IMT
: .............
Interpretasi : .........................................
c. LOLA
: .............
MASALAH KEPERAWATAN :
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d. Mulut :
e. Mukosa mulut :
f. Tenggorokan

Bersih
Kotor
Lembab
Kering
Merah
stomatitis
Nyeri telan
Sulit menelan
Pembesaran Tonsil
Nyeri Tekan
g. Abdomen
Supel
Tegang nyeri tekan, lokasi :
Luka operasi
Jejas
lokasi :
Pembesaran hepar
ya
tidak
Pembesaran lien
ya
tidak
Ascites
ya
tidak
Drain
Ada
Tidak
- Jumlah
: ......................
- Warna
: ......................
- Kondisi area sekitar insersi : .....................................
Mual
ya
tidak
Muntah
ya
tidak
Terpasang NGT
ya
tidak
Bising usus :..........x/mnt
h. BAB :........x/hr, konsistensi : lunak
cair
lendir/darah
konstipasi
inkontinensia
kolostomi
i. Diet
padat
lunak
cair
Diet Khusus : ......................................................................................................................
Nafsu Makan
Baik
Menurun
Frekuensi :...............x/hari
jumlah:............... jenis : .......................
Lain lain : ..........................................................................................................................
MASALAH KEPERAWATAN :
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7. Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
OD
CS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO

b. Keluhan nyeri
Ya
Tidak
P : ..................................................................
Q : ..................................................................
R : ..................................................................
T : ..................................................................
c. Luka opreasi
Ada
Tidak
Tanggal operasi
: ........................
Jenis Operasi
: ........................
Lokasi
: ........................
Keadaan
: ........................
d. Pemeriksaan penunjang lain
..........................................................................................................................................................
e. Lain .................................................................................................................................................
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MASALAH KEPERAWATAN
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8. Sistem pendengaran
a. Pengkajian segmen dan posterior
OD
OS
Aurcicula
MAE
Membran Tympani
Rinne
Webber
Swabach
b. Tes audiometri
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
c. Keluhan nyeri
Ya
Tidak
P : ..................................................................
Q : ..................................................................
R : ..................................................................
S : ..................................................................
T : ..................................................................
d. Luka opreasi
Ada
Tidak
Tanggal operasi
: ........................
Jenis Operasi
: ........................
Lokasi
: ........................
Keadaan
: ........................
e. Alat bantu dengar : .......................................................
f. Lain-lain. ......................................................................................................................................
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MASALAH KEPERAWATAN
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9. Sistem Muskuloskeletal dan Integumen (B6)

a. Kekuatan otot

b. Pergerakan sendi
bebas
terbatas
c. Kelainan ekstremitas
ya
tidak
d. Kelainan tlg. belakang
ya
tidak
Frankel : .....................................................................................................................................
e. Fraktur
ya
tidak
- Jenis :..............................................................
f. Traksi/spalk/gips
ya
tidak
- Jenis : ............................................
- Beban : ............................................
- Lama pemasangan : ...........................................
g. Penggunaan spalk/gips
ya
tidak
h. Keluhan nyeri :
ya
tidak
P : ..................................................................
Q : ..................................................................
R : ..................................................................
S : ..................................................................
T : ..................................................................
i. Sirkulasi perifer : ...........................................
j. Kompartemen sindrom
ya
tidak
k. Kulit
ikterik sianosis
kemerahan
hiperpigmentasi
l. Akral
hangat panas
dingin
kering
basah
m. Turgor
baik
kurang
jelek
n. Odema:
Ada
Tidak ada
Lokasi
o. Luka operasi : jenis :.............
luas : ............... bersih kotor
p. Tanggal operasi
: ..................
q. Jenis operasi
: ..................
r. Lokasi
: ..................
s. Keadaan
: ..................
t. Drain
:
Ada
Tidak
u. Jumlah
: ...................................................
v. Warna
: ...................................................
w. Kondisi area sekitar insersi : ......................................
x. ROM
: ..................................................
y. POD
: ..................................................
z. Cardial Sign
: ..................................................
Lain-lain
: ...............................................................................................................
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MASALAH KEPERAWATAN :
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10. Sistem Integumen

a. Penilaian risiko decubitus :
KRITERIA YANG DINILAI
3
3
PERSEPSI
SANGAT
KETERBATASAN
SENSORI
TERBATAS
RINGAN
KELEMBABAN
SANGAT LEMBAB
KADANG-KADANG
BASAH
AKTIVITAS
CHAIRFAST
KADANG-KADANG
JALAN
MOBILISASI
IMMOBILE
SANGAT
KETERBATASAN
SEPENUHNYA
TERBATAS
RINGAN
NUTRISI
SANGAT BURUK
KEMUNGKINAN
ADEKUAT
TIDAK ADEKUAT
GESEKAN &
BERMASALAH
POTENSIAL
TIDAK
PERGESERAN
BERMASALAH
MENIMBULKAN
MASALAH
NOTE : Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien beresiko mengalami
dekubitus (Pressure ulcers)
(15 or 16 =low risk, 13 or 14 = moderate risk, 12 or less= high risk)
Aspek yang dinilai

1
TERBATAS
SEPENUHNYA
TERUS MENERUS
BASAH
BEDFAST

NILAI
4
TIDAK ADA
GANGGUAN
JARANG BASAH
LEBIH SERING
JALAN
TIDAK ADA
KETERBATASAN
SANGAT BAIK

TOTAL NILAI

b.
c.
d.
e.
f.
g.

Warna : ...........................................................
Pitting edema : +/- grade : .............................
Ekskoriasis :
ya
tidak
Psoriasis :
ya
tidak
Urtikaria :
ya
tidak
Lain-lain : ............................................................................................................................
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MASALAH KEPERAWATAN
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11. Sistem Endokrin

a. Pembesaran kelenjar tyroid
ya
tidak
b. Pembesaran kelenjar getah bening
ya
tidak
c. Hiperglikemia Ya
Tidak Hipoglikemia
Ya
d. Kondisi kaki DM :
- Luka gangrene Ya
Tidak
- Jenis Luka
: .....................................................
- Lama luka
: .....................................................
- Warna
: .....................................................
- Luas Luka
: .....................................................
- Kedalaman
: .....................................................
- Kulit Kaki
: ..............................................
- Kuku kaki
: ..............................................
- Telapak kaki : ..............................................
- Jari kaki
: ..............................................
- Infeksi
: Ya
Tidak
- Riwayat luka sebelumnya : Ya
Tidak
- Tahun
: ..................................................
- Jenis Luka : ..................................................
- Lokasi
: ..................................................
- Riwayat amputansi sebelumnya : Ya
Tidak

Tidak

Jika Ya
- Tahun : ..........................
- Lokasi : .........................
- Lain-lain : .....................................................................................................
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MASALAH KEPERAWATAN :

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G. PENGKAJIAN PSIKOSOSIAL
1. Persepsi klien terhadap penyakitnya
cobaan Tuhan
hukuman
2. Ekspresi klien terhadap penyakitnya
murung
gelisah
tegang
3. Reaksi saat interaksi
kooperatif
4. Gangguan konsep diri
ya

lainnya
marah/menangis
tak kooperatif
tidak

curiga

MASALAH KEPERAWATAN :
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H. PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah
- Sebelum sakit
sering
kadang-kadang
tidak pernah
- Selama sakit
sering
kadang-kadang
tidak pernah
b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah :
...............................................................................................................................................
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MASALAH KEPERAWATAN :
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I.

PERSONAL HYGIEN
a.

Kebersihan diri :

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
b.

Kemampuan klien dalam pemenuhan kebutuhan :

- Mandi
:
Dibantu seluruhnya
- Ganti pakaian :
Dibantu seluruhnya
- Keramas
:
Dibantu seluruhnya
- Sikat gigi :
Dibantu seluruhnya
- Memotong kuku:
Dibantu seluruhnya
- Berhias
:
Dibantu seluruhnya
- Makan
:
Dibantu seluruhnya

dibantu sebagian
dibantu sebagian
dibantu sebagian
dibantu sebagian
dibantu sebagian
dibantu sebagian
dibantu sebagian

mandiri
mandiri
mandiri
mandiri
mandiri
mandiri
mandiri

MASALAH KEPERAWATAN :
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J. PEMERIKSAAN PENUNJANG (Laboratorium, radiologi, EKG, USG)

K. TERAPI

Tuban,.................................
Perawat Primer,

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

ANALISA DATA
DATA

ETIOLOGI

MASALAH

DIAGNOSA KEPERAWATAN
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

No
Dx

Kriteria Hasil/ Tujuan

Tgl/jam

INTERVENSI, IMPLEMENTASI
Intervensi
Rasional

Implementasi

Tgl/jam

TTD

No

Diagnosa

EVALUASI
Tgl/jam

SOAP

TTD