FAKULTAS KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN KEPERAWATAN BEDAH

Nama Mahasiswa :
NIM :
Tempat Pengkajian :
Tanggal :

I. Identitas Klien
Nama : No. RM :
Umur : Pekerjaan :
Jenis kelamin : Status perkawinan :
Agama : Tanggal MRS :
Pendidikan : Tanggal :
pengkajian
Alamat : Sumber informasi :

II. Riwayat Kesehatan

1. Diagnosa medik:
......................................................................................................................................................

2. Keluhan utama:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

3. Riwayat penyakit sekarang:

......................................................................................................................................................
......................................................................................................................................................
...................................................................................................................................................... ..
....................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

4. Riwayat kesehatan terdahulu:

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

a. Penyakit yang pernah dialami:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
b. Alergi (obat, makanan, plester, dll):
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
c. Imunisasi:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
d. Kebiasaan/pola hidup/life style:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
e. Obat-obat yang digunakan:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

5. Riwayat penyakit keluarga:

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

6. Genogram:

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

 Keterangan :

: Laki-laki
: Perempuan
: Menikah
// : Cerai
: Anak kandung
: Anak angkat
: Anak kembar
: Pasien
: Meninggal
: Tinggal
serumah

III. Pengkajian Keperawatan

1. Persepsi & pemeliharaan kesehatan
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Interpretasi:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

2. Pola nutrisi/ metabolik (ABCD) (saat sebelum dan saat di rumah sakit)
- Antropometri:
..................................................................................................................................................
..................................................................................................................................................
Interpretasi:
..................................................................................................................................................
..................................................................................................................................................
- Biomedical Sign:
..................................................................................................................................................
..................................................................................................................................................
Interpretasi:
..................................................................................................................................................
..................................................................................................................................................
- Clinical Sign:

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

 ..................................................................................................................................................
..................................................................................................................................................
Interpretasi:
..................................................................................................................................................
..................................................................................................................................................
- Diet Pattern:
..................................................................................................................................................
..................................................................................................................................................
Interpretasi:
..................................................................................................................................................
..................................................................................................................................................

3. Pola eliminasi: (saat sebelum sakit dan saat di rumah sakit)

BAK
- Frekuensi : ....................................................................................................
- Jumlah : ....................................................................................................
- Warna : ....................................................................................................
- Bau : ....................................................................................................
- Karakter : ....................................................................................................
- BJ : ....................................................................................................
- Alat Bantu : ....................................................................................................
- Kemandirian : mandiri/dibantu
- Lain : ....................................................................................................
BAB
- Frekuensi : ....................................................................................................
- Jumlah : ....................................................................................................
- Warna : ....................................................................................................
- Bau : ....................................................................................................
- Karakter : ....................................................................................................
- BJ : ....................................................................................................
- Alat Bantu : ....................................................................................................
- Kemandirian : mandiri/dibantu
- Lain : ....................................................................................................

Interpretasi:
Balance cairan:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

 ......................................................................................................................................................

4. Pola aktivitas & latihan (saat sebelum sakit dan saat di rumah sakit)
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

c.1. Aktivitas harian (Activity Daily Living)

Kemampuan perawatan diri 0 1 2 3 4
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi / ROM
Ket: 0: tergantung total, 1: bantuan petugas dan alat, 2: bantuan petugas,
3: bantuan alat, 4: mandiri
Status Oksigenasi:
......................................................................................................................................................
......................................................................................................................................................
Fungsi kardiovaskuler:
......................................................................................................................................................
......................................................................................................................................................
Terapi oksigen:
......................................................................................................................................................
......................................................................................................................................................
Interpretasi:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

5. Pola tidur & istirahat (saat sebelum sakit dan saat di rumah sakit)
Durasi : ....................................................................................................
Gangguan tidur : ....................................................................................................
Keadaan bangun tidur : ....................................................................................................
Lain-lain : ....................................................................................................

Interpretasi:
......................................................................................................................................................

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

 ......................................................................................................................................................
......................................................................................................................................................

6. Pola kognitif & perceptual

Fungsi Kognitif dan Memori:
......................................................................................................................................................
......................................................................................................................................................
Fungsi dan keadaan indera:
......................................................................................................................................................
......................................................................................................................................................
Interpretasi:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

7. Pola persepsi diri

Gambaran diri:
......................................................................................................................................................
......................................................................................................................................................
Identitas diri:
......................................................................................................................................................
......................................................................................................................................................
Harga diri:
......................................................................................................................................................
......................................................................................................................................................
Ideal diri:
......................................................................................................................................................
......................................................................................................................................................
Peran diri:
......................................................................................................................................................
......................................................................................................................................................
Interpretasi:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

8. Pola seksualitas & reproduksi

Pola seksualitas:

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

 ......................................................................................................................................................
......................................................................................................................................................
Fungsi reproduksi:
......................................................................................................................................................
......................................................................................................................................................
Interpretasi:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

9. Pola peran & hubungan

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Interpretasi:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

10. Pola manajemen koping-stress:

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

Interpretasi:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

11. System nilai & keyakinan:

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

 Interpretasi:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

IV. Pemeriksaan Fisik

Keadaan umum:
................................................................................................................................................... ..............
..................................................................................................................................................... ............
Tanda vital:
- Tekanan Darah : mm/Hg
- Nadi : X/mnt
- RR : X/mnt
- Suhu : C

Interpretasi:
................................................................................................................................................... ..............
..................................................................................................................................................... ............
................................................................................................................................................... ..............

Pengkajian Fisik Head to toe (Inspeksi, Palpasi, Perkusi, Auskultasi)

1. Kepala
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
2. Mata:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
3. Telinga:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

 4. Hidung:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
5. Mulut:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
6. Leher:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
7. Dada:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
8. Abdomen:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
9. Urogenital:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................

10. Ekstremitas:
..................................................................................................................................................

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

 ..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
11. Kulit dan kuku:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
12. Keadaan lokal:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................

V. Terapi
No Jenis Farmako Dosis dan Indikasi Efek Implikasi
Terapi dinamik Rute dan samping Keperawatan
dan Pemberian Kontra
Farmako Indikasi
kinetik
1.
2.
3.
4.
5.
dst

VI. Pemeriksaan Penunjang & Laboratorium

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

No Jenis Nilai normal Hasil
Pemeriksaan (rujukan) (hari/tanggal)
Nilai Satuan
1.
2.
3.
4.
5.
6.
7.
8.
dst

……………, ….......................... 20….

Pengambil Data

( _____________________ )
NIM.

ANALISA DATA

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

NO DATA PENUNJANG ETIOLOGI MASALAH

DIAGNOSA KEPERAWATAN

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

Daftar Diagnosa Keperawatan Sesuai Prioritas
TANGGAL TANGGAL
NO DIAGNOSA KETERANGAN
PERUMUSAN PENCAPAIAN

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

 PERENCANAAN KEPERAWATAN

NO DIAGNOSA TUJUAN DAN KRITERIA HASIL INTERVENSI RASIONAL

CATATAN PERKEMBANGAN

DIAGNOSA:

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018

 WAKTU IMPLEMENTASI PARAF EVALUASI
JAM:

Panduan Profesi Ners Keperawatan Bedah Fkep UNEJ 2018