PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :
NIM :
Kelompok :
Tanggal Praktik/Minggu ke :
Tempat Praktik :

Tanggal/jam pengkajian :
Tanggal /jam MRS :

Identitas Pasien:
Nama : ......................................................................................
Umur : ......................................................................................
Jenis Kelamin : ......................................................................................
Alamat : ......................................................................................
Pendidikan terakhir : ......................................................................................
Suku : ......................................................................................
Agama : ......................................................................................
Status Perkawinan : ......................................................................................
Pekerjaan : ......................................................................................
No.Rekam Medik : ......................................................................................
Diagnosis : ......................................................................................

Keadaan Umum : ......................................................................................

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Keluhan Utama : ......................................................................................
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1. Pola Persepsi Kesehatan dan Penanganan Kesehatan

Alasan masuk rumah
sakit: ................................................................................................................
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a. Riwayat penyakit sekarang:
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b. Riwayat penyakit dahulu :
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c.Riwayat penyakit keluarga :
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Riwayat medik dan sosial Riwayat pengobatan
 Kecelakaan ………………………..  Sebelumnya …………………….
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 Dirawat …………………………… ......................................................
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 Operasi …………………………..... ..........................................………
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 Alergi ……………………………...  Saat ini ………………………….
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 Penyakit …………………………... …………………………..………………
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 Lain-lain
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 Persepsi klien tentang kesehatan
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Diagnosis
keperawatan: ........................................................................................................
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 2. Pola Nutrisi – Metabolik
Intake nutrisi sebelum sakit
 Makanan
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Intake nutrisi saat sakit
 Makanan
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 Minuman  Minuman
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 Nafsu makan  Nafsu makan
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 Muntah  Muntah
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 Keluhan /masalah yang  Keluhan /masalah yang
mempengaruhi asupan nutrisi mempengaruhi asupan nutrisi
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 Keadaan kulit, rambut dan kuku
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BB : TB : Suhu :
 Kelembaban kulit…………………………………………………………………
 Warna kulit ………………………………………………………………………
 Turgor…………………………………………………………………………….
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 Kondisi kulit………………………………………………………………………
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 Kuku……………………………………………………………………………....
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 Rambut dan kepala ………………………………………………………………
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 Kelenjar tiroid ……………………………………………………………………
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 JVP ……………………………………………………………………………….
 Kaku kuduk ………………………………………………………………………
 Mukosa bibir ……………………………………………………………………..
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 Kebersihan mulut …………………………………………………………...........
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 Peradangan tonsil ………………………………………………………………...
 Gigi ………………………………………………………………………………
 Penggunaan NGT ………………………………………………………………..
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 Terapi intravena / parenteral …………………………………………………….
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 Lain-lain …………………………………………………………………………
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Diagnosis
keperawatan: ........................................................................................................
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3. Pola Eliminasi
 Tanggal defekasi terakhir :
 Frekuensi defekasi …………………………………………………………...
Konsistensi.......................................................................................................
Warna...............................................................................................................
 Masalah defekasi………………………………………………………..........
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 Penggunaan alat bantu (laksatif/pispot)…………………………...................
 Bising usus ……………………………………………………......................
 Struktur abdomen
 I :.................................................................................................................
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 A :................................................................................................................
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 Distensi …………………………………………………………....................
 Nyeri tekan …………………………………………………………………..
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 Lain-lain ………………………………………………………………..........
 Frekuensi berkemih………………..................................................................
Jumlah………………………………………………………………………..
Warna………………………………………………………………………...
 Penggunaan alat bantu berkemih……………………………………………..
 Keluhan /masalah berkemih …………………………………………………
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 Sakit pinggang……………………………………………………..................
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 Palpasi ginjal………………………………………………………………....
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 Perkusi ginjal……………………………………………………………........
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 Kondisi blast…………………………………………………………………
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 Lain-lain……………………………………………………………………...
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Diagnosis
keperawatan: ........................................................................................................
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4. Pola Aktivitas – Latihan
Kemampuan perawatan diri:
SMRS MRS
Aktivitas
0 1 2 3 4 0 1 2 3 4
Mandi
Berpakaian/ berdandan
Eliminasi/ toileting
Mobilitas di tempat tidur
Berpindah
Berjalan
Naik tangga
Berbelanja
Memasak
Pemeliharaan rumah
Skor:
0 = mandiri 1 = alat bantu 2 = dibantu orang lain
3 = dibantu orang lain & alat 4 = tergantung/tidak mampu
Kebersihan diri:
Di rumah
 Mandi : ........................  /hr
 Gosok gigi : ........................  /hr
 Keramas : ....................  /mgg
 Potong kuku : ....................  /mgg
Di rumah sakit
 Mandi : ........................  /hr
 Gosok gigi : ........................  /hr
 Keramas : ....................  /mgg
 Potong kuku : ....................  /mgg
Pernapasan
 Frekuensi napas: …………………………………………………………….
Kedalaman: ………………………………………………………………….
Irama: ………..................................................................................................
 Bunyi napas: ...................................................................................................
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 Riwayat merokok: ..........................................................................................
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 Riwayat asma/ bronchitis/ emfisema: ............................................................
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 Riwayat penyakit paru dalam keluarga: ..........................................................
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 Batuk : .............................................................................................................
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 Penggunaan otot bantu napas : ........................................................................
 Suara napas tambahan : ...................................................................................
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 Adanya sputum : ..............................................................................................
 Lain-lain : pemeriksaan dada (Pernafasan)
 I :................................................................................................................
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Sirkulasi
 Frekuensi nadi ……………………………………………………………….
Irama …………………………………………………………………………
TD…………………………………………………………………………….
 Pemeriksaan dada (Jantung)
 I :................................................................................................................
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 P:................................................................................................................
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 Nyeri dada…....................................................................................................
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 Capillary refill..................................................................................................
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 Edema...............................................................................................................
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 Palpitasi............................................................................................................
 Suhu ekstrimitas...............................................................................................
 Riwayat penyakit jantung dalam keluarga.......................................................
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Mobilitas
 Pola latihan yang biasa dilakukan....................................................................
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 Aktivitas di waktu luang……………………………………………………...
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Sejak sakit ……………………………………………………………………
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 Rentang gerak………………………………………………………………...
Skala kekuatan otot..........................................................................................
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 Keseimbangan dan cara jalan…………….......................................................
Bentuk tulang belakang………........................................................................
 Genggaman tangan/ refleks..............................................................................
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 Penggunaan tongkat/ walker/ prostese.............................................................
 Persendian:
Nyeri………………………………………………………………………….
Kekakuan……………………………………………………………………..
Edema………………………………………………………………………...
Deformitas……………………………………………………………………
 Lain-lain: Pengkajian nyeri
P:
Q:
R:
S:
T:

Diagnosis
keperawatan: ........................................................................................................
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5. Pola Istirahat dan Tidur
 Waktu tidur:
Sebelum sakit………………………………………………………………...
Saat sakit…………..........................................................................................
 Keluhan yang mempengaruhi tidur …………………………………….........
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 Keluhan letih: ………………………….........................................................
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 Lingkaran gelap di mata …………………………..........................................
 Penggunaan hipnotik / sedasi …………………………..................................
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 Lain-lain…………………………………………….......................................

Diagnosis
keperawatan: ........................................................................................................
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6. Pola Kognitif – Persepsi
 Fungsi penglihatan : ........................................................................................
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 Posisi bola mata : .............................................................................................
 Gerakan mata : .................................................................................................
 Konjungtiva : ...................................................................................................
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 Kornea : ...........................................................................................................
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 Sklera : .............................................................................................................
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 Pupil :...............................................................................................................
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 Keluhan nyeri : ................................................................................................
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 Pemakaian alat bantu penglihatan : .................................................................
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 Fungsi
pendengaran : .......................................................................................
 Struktur luar telinga : .......................................................................................
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 Cairan dari telinga : .........................................................................................
 Perasaan penuh dalam telinga : .......................................................................
 Tinnitus : ..........................................................................................................
 Keluhan nyeri : ................................................................................................
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 Penggunaan alat bantu dengar : .......................................................................
 Fungsi penciuman : .........................................................................................
 Kondisi hidung : ..............................................................................................
 Cairan dari hidung : .........................................................................................
 Vertigo ………………………........................................................................
Pusing…………………..................................................................................
 Tingkat kesadaran………………………….. GCS ………………………….
 Kemampuan mengambil keputusan................................................................
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 Lain-lain ..........................................................................…………………....

Diagnosis
keperawatan: ........................................................................................................
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7. Pola Persepsi Diri – Konsep Diri
 Persepsi klien tentang penyakitnya…………………………………………..
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 Harapan setelah dirawat ………………………………………......................
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 Persepsi klien tentang diri ……………………………………………….......
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 Ekspresi afek/ emosi ……………………………………………………........
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 Isyarat nonverbal perubahan harga diri………………………………............
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 Lain-lain ……………………………………………………………………..
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Diagnosis
keperawatan: ........................................................................................................
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8. Pola Seksualitas – Reproduksi
 Dampak sakit terhadap seksualitas: ................................................................
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 Riwayat haid: ..................................................................................................
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 Pemeriksaan payudara sendiri : .......................................................................
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 Keluhan mengenai keturunan : ........................................................................
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 Tindakan pengendalian kelahiran : ..................................................................
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 Riwayat penyakit hubungan seksual : .............................................................
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 Keluhan gatal-gatal : .......................................................................................
 Lain-lain …………………………………………………………………….

Diagnosis
keperawatan: ........................................................................................................
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9. Pola Koping – Toleransi Stres
 Cara pengambilan keputusan klien: ................................................................
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 Stresor dalam 1 tahun terakhir: .......................................................................
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 Koping yang biasa digunakan: .......................................................................
 Pengobatan untuk mengatasi stress: ...............................................................
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 Kecemasan : .....................................................................................................
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 Sistem pendukung : .........................................................................................
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 Perilaku yang ditunjukkan klien : ....................................................................
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 Lain-lain ………………………………………………………………….......

Diagnosis
keperawatan: .........................................................................................................
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10. Pola Peran – Hubungan
 Peran dalam keluarga: ....................................................................................
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 Hubungan dengan orang terdekat: ..................................................................
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 Interaksi dengan pasien lain: ..........................................................................
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 Cara berkomunikasi: .......................................................................................
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 Efek perubahan peran: ....................................................................................
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 Perilaku selama dirawat: .................................................................................

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 Bahasa yang digunakan sehari-hari: ...............................................................
 Lain-lain ………………………………………………………………...........

Diagnosis
keperawatan: .........................................................................................................
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Diagnosa
keperawatan: .........................................................................................................
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11. Pola Nilai – Kepercayaan
 Persepsi klien tentang agama: ........................................................................
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 Kegiatan keagamaan: ......................................................................................
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 Sikap terhadap nilai: .......................................................................................
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 Bantuan spiritual: ............................................................................................
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 Lain-lain ………………………………………………………………...........

Diagnosis
keperawatan: .........................................................................................................
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 TERAPI MEDIS

Nama Obat Rute Pemberian Dosis Indikasi

PEMERIKSAAN LABORATORIUM

PEMERIKSAAN HASIL NILAI RUJUKAN SATUAN METODA

HEMATOLOGI
Hemoglobin 12.50 – 16.70 g/dl Colorimetric
Leukosit 4.65 - 10.3 ribu/ul Impedance
Eritrosit 4.10 – 6.00 juta/ul Impedance
Hematokrit 42.00 - 52.00 vol% Analyze Calculates
Trombosit 150 – 356 ribu/ul Impedance
RDW-CV 12.1 - 14.0 % Analyze Calculates
MCV, MCH, MCHC
MCV 75.0 - 96.0 fl Analyze Calculates
MCH 28.0 - 32.0 pg Analyze Calculates
MCHC 33.0 – 37.0 % Analyze Calculates
HITUNG JENIS
Gran% 50.0 – 70.0 % Impedance
Limfosit% 25.0 – 40.0 % Impedance
MID% 4.0 – 11.0 % Impedance
Gran# 2.50 – 7.00 ribu/ul Impedance
Limfosit# 1.25 – 4.0 ribu/ul Impedance
MID# ribu/ul Impedance
PROTHROMBIN TIME
Hasil PT 9.9 – 13.5 Detik Nephelometri
INR - Nephelometri
Control Normal PT - - Nephelometri
Hasil APTT 22.2 – 37.0 Detik Nephelometri
Control Normal
- Nephelometri
APTT
KIMIA
GULA DARAH
Gula darah sewaktu <200 mg/dl GOD-PAP
URINALISA
Warna Kekeruhan Kuning-jernih Urinalysis Strips
BJ 1.005 – 1.030 Urinalysis Strips
pH 5.0 – 6.5 Urinalysis Strips
Keton Negative Urinalysis Strips
Protein-Albumin Negative Urinalysis Strips
Glukosa Negative Urinalysis Strips
Bilirubin Negative Urinalysis Strips
Darah Samar Negative Urinalysis Strips
Nitrit Negatif Urinalysis Strips
Urobilinogen 0.1 – 1.0 Urinalysis Strips
Leukosit Negative Urinalysis Strips
URINALISA (SEDIMEN)
Leukosit 0–3 Manual Mikroskop
Eritrosit 0–2 Manual Mikroskop
Selinder Negative Manual Mikroskop
Epithel 1+ Manual Mikroskop
Bakteri Negative Manual Mikroskop
Kristal Negative Manual Mikroskop
Lain-lain Negative Manual Mikroskop
FAAL LEMAK DAN JANTUNG
CKMB 0 - 24 U/L Optimised (C)
HATI
SGOT 0 - 46 U/I IFCC
SGPT 0 - 45 U/I IFCC
Albumin 3.5 – 5.5
GINJAL
Ureum 10 – 50 mg/dl Moodif-Berhelot
Creatinin 0.7 – 1.4 mg/dl Jaffe
ELEKTROLIT
Natrium 135 – 146 mmol/I ISE
Kalium 3.4 – 5.4 mmol/I ISE
Chlorida 95 – 100 mmol/I ISE

FOTO RONTGEN