FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH

 STIKes PANTI RAPIH YOGYAKARTA
Jln. Tantular No.401, Pringwulung, Condongcatur, Depok, Sleman
Telp (0274)518977
Jln.Kaliurang KM 14 Po.Box. 40 PKM Yogyakarta 55584 Telp (0274)896124

Nama Mahasiswa : ……………………………………………………………………………

NIM : ……………………………………………………………………………
Tempat Praktik : ……………………………………………………………………………
Waktu Praktik : ……………………………………………………………………………
PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

A. Identitas Diri Klien

Nama : ……………… Suku : …………………………….....

Umur : …………....... Pendidikan : ……………………………....
Jenis Kelamin : …………….... Pekerjaan : …………………………….....
Alamat : …………….... Diagnosa Medik saat masuk RS : ...................
.……………… Diagnosa Medik saat ini :................................
RM : ………………. Tanggal Masuk RS : ………… Jam :………..
Status Perkawinan : …………. Tanggal Pengkajian : …………………………
Agama : …………. Sumber Informasi : …………………………

B. Riwayat Penyakit
1. Keluhan utama saat masuk rumah sakit
………………………………………………………………………………………………………………………………………………………………………………………………

…….………………………………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………

…….

………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………
 ………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

2. a.Riwayat penyakit sekarang

………………………………………………………………………………………………………………………………………………………………………………………………

……..

………………………………………………………………………………………………………………………………………………………………………………………………

…….…………..

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

.………………...

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

………………..

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

……………………..

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………

b.Tindakan yang telah dilakukan di Poliklinik atau IGD

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

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

………………………………………………………………………………………………………………………………………………………………………………………………

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

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………....

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

3. Riwayat penyakit dahulu

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

……………………..

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

……………………..

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………

4. Riwayat Penyakit Keluarga

 ………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

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

………………………………………………………………………………………………………………………………………………………………………………………………

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

………………………………………………………………………………………………………………………………………………………………………………………………

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

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

…...............................................................................................................................................................................................................................................................

C. Pengkajiaan Keperawatan

1. Persepsi dan Pemeliharaan Kesehatan

Pengetahuan tentang penyakit/keperawatan
…………………………………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………...........................................................................................................................................................................................

1. Pola Nutrisi/Metabolik
Program diit di rumah sakit
…………………………………………………………………………………………………………………………………….......................................................................................

Intake makanan
Sehari-hari
………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………...

Saat ini (kondisi sakit)

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………………….

Intake cairan

Sehari-hari
………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………..
 Saat ini (kondisi sakit)
………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………..

2. Pola Eliminasi

BAB
Sehari-hari
………………………………………………………………………………………………………………………………………………………………………………………………
.
……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………

Saat ini (kondisi sakit)

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………

BAK
Sehari-hari
………………………………………………………………………………………………………………………………………………………………………………………………
.
……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………… Saat ini (kondisi sakit)

………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………

3. Pola Aktivitas dan Latihan saat ini (kondisi saat ini)

Kemampuan Perawatan Diri 0 1 2 3 4

Makan/minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi/ROM
0: Mandiri, 1: Dengan alat bantu, 2: Dibantu orang lain, 3: Dibantu orang lain dan alat, 4: Tergantung total

Oksigenasi…………………………………………………………………………………………………………………………………………………………………………..
 ……………………………………………………………………………………………………………………………………………..………………………………………………

………………………………………………………………………………………………………………………………………………………..……………………………………

……………………………………………………………………………………………………………………………………………………………………………………

4. Pola Tidur dan Istirahat

(Lama tidur, Gangguan tidur, Perasaan saat bangun tidur)
Sehari-hari
………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………… Saat ini (kondisi sakit)

………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

5. Pola Perceptual

(Penglihatan, Pendengaran, Pengecapan, Perabaan)

Sehari-hari
………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………… Saat ini (kondisi sakit)

………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………

Pola Persepsi Diri

(Pandangan klien tentang sakitnya, Kecemasan, Konsep diri)

Sehari-hari
………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………… Saat ini (kondisi sakit)

………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………

6. Pola Seksualitas dan Reproduksi

(Fertilitas, Libido, Menstruasi, Kontrasepsi, dll)
 Sehari-hari
………………………………………………………………………………………………………………………………………………………………………………………………
.
……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………… Saat ini (kondisi sakit)

………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………

7. Pola Peran dan Hubungan

(Komunikasi, Hubungan dengan orang lain, Kemampuan keuangan)
Sehari-hari
………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………

Saat ini (kondisi sakit)

………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………

8. Pola Managemen Koping Stress

(Perubahan terbesar dalam hidup pada akhir-akhir ini)
Sehari-hari
………………………………………………………………………………………………………………………………………………………………………………………………
.
……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………… Saat ini (kondisi sakit)

………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………

9. Sistem Nilai dan Kepercayaan

(Pandangan klien tentang agama, Kegiatan keagamaan , dll)
Sehari-hari
………………………………………………………………………………………………………………………………………………………………………………………………
.
 ……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………… Saat ini (kondisi sakit)

………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………..

D. Pemeriksaan Fisik

1. Keadaan sakit pasien

Pasien tampak sakit berat

Pasien tampak sakit sedang

Pasien tampak sakit ringan

Pasien tampak tidak sakit

Penilaian dilengkapi dengan data obyektif hasil inspeksi:

………………………………………………………………………………………………
………………………………………………………………………………………………
……………………………………………………………………………………………….

2. Tingkat kesadaran

Kuantitatif : GCS : E:…………V:…………M:………… Total:………………………

Kualitatif : ……………………………………………………………………………..

3. Tanda-tanda vital

TD: mmHg P: x/menit N: x/menit S: C

BB/TB: kg/ cm Skore nyeri: ……….. Skore jatuh:………

4. Pemeriksaan sistemik

a. Rambut (inspeksi dan palpasi)

……………………………………………………………………………………..........
..........................................................................................................................................

b. Mata:
…………………………………………………………………………………………
…………………………………………………………………………………………
c. Telinga
…………………………………………………………………………………………
…………………………………………………………………………………………

d. Hidung:
…………………………………………………………………………………………
…………………………………………………………………………………………

e. Mulut:
..........................................................................................................................................
…………………………………………………………………………………………

f. Leher:

1) Kelenjar tiroid
...................................................................................................................................

2) Kelenjar getah bening

……………………………………………………………………………………

3) Kaku kuduk:
……………………………………………………………………………………

g. Dada dan pernapasan

1) Inspeksi

Bentuk dada:……………………………………………………………..............
Deviasi trakhea:…………………………………………………………………
Jejas : …………………………………………………………………………….
Pengembangan dada : ……………………………………………………………

2) Palpasi
Focal fremitus:……………………………………………………………………
……………………………………………………………………………………

3) Perkusi
……………………………………………………………………………………
……………………………………………………………………………………

4) Auskultasi
Suara nafas:………………………………………………………………………
Suara tambahan:……………………………………………………………………
h. Kardiovaskuler

1) Inspeksi dan palpasi

Iktus cordis:………………………………………………………………………

2) Perkusi
Batas jantung kiri:…………………………………………………………………
Batas jantung kanan:………………………………………………………………
Batas atas jantung:…………………………………………………………………

3) Auskultasi
BJ I:………………………………………BJ II:…………………………………
BJ III:………………………Murmur:……..……………….Gallop:……………...

i. Abdomen

1) Inspeksi
……………………………………………………………………………………
……………………………………………………………………………………
2) Auskultasi
……………………………………………………………………………………
……………………………………………………………………………………

3) Palpasi
……………………………………………………………………………………
……………………………………………………………………………………

4) Perkusi
……………………………………………………………………………………
……………………………………………………………………………………

j. Inguinal, genital, dan anus

1) Inspeksi (inguinal, genital,anus)

……………………………………………………………………………………
……………………………………………………………………………………
2) Palpasi (inguinal)
……………………………………………………………………………………
…………………………………………………………………………………...…

k. Perkemihan

1) Inspeksi
...................................................................................................................................
 ……………………………………………………………………………………..

2) Palpasi VU
……………………………………………………………………………………
……………………………………………………………………………………
3) Perkusi ginjal:
……………………………………………………………………………………
……………………………………………………………………………………

l. Muskuloskeletal (lengan, tungkai, dan kolumna vertebra)

1) Inspeksi :
Bengkak: …………………………..Deformitas: ………………………………...
Dislokasi :……………………………Pemendekan:………………………………

2) Palpasi
Krepitasi :…………………………………………………………………………
5P (Pain, Palor, Parestesia, Pulselesness, Paresis):
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
Uji kekuatan otot:

Gerakan :………………………………………………………………………….
m. Integumen

1) Inspeksi:
Keutuhan kulit:……………………………………………………………………
Tekstur kulit:………………………………………………………………………
Warna kulit:……………………………………………………………………….
Perubahan setempat (distribusi lesi, susunan lesi, jenis lesi):……………………

2) Palpasi
Kelembaban kulit:…………………………………………………………………
Turgor kulit:……………………………………………………………………….
Letak/kedalaman lesi (bila ada) :………………………………………………….

n. Endokrin
1) ABI:………………………………………………………………………………...
2) Deteksi dini kaki diabetik:…………………………………………………………

o. Persyarafan

1) Pemeriksaan 12 saraf kranial:

 Saraf I:

Saraf II:

Saraf III:

Saraf IV:

Saraf V:

Saraf VI:

Saraf VII:

Saraf VIII:

Saraf IX:

Saraf X:

Saraf XI:

Saraf XII:

Inspeksi:

Hemiplegia Hemiparese

Reflek Babinski Refleks Patela

Pupil : Diameter (Ø): / Reaksi: /

2) Dermatome test

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

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

3) Refleks fisiologis dan patologis

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

............................................................................................................................
 E. PEMERIKSAAN PENUNJANG

1. Pemeriksaan Laboratorium

Tanggal Jenis Komponen yang Hasil Nilai Satuan Interpretasi

Pemeriksaan diperiksa Rujukan
2. Pemeriksaan Radiologi, EKG, CT-SCAN, Pemeriksaan Penunjang Lainnya (sesuai yang
diperiksa)
Tanggal Jenis Pemeriksaan Hasil
 F. Program Therapi

Nama Obat Dosis Indikasi Kontra Indikasi Alasan Pasien

Mendapat Obat
 Yogyakarta, ……………………

Perawat yang mengkaji,

……………………………………

PENGELOMPOKAN DATA

Data Subyektif

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Data Obyektif

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

……………………………………………………………………………………………………………….

Penguji, Mahasiswa,

Tanggal……………………………. Tanggal...…………………

(…………………………………….) (…………………………….)

ANALISIS DATA

Nama :………………………….. Ruang :…………………..

No.RM :………………………….. Kamar:………………….

NO. DATA MASALAH KEMUNGKINAN

PENYEBAB/FAKTOR
RESIKO
 DIAGNOSIS KEPERAWATAN

Nama :………………………….. Ruang :…………………..

No.RM :………………………….. Kamar:………………….

NO. TANGGAL DIAGNOSIS KEPERAWATAN TANDA

MUNCUL TANGAN
 RENCANA KEPERAWATAN
Nama :………………………….. Ruang :…………………..

No.RM :………………………….. Kamar:………………….

No. TUJUAN DAN KRITERIA

RENCANA TINDAKAN RASIONAL TTD
DP HASIL
 TINDAKAN DAN EVALUASI KEPERAWATAN
Nama :………………………….. Ruang :…………………..

No.RM :………………………….. Kamar:………………….

No. Tanggal, Tanda Tanggal, Evaluasi Tanda

Tindakan
DP jam tangan jam tangan