PROGRAM STUDI PROFESI NERS FAKULTAS KEPERAWATAN

UNIVERSITAS JEMBER
FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL DAN 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: ………………………………………………………………………….................................
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2. Keluhan Utama: ……………..………………………………………………………………………….………....

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3. Riwayat penyakit sekarang:

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4. Riwayat kesehatan terdahulu:

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

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e. Obat-obat yang digunakan:

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5. Riwayat penyakit keluarga:

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Genogram:

III. Pengkajian Keperawatan

1. Persepsi kesehatan & pemeliharaan kesehatan
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Interpretasi :
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2. Pola nutrisi/ metabolik (ABCD) (saat sebelum sakit dan saat di rumah sakit)
- Antropometeri
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Interpretasi :
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- Biomedical sign :
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Interpretasi :
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- Clinical Sign :
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Interpretasi :
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- Diet Pattern (intake makanan dan cairan):

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Interpretasi :
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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 :……………………………………………………………………………..
- Konsistensi : ……………………………………………………………………………..
- Warna : ……………………………………………………………………………..
- Bau : ……………………………………………………………………………..
- Karakter : ……………………………………………………………………………..
- BJ : ……………………………………………………………………………..
- Alat Bantu : ……………………………………………………………………………..
- Kemandirian : mandiri/dibantu
- Lain : ……………………………………………………………………………..

Interpretasi :
Balance cairan:
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4. Pola aktivitas & latihan (saat sebelum sakit dan saat di rumah sakit)
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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: dibantu petugas dan alat, 2: dibantu petugas, 3: dibantu alat,
4: mandiri
Status Oksigenasi :
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Fungsi kardiovaskuler :
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Terapi oksigen :
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Interpretasi :
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5. Pola tidur & istirahat (saat sebelum sakit dan saat di rumah sakit)
Durasi : ……………………………………………………………………………………………………
Gangguan tidur : ……………………………………………………………………………………….
Keadaan bangun tidur : ………………………………………………………………..……………
Lain-lain : …………………………………………………………………………………………………
Interpretasi :
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6. Pola kognitif & perceptual

Fungsi Kognitif dan Memori :
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Fungsi dan keadaan indera :
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Interpretasi :
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7. Pola persepsi diri
Gambaran diri :
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Identitas diri :
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Harga diri :
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Ideal Diri :
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Peran Diri :
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Interpretasi :
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8. Pola seksualitas & reproduksi
Pola seksualitas
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Fungsi reproduksi
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Interpretasi :
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9. Pola peran & hubungan
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Interpretasi :
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10. Pola manajemen koping-stress
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Interpretasi :
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11. System nilai & keyakinan
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Interpretasi :
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IV. Pemeriksaan Fisik (PENDEKATAN SISTEMATIS: INSPEKSI, PERKUSI, PALPASI

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

Interpretasi :
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Pengkajian Fisik Head to toe (Inspeksi, Palpasi, Perkusi, Auskultasi)
1. Kepala
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2. Mata …………………………………………………………………………………………………………………
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3. Telinga
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4. Hidung
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5. Mulut
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6. Leher
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7. Dada
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8. Abdomen
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9. Urogenital
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10. Ekstremitas
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11. Kulit dan kuku
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12. Keadaan lokal
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V. Terapi

NO jenis Farmako Dosis dan Indikasi Efek implikasi

terapi dinamik rute dan samping keperawa
dan pemberian Kontra tan
farmako Indikasi
kinetik
1
2
3
4
5

VI. Pemeriksaan Penunjang & Laboratorium (bisa dikembangkan )

No Jenis Nilai normal Hasil
pemeriksaan (rujukan) (hari/tanggal)
nilai Satuan Tgl: Tgl: Tgl:

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Pengambil Data,

(__________________________)
NIM
 ANALISA DATA

NO DATA PENUNJANG ETIOLOGI MASALAH

 DIAGNOSA KEPERAWATAN

Daftar Diagnosa Keperawatan (sesuai prioritas):

No Diagnosa (Problem- Tanggal Tanggal Keterangan
Etiologi-Signs/Symptoms perumusan pencapaian
1

PERENCANAAN KEPERAWATAN

NO DIAGNOSA (Dx) TUJUAN (SMART) INTERVENSI RASIONAL

DAN KRITERIA
HASIL
Dx 1. Tujuan: NIC:
 Kriteria NOC:

Dx 2. Tujuan: NIC:

Kriteria NOC:

Dx 3. Tujuan: NIC:

Kriteria NOC:

Dx 4. Tujuan: NIC:

Kriteria NOC:

Dx 5. Tujuan: NIC:

Kriteria NOC:

IMPLEMENTASI KEPERAWATAN

DIAGNOSA:
WAKTU/ IMPLEMENTASI PARAF EVALUASI
Tanggal
dan Jam
Implentasi Dx 1: S:
 1............................
Respon:

2...............................
Respon:
O:
3.................................
Respon:

Implentasi Dx 2:

A:

Implentasi Dx 3:

P:

Implentasi Dx 4:

Implentasi Dx 5:

CATATAN PERKEMBANGAN KEPERAWATAN

HARI KEDUA, KETIGA DAN SETERUSNYA

WAKTU/ EVALUASI PARAF
Tanggal
dan Jam
S:
O:

A:

P:

I:

E: