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INSTITUT ILMU KESEHATAN STRADA INDONESIA

FAKULTAS KEPERAWATAN DAN KEBIDANAN


PROGRAM STUDI ILMU KEPERAWATAN
ALAMAT : JL. Manila No. 37 Sumberece Kediri Telp. (0354) 7009713 Fax. (0354) 695130

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahahasiswa :
NIM :

I. PENGKAJIAN

A. IDENTITAS KLIEN IDENTITAS PENANGGUNG

Nama : ………………………… Nama : …………………….............


Umur : ………………………… Umur : …………………………….
Agama : ………………………… Agama : …………………………….
Suku : ………………………… suku : …………………………….
Bangsa : ………………………… Bangsa : …………………………….
Pendidikan : ………………………… Pendidikan : …………………………….
Pekerjaan : ………………………… Pekerjaan : …………………………….
Status : ………………………… Status : …………….....……………
Alamat : ………………………… Alamat : …………………………….
Penghasilan : ………………………… penghasilan : …………………………….
Gol. Darah : ………………………… Gol. Darah : …………………………….
Diagnosa Medis : …………………………
No. Regester : …………………………
Tgl. MRS : …………………………
Tgl. Pengkajian : …………………………

B. RIWAYAT KESEHATAN

1. KELUHAN UTAMA :
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2. RIWAYAT PENYAKIT SEKARANG :
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3. RIWAYAT PENYAKIT MASA LALU :
a. Penyakit yang pernah dialami
……………………………………………………………………………………….....................
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b. Pengobatan /tindakan yang dilakukan
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c. Pernah Operasi
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d. Riwayat alergi
…………………………………………………………………………………………………….

4. RIWAYAT KESEHATAN KELUARGA


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5. GENOGRAM ( 3 GENERASI)

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6. RIWAYAT PSIKOSOSIAL :
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7. POLA AKTIVITAS SEHARI – HARI :

Kemampuan 0 1 2 3 4 5
Perawatan diri

Makan dan Minum

Mandi

Toileting

Berpakaian

Mobilitas di tempat
tidur

Berpindah

Ambulasi (ROM)

Interpretasi Hasil :
0 : mandiri
1 : alat Bantu
2 : dibantu olang lain
3 : tergantung total

8. PEMERIKSAAN FISIK :
a. Keadaam umum : .................................................................................................................
Kesadaran : .................................................................................................................
GCS : .................................................................................................................

b. Tanda - tanda Vital


- Tekanan darah : …………………………. mmHg
- Nadi : …………………………. x/mnt
- Respirasi rate : …………………………. x/mnt
- Suhu : …………………………. ° C

c. Tinggi Badan : …………………………. Cm


Berat Badan : …………………………. Kg
Status Nutrisi : ..............................................

d. Kepala dan leher :


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e. Payudara dan ketiak :
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f. Pemeriksaan thorak / dada :


a) Inspeksi thoraks
a. Bentuk thoraks : ....................................................................................................
b. Pernafasan : ........................ Frekuensi : ................ Irama : ....................................
c. Tanda dan gejala kesulitan bernafas : .....................................................................
b) Pemeriksaan paru
a. Palpasi getaran suara : .........................................................................
b. Perkusi : .........................................................................
c. Auskultasi
- Suara nafas : .........................................................................
- Suara ucapan : .........................................................................
c) Pemeriksaan jantung
a. Inspeksi : .........................................................................
b. Palapasi : .........................................................................
- Pulsasi : .........................................................................
- Ictus Cordis : .........................................................................
c. Perkusi
- Batas jantung : .........................................................................
d. Auskultasi
- Bunyi jantung I : .........................................................................
- Bunyi jantung II : .........................................................................
- Bunyi jantung tambahan : .........................................................................
- Murmur : .........................................................................
- Frekuensi : .........................................................................

g. Pemeriksaan Abdomen :
a) Inspeksi
a. Bentuk abdomen : .........................................................................
b. Benjolan / massa : .........................................................................
c. Bayangan pembuluh darah : .........................................................................
b) Auskultasi
a. Peristaltik usus : .........................................................................
c) Palpasi
a. Tanda nyeri tekan : .........................................................................
b. Benjolan / massa : .........................................................................
c. Tanda ascites : .........................................................................
d. Hepar : .........................................................................
e. Lien : .........................................................................
f. Titik Mc Burney : .........................................................................
d) Perkusi
a. Suara abdomen : .........................................................................
b. Pemeriksaan ascites : .........................................................................

h. Punggung (Skoliosis, Kyphose, Lordose) :


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i. Ekstrimitas / Pemeriksaan muskuloskeletal
a) Kesimetrisan otot : .........................................................................
b) Edema : .........................................................................
c) Kekuatan otot : .........................................................................
d) Kelainan pada ekstrimitas dan kuku : .........................................................................

j. Pemeriksaan Integumen :
a.Kebersihan : .........................................................................
b. Kehangatan : .........................................................................
c.Warna : .........................................................................
d. Turgor : .........................................................................
e.Kelembapan : .........................................................................
f. Kelainan pada kulit : .........................................................................

k. Pemeriksaan Neurologi (N I s/d N IX, Reflek Ekstrimitas)


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l. Pemeriksaan Genetalia
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9. SPIRITUAL :
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10. PENATALAKSANAAN / TERAPI :


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11. PEMERIKSAAN PENUNJANG (Laboratorium, USG, Thorax Foto) :


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12. HARAPAN PASIEN DAN KELUARGA :


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Nama Pasien : ………………………………. No. Register : ……………………

ANALISIS DATA

Hari/Tgl Data Masalah Etiologi


DS; DATA SUBYEKTIF NYERI INFEKSI APENDIK
DO; DATA OBYEKTIF

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Nama Pasien : ………………………………. No. Register : ……………………

DAFTAR DIAGNOSA KEPERAWATAN


BERDASARKAN PRIORITAS

No. Diagnosa Keperawatan

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Nama Pasien : ……………………………………… No. Register :………………………………………..

RENCANA KEPERAWATAN

Hari No Diagnosa NOC NIC


/Tgl (Nursing Outcome Classification) (Nursing Intervention Classification )

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Nama Pasien : ……………………………………… No. Register :………………………………………..

CATATAN PERKEMBANGAN

No. Hari/Tgl/Jam Implementasi Evaluasi Ttd


Dx

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