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
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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
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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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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