FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH PROGRAM STUDI NERS STIKes AL-INSYIRAH

Nama Mahasiswa : ……………………………….. NIM : ………………………

I. Identitas diri klien

Nama : .....................................................................................................................
Umur : .....................................................................................................................
Jenis Kelamin : .....................................................................................................................
Pendidikan :...................................................................................................................... .
Agama : .....................................................................................................................
Pekerjaan : .....................................................................................................................
Status Perkawinan : .....................................................................................................................
Agama : .....................................................................................................................
Suku : .....................................................................................................................
Alamat : .....................................................................................................................
Tanggal masuk RS : .....................................................................................................................
Alasan masuk RS : .....................................................................................................................
Yang mengirim : .....................................................................................................................
Diagnosa Medis : .....................................................................................................................
Tanggal Pengkajian : .....................................................................................................................
Nomor Medkal Record : .....................................................................................................................

II. Riwayat Penyakit

1. Keluhan utama saat masuk RS
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2. Riwayat penyakit sekarang
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3. Riwayat penyakit dahulu
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 4. Riwayat Kesehatan Keluarga
Genogram
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III. Pengkajiaan saat ini

1. Persepsi dan Pemeliharaan kesehatan
Pengetahuan tentang penyakit / perawatan
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Pola nutrisi / metabolik
Program di rumah sakit
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Intake makanan
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Intake cairan
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2. Pola eliminasi
Buang air besar
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Buang air kecil
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3. Pola Aktivitas dan Latihan

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
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4. Pola tidur dan istirahat

(lama tidur, gangguan tidur, perasaan saat bangun tidur)
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5. Pola Perceptual
(penglihatan, pendengaran, pengecap, sensasi)
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6. Pola Persepsi diri

(pandangan klien tentang sakitnya, kecemasan, konsep diri)
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7. Pola seksualitas dan reproduksi

(fertilitas, libido, menstruasi, kontrasepsi, dll)
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8. Pola peran dan hubungan

(komunikasi, hubungan dengan orang lain, kemampuan keuangan)
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9. Pola Managemen koping stress

(perubahan terbesar dalam hidup pada akhir-akhir ini)
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10. Sistem nilai dan kepercayaan

(pandangan klien tentang agama, kegiatan keagamaan, dll)
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Observasi dan Pemeriksaan Fisik :

Pemeriksaan Tanda-Tanda Fital

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

Pemeriksaan nyeri

Provokatif/Paliatif (P) :
Qualitas/Quantitas (Q) :
Region/Radiasi (R) :
Skala Seviritas (S) :
Timing (T) :

I. KEPALA
Rambut : warna/panjang/pendek/tanpa rambut/tekstur kotor/mudah rontok/gatal
gatal dll
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Mata : anemis/ikterik/midriasis/pakai mata/simetris/strabismus/katarak/glukoma

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Mulut : kotor /bau/terpasang ETT/OPA /pendarahan/lidah kotor/gangguan

pengecapan
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Bibir : kering/stomatitis
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Gigi : gigi palsu/kawat gigi/karies/tidak ada gigi
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 Telinga : Pendarahan/terpasang alat bantu/infeksi/gangguan pendengaran/
bersih/kotor

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II. LEHER : Pembesaran KGB/kaku kuduk/terpasang trakeotomi/terpsang

necolar//JVP
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III.TANGAN : Utuh/luka/lecet/sianosis/clubbing
finger/dingin/fraktur/edema/CRT/LILA/kekuatan otot

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IV. DADA (PARU DAN JANTUNG )

Inspeksi : Warna/bentuk dada/barel chest/pigion chest/kifosis/funnel
chest/devisiasi thorak/pola napas/penggunaan otot bantu
pernapasan/iktus cordis/retraksi dada/area klavikularis/fosa
klavikularis/fosa intraklavikulris
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Palpasi : Hangat/dingin/nyeri tekan/massa/tactile fremitus/denyut
apical/pengembangan dada
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Perkusi :
ð Resonan Letak……………………………
ð Hiperesonane Letak…………………………….
ð Batas jantung
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Auskultasi :
ð Bronkial Letak……………………………
ð Bronkovesikuler Letak…………………………….
ð Vesikuler Letak…………………………….
ð Krakles Letak……………………………..
ð Whezzing Letak…………………………….
ð Ronchi Letak…………………………….
ð Friction Rub Letak……………………………..
ð S1 Letak……………Suara……………….Frekuesi………………..
ð S2 Ltak…………… Suara………………Frekuesi………………..
ð S3 Letak……………Suara ………………Frekuesi……………….
ð S4 Letak……………suara ………………Frekuesi……………….
V. Abdomen
Inspeksi ð Normal ð Asites ð Stoma ð Luka
Palpasi : .......................................................................................................................................
Perkusi : .......................................................................................................................................
Auskultasi : .......................................................................................................................................

VI. Genetelia : Pendarahan/terpasang kateter/trauma/mentruasi/infeksi

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VII. Kaki :
fraktur/edema/malforasi/luka/infeksi/sianosis/dingvin/vgarises/
pulsasi/atrofi/kekuatan otot

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VIII. Punggung : Lordosis/kiposis/skledosis/luka/dekubetus/nyeri

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IX.Program terapi :

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X. Hasil Pemeriksaan Penunjang dan laboratorium (dimulai saat anda

mengambil sebagai kasus kelolaan, cantumkan tanggal pemeriksaan dan
kesimpulan hasilnya)
Hari……..tanggal……..tahun ...........................................................................................................

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Hari……..tanggal……..tahun ............................................................................................................
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Hari……..tanggal……..tahun ...........................................................................................................

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Pekanbaru, ..............................................
Mahasiswa

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