Professional Documents
Culture Documents
KEPERAWATAN MEDIKAL
BEDAH
I. BIODATA
Identitas Pasien
Initial pasien : ………………......…… Pekerjaan : ………………......……
Jenis kelamin : ………………......…… No. RM : ………………......……
Agaman : ………………......…… Tgl pengkajian : ………………......……
Pekerjaan : ………………......……
Status pernikahan : ………………......……
Penanggung jawab
Initial : ………………......……
Usia : ………………......……
Jenis kelamin : ………………......……
Pekerjaan : ………………......……
Hub dg pasien : ………………......……
Tanda (Objektif)
Respons terhadap aktivitas yang teramati : ...................................... ..............................................
Kardiovaskular : ...................................... ..............................................
Pernapasan : ...................................... .............................................
Status mental (mis.menarik diri/ letargi) : ...................................... ..............................................
Pengkajian neuromuskular
Massa/ tonus otot : ...................................... ..............................................
Postur : ...................................... ..............................................
Tremor : ...................................... ............................................
Rentang gerak : ...................................... .............................................
Kekuatan : ...................................... ..............................................
Deformitas : ...................................... ..............................................
V. SIRKULASI
Gejala (Subjektif)
Riwayat tentang :
Hipertensi : ....................................... Masalah jantung : .......................................
Demam rematik : ....................................... Edema mata kaki/ kaki : ..................................
Flebitis : ....................................... Penyembuhan lambat : ..................................
Klaudikasi : ....................................... ....................................... ....................................... ......
Ekstremitas :
Kesemutan : ....................................... Kebas : ...........................................................
Batuk/ hemoptisis : ....................................... ....................................... ............................................
Perubahan frekuensi/ jumlah urine : ....................................... ..........................................................
Tanda (Objektif)
TD : ..................................... ..................................................... ..................................
Tekanan nadi : ....................................................................Gap auskultatori ..............................
Nadi (palpasi) :
Karotis : ................................................. Temporal : ..................................................
Jugularis : ................................................... Radialis : ..................................................
Femoralis : ................................................ Popliteal : ..................................................
Postibial : .................................................. Dorsalis pedis : ................................................
Jantung (palpasi) :
Getaran : .................................................. Dorongan : .................................................
Bunyi jantung :
Frekuensi : ......... ................... Irama : .................................. Kualitas : ...........................................
Friksi gesek : ..................................................... Murmur : ..............................................................
Bunyi napas :
Desiran vaskular : ................................... .............................................................................
Distensi vena jugularis : ................................... .............................................................................
Ekstremitas :
suhu : ................................................. Warna : ..................................................
Pengisian kapiler : .................................................. ..........................................................................
Tanda Homan’s : ............................................ Varises : ...................................................
Abnormalitas kuku : .................................................. .......................................................................
Penyebaran/ kualitas rambut : .......................................................... ..................................................
Warna : ..............................Membran mukosa : ...............................Bibir : .......................................
Punggung kuku : ....................... .................................................. ....................................................
Konjungtiva : ................................................. Sklera : .................................................
Diaforesis : .................................................. .................................................. ............................
Tanda (Obyektif)
Status emosional (beri tanda cek untuk yang sesuai) :
Tenang : ........ Cemas : ........Marah: ........Menarik diri : ........ Takut : ........
Mudah tersinggung : ........Tidak sabar : ........Euforik : ........
Respons-respons fisiologis yang terobservasi :
........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ..............
VII. ELIMINASI
Gejala (Subjektif)
Pola BAB : ................................... Penggunaan laksatif : ...........................................
Karakter fases : .................................. BAB terakhir : ...........................................
Riwayat perdarahan : .................................. Hemoroid : ...........................................
Konstipasi : .................................. Diare : ...........................................
Pola BAK : ................................... Inkontimensia/ kapan : .........................................
Dorongan : ................................Frekuensi : .............................. Retensi : .........................................
Karakter urine : ................................................................................ .......................................
Nyeri/ rasa terbakar/ kesulitan BAK : ............................................. .................................................
Riwayat penyakit ginjal/ kandung kemih : ...................................... ..................................................
Penggunaan diuretik : ...................................................................... .................................................
Tanda (Objektif)
Abdomen :
Nyeri tekan : ........................................ Lunak/ keras : ......................................................
Massa : ....................................... Ukuran/ lingkar abdomen : ..................................
Bising usus : ...................................... Hemoroid : ........................................................
Perubahan kandungan kemih : ..................................BAK terlalu sering : ......................................
VIII.MAKANAN/ CAIRAN
Gejala (Subjektif)
Diit biasa (tipe) : ........................... Jumlah makanan per hari : ..... ................................
Makan terakhir/ masukan : ........................... Pola diit : ............................................................
Kehilangan selera makan : .......................... Mual/ muntah : ......................................................
Nyeri ulu hati/ salah cerna : ........................................ Yang berhubungan dengan..........................
Disembuhkan oleh : ........................................................................ .................................................
Alergi/ intoleransi makanan : .......................................................... ...............................................
Masalah-masalah mengunyah/ menelan : ........................................ ................................................
Gigi : ................................................................................................ .................................................
Berat badan biasa : .........................................Perubahan berat badan : ..........................................
Penggunaan diuretik : ...................................................................... ................................................
Tanda (Objektif)
Berat badan sekarang : .…….... Tinggi badan : ...................... Bentuk tubuh : ...............................
Turgor kulit :……. .................... Kelembaban/ kering membran mukosa : . . . . . .. . . .. .....................
Edema :
Umum : .........................................................Dependen : ..............................................................
Periorbital : .................................................. Asites : .....................................................................
Distensi vena jugularis : .................................................................. ..............................................
Pembesaran tiroid : ..................Hernia/ massa : ..........................Halitosis : .................................
Kondisi gigi/ gusi : .......................................................................... ...................................
Penampilan lidah : ........................................................................... ...................................
Membran mukosa : .......................................................................... ....................................
Bising usus : .................................................................................... .........................
Bunyi napas : ................................................................................... ...........................
Urin S/ A atau Kemstiks : ................................................................ .............................................
IX. HIGIENE
Gejala (Subjektif)
Aktivitas sehari-hari : Tergantung/ Mandiri .................................. ...................................................
Mobilitas :
Makan : .................................. .................................................................
Hegiene : ....................................................................................................
Berpakaian : ........................................... .................................. ....................
Toileting : ........................................................................................ ............
Waktu mandi yang diinginkan : ....................................................... ...........................................
Pemakaian alat bantu/ prostetik : ..................................................... .............................................
Bantu diberikan oleh : ...................................................................... ..............................
Tanda (Objektif)
Penampilan umum : ...................................................................... .................................................
Cara berpakaian : .......................................... Kebiasaan pribadi : ................................................
Bau badan : ................................................... Kondisi kulit kepala : ............................................
Adanya kutu : .................................................................................. ................................................
X. NEUROSENSORI
Gejala (Subjektif)
Rasa ingin pingsan/ pusing : ............................................................ ................................................
Sakit kepala :
Lokasi nyeri : ................................................... Frekuensi : ............................................................
Kesemutan/ kebas/ kelemahan (lokasi): ......................................... ................................................
Stroke (gejala sisa) : ........................................................................ ................................................
Kejang : ........…………...Tipe : ....................................Frekuensi : .............................................
Status postikal : .............................................. Cara mengontrol : .................................................
Mata :
Kehilangan penglihatan : ..................................... Pemeriksaan terakhir : ....................................
Glaukoma : ......................................................... Katarak : . . . . . . . . . ..............................................
Telinga :
Kehilangan pendengaran : ............................... Pemeriksaan terakhir : ......................................
Epistaksis : ........................................................................................ ...............................................
Tanda (Objektif)
Status mental : ................................................................................. ..............................................
Terorientasi/ disorientasi : Waktu ............... ... Tempat ....................Orang .................................
Kesadaran : ............................... Mengantuk : ............................ Letargi : ..................................
Stupor : ...................................................... Koma : ....................................................................
Kooperatif : ............................... Menyerang : ............................. Delusi : ................................
Halusinasi : .............................................. Afek (gambarkan) : ....................................................
Memori : Saat ini ................................................................Yang lalu ............................................
Kaca mata :………................. Kontak lensa ...................Alat bantu dengar ..................................
Ukuran/ rekasi pupil : Ka/ Ki ........................................................ ..................................................
Facial drop :…………………………..............................Menelan : ..............................................
Genggaman tangan/ lepas : Ka/ Ki :…………………....Postur : ... ................................................
Refleks tendom dalam : ...................................................Paralisis : . ..............................................
XII. PERNAPASAN
Gejala (Subjektif)
Dispnea yang berhubungan dengan batuk/ sputum :………………….. ………………….…………....
Riwayat bronkitis :……………………......... ...... Asma :…………….……………............................
Tuberkulosis : ………………….......................... Emifisema :…………………………......................
Pneumonia kambuhan :………………………………..…………….. …………………........................
Pemanjanan terhadap udara berbahaya :…………………………. …………………..………………...
Perokok :……........ Pak/ hari :………… Lama dalam tahun :…..……..
Penggunaan alat bantu pernapasan :…………… ................ Oksigen :……...…….............
Tanda (Objektif)
Pernapasan :
Frekuensi :……… Kedalaman :……… Simetris :……..…
Penggunaan otot-otot asesori :…….. Napas cuping hidung :……..…..
Fremitus :…………………………………………………...…………….… ………………….............
Bunyi napas :……………………………………………………………….. ………………….............
Egofoni :…………………………………………………………………….. …………………............
Sianosis :…………………… Jari tubuh :…………………………….……
Karakteristik sputum :…………………………………………..…………. …………………...............
Fungsi mental/ gelisah :…………………………………………………… …………………...............
XIII. KEAMANAN
Gejala (Subjektif)
Alergi/ sensitivitas :………………………. Reaksi :……………….……................
Perubahan sistem imun sebelumnya :….…….................. Penyebab :……………..........................
Riwayat penyakit hubungan seksual (tanggal/ tipe) :…………………. ………………….......................
Perilaku resiko tinggi :…………...…… Periksaan :……....….…..…….
Tranfusi darah/ jumlah :…………………… Kapan :……………..……..
Gambaran reaksi : ………………………………………………………………………..……………....
Riwayat cedera kecelakaan :……………………………………………. …………………....................
Fraktur/ dislokasi :…………………………………………………………..............................................
Artritis/ sendi tak stabil :………………………………………………….. ………………….................
Masalah punggung :……………………………………..………………. …………………...................
Perubahan pada tahi lalat :………….. Pembesaran nodus :………….
Kerusakan penglihatan, pendengaran :…………………………....…… ………………….....................
Protese :………………… Alat ambulatori :………………………………
Tanda (Objektif)
Suhu tubuh :…………………… Diaforesis :……………………………..
Integritas kulit :………………...…………………………………………… …………………..............
Jaringan parut :………………… Kemerahan :………………………....
Laserasi :…………………….. Ulserasi :……………......……………
Ekimosis :……………………… Lepuh :…………………………….....
Pria
Gejala (Subjektif)
Rabas penis :……………………. Gangguan prostat :……………..……
Sukumsisi :…………….………. Vasektomi :……………………………..
Melakukan pemeriksaan sendiri :……… Payudara/ Testis :…………..
Prostoskopi/ pemeriksaan prostat terakhir :……………………….....…
Tanda (Objektif)
Pemeriksaan :……………. Payudara/ penis/ testis :……………….…..
Kutil genital/ lest :………………………………………………………….
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