PROGRAM STUDI S1 KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN NAHDLATUL ULAMA TUBAN

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Tuban (62351) | Telp. (0356) 325789 | (0356) 712572 | Website. http://www.stikesnu.com | Email. info@stikesnu.com

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Pengkajian tgl. : Jam :

MRS tanggal : No. RM :
Diagnosa Masuk : Hari Rawat Ke :
Ruangan/kelas :

A. IDENTITAS PASIEN
Nama : Penanggung jawab biaya :
Usia : Nama :
Jenis kelamin : Alamat :
Suku /Bangsa : Hub. Keluarga :
Agama : Telepon :
Pendidikan :
Status perkawinan :
Pekerjaan :
Alamat :

Keluhan Utama : .......................................................................................................................

B. RIWAYAT PENYAKIT SEKARANG

C. RIWAYAT PENYAKIT DAHULU

1. Pernah di rawat ya, jenis : ....................... tidak
2. Riwayat Penyakit Kronik dan Menular ya, jenis : ....................... tidak
3. Riwayat Penyakit Alergi ya, jenis : ....................... tidak
4. Riwayat Operasi ya, jenis : ....................... tidak
- Kapan : ...............................
- Jenis Operasi : ...............................
5. Lain-lain :
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D. RIWAYAT PENYAKIT KELUARGA

ya : ........................................ tidak

GENOGRAM
E. PERILAKU YANG MEMPENGARUHI KESEHATAN
Perilaku sebelum sakit yang mempengaruhi kesehatan
Alkohol ya tidak
Keterangan ..........................................................................................................
Merokok ya tidak
Keterangan ..........................................................................................................
Obat ya tidak
Keterangan ..........................................................................................................
Olahraga ya tidak
Keterangan ..........................................................................................................

F. OBSERVASI DAN PEMERIKSAAN FISIK

1. Keadaan Umum
Tanda-tanda vital
Keadaan umum baik sedang lemah
S: ºC N: x/mnt TD : mmHg
RR : x/mnt

MASALAH KEPERAWATAN :
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2. Sistem Pernafasan (B1)
a. RR : ...............................
b. Keluhan : Sesak Nyeri waktu sesak Orthopnea
Batuk Produktif Tidak Produktif
Sekret : .................... Konsistensi : .......................
Warna : ................... Bau : ....................................
c. Pola nafas irama:  Teratur  Tidak teratur
d. Jenis  Dispnoe  Kusmaul  Ceyne Stokes Lain-lain:
Pernafasan cuping hidung ada tidak
Septum nasi simetris tidak simetris
Lain-lain :
e. Bentuk dada simetris asimetris barrel chest
Funnel chest Pigeons chest
f. Suara napas vesiculer ronchi D/S wheezing D/S rales D/S
g. Alat bantu nafas Ya Tidak
Jenis .........................Flow ................Lpm
h. Penggunaan WSD :
- Jenis : ....................................................................................................................
- Jumlah Cairan : .........................................................................................................
- Undulasi : .................................................................................................................
- Tekanan : .................................................................................................................

i. Trakeostomy Ya Tidak
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j. Lain-lain :
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MASALAH KEPERAWATAN :
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3. Sistem Kardiovakuler (B2)
a. Keluhan nyeri dada ya tidak
P : .....................................................................................
Q : .....................................................................................
R : .....................................................................................
S : .....................................................................................
T : .....................................................................................
b. CRT : ...............
c. Konjungtiva pucat ya tidak
d. Bunyi jantung:  Normal  Murmur  Gallop lain-lain
e. Irama jantung:  Reguler  Ireguler S1/S2 tunggal  Ya  Tidak
f. Akral:  Hangat  Panas  Dingin kering  Dingin basah
g. Siklus perifer Normal Menurun
h. JVP : ..........................
Lain-lain :
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MASALAH KEPERAWATAN :
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4. Sistem Persarafan (B3)

a. Kesadaran composmentis apatis somnolen sopor koma
GCS :
b. Pupil isokor anisokor
c. Sclera Anikterus Ikterus
d. Konjungtiva Ananemis Anemis
e. Istirahat/Tidur : .................................................
f. Nyeri tidak ya, skala nyeri : lokasi :
g. Refleks fisiologis:  patella  triceps  biceps lain-lain:
h. Refleks patologis:  babinsky  budzinsky  kernig lain-lain
i. Keluhan Pusing O ya O Tidak
MASALAH KEPERAWATAN :
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5. Sistem Perkemihan (B4)

a. Kebersihan genetalia : Bersih Kotor
b. Sekret : Ada Tidak
c. Ulkus : Ada Tidak
d. Kebersihan Meatus uretera : Bersih Kotor
e. Keluhan Kencing Ada Tidak
Bila ada jelaskan :
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f. Kemampuan berkemih
Spontan Alat bantu, sebutkan : ...................................................................
Jenis : ........................................................................................
Ukuran : ........................................................................................
Hari Ke: ........................................................................................
 g. Produksi urine : ...........................ml/jam
Warnah : ...............................
Bau : ...............................
h. Kandung kemih : Membesar Ya Tidak
i. Nyeri Tekan : Ya Tidak
j. Intake Cairan : Oral :....................cc/hari Parenteral : ..............cc/hari
k. Balance Cairan : ..................................................................................................................
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o. Lain-lain : .....................................................................................................................................
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MASALAH KEPERAWATAN :
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6. Sistem Pencernaan (B5)
a. TB : ............. cm BB : ..............kg
b. IMT : ............. Interpretasi : .........................................
c. LLA : .............
MASALAH KEPERAWATAN :
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d. Mulut : Bersih Kotor
e. Mukosa mulut : Lembab Kering Merah stomatitis
f. Tenggorokan Nyeri telan Sulit menelan
Pembesaran Tonsil Nyeri Tekan
g. Abdomen Supel Tegang nyeri tekan, lokasi :
Luka operasi Jejas lokasi :
Pembesaran hepar ya tidak
Pembesaran lien ya tidak
Ascites ya tidak
Drain Ada Tidak
- Jumlah : ......................
- Warna : ......................
- Kondisi area sekitar insersi : .....................................
Mual ya tidak
Muntah ya tidak
Terpasang NGT ya tidak
Bising usus :..........x/mnt
h. BAB :........x/hr, konsistensi : lunak cair lendir/darah
konstipasi inkontinensia kolostomi
i. Diet padat lunak cair
Diet Khusus : ......................................................................................................................
Nafsu Makan Baik Menurun
Frekuensi :...............x/hari jumlah:............... jenis : .......................
Lain –lain : ..........................................................................................................................
MASALAH KEPERAWATAN :
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7. Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
Orbita Dextra Orbita Sinistra
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO

b. Keluhan nyeri Ya Tidak

c. Luka opreasi Ada Tidak
Tanggal operasi : ........................
Jenis Operasi : ........................
Lokasi : ........................
Keadaan : ........................
d. Pemeriksaan penunjang lain
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e. Lain .................................................................................................................................................
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MASALAH KEPERAWATAN
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8. Sistem pendengaran
a. Pengkajian segmen dan posterior
b. Aurcicula :
c. MAE :
d. Membran Tympani :
e. Rinne :
f. Webber :
g. Swabach :
h. Tes audiometri :
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i. Keluhan nyeri Ya Tidak
j. Luka opreasi Ada Tidak
Tanggal operasi : ........................
Jenis Operasi : ........................
Lokasi : ........................
Keadaan : ........................
k. Alat bantu dengar : .......................................................
l. Lain-lain. ......................................................................................................................................
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MASALAH KEPERAWATAN
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9. Sistem Muskuloskeletal dan Integumen (B6)
a. Kekuatan otot

b. Pergerakan sendi bebas terbatas

c. Kelainan ekstremitas ya tidak
d. Kelainan tlg. belakang ya tidak
e. Fraktur ya tidak
- Jenis :..............................................................
f. Traksi/spalk/gips ya tidak
- Jenis : ............................................
- Beban : ............................................
- Lama pemasangan : ...........................................
g. Penggunaan spalk/gips ya tidak
h. Keluhan nyeri : ya tidak
i. Sirkulasi perifer : ...........................................
j. Kompartemen sindrom ya tidak
k. Kulit ikterik sianosis kemerahan hiperpigmentasi
l. Akral hangat panas dingin kering basah
m. Turgor baik kurang jelek
n. Odema:  Ada  Tidak ada Lokasi
o. Luka operasi : jenis :............. luas : ............... bersih kotor
p. Tanggal operasi : ..................
q. Jenis operasi : ..................
r. Lokasi : ..................
s. Keadaan : ..................
t. Drain : Ada Tidak
u. Jumlah : ...................................................
v. Warna : ...................................................
Lain-lain : ...............................................................................................................
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MASALAH KEPERAWATAN :
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10. Sistem Integumen
a. Penilaian risiko decubitus :
Aspek yang dinilai KRITERIA YANG DINILAI NILAI
1 3 3 4
PERSEPSI TERBATAS SANGAT KETERBATASAN TIDAK ADA
SENSORI SEPENUHNYA TERBATAS RINGAN GANGGUAN
KELEMBABAN TERUS MENERUS SANGAT LEMBAB KADANG-KADANG JARANG BASAH
BASAH BASAH
AKTIVITAS BEDFAST CHAIRFAST KADANG-KADANG LEBIH SERING
JALAN JALAN
MOBILISASI IMMOBILE SANGAT KETERBATASAN TIDAK ADA
SEPENUHNYA TERBATAS RINGAN KETERBATASAN
NUTRISI SANGAT BURUK KEMUNGKINAN ADEKUAT SANGAT BAIK
TIDAK ADEKUAT
GESEKAN & BERMASALAH POTENSIAL TIDAK
PERGESERAN BERMASALAH MENIMBULKAN
MASALAH
NOTE : Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien beresiko mengalami
dekubitus (Pressure ulcers) TOTAL NILAI
(15 or 16 =low risk, 13 or 14 = moderate risk, 12 or less= high risk)
 b. Warna : ...........................................................
c. Pitting edema : +/- grade : ..............................
d. Ekskoriasis : ya tidak
e. Psoriasis : ya tidak
f. Urtikaria : ya tidak
g. Lain-lain : ............................................................................................................................
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MASALAH KEPERAWATAN
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11. Sistem Endokrin
a. Pembesaran kelenjar tyroid ya tidak
b. Pembesaran kelenjar getah bening ya tidak
c. Hiperglikemia  Ya  Tidak Hipoglikemia  Ya  Tidak
d. Kondisi kaki DM :
- Luka gangrene  Ya  Tidak
- Jenis Luka : .....................................................
- Lama luka : .....................................................
- Warna : .....................................................
- Luas Luka : .....................................................
- Kedalaman : .....................................................
- Kulit Kaki : ..............................................
- Kuku kaki : ..............................................
- Telapak kaki : ..............................................
- Jari kaki : ..............................................
- Infeksi :  Ya  Tidak
- Riwayat luka sebelumnya :  Ya  Tidak
- Tahun : ..................................................
- Jenis Luka : ..................................................
- Lokasi : ..................................................

- Riwayat amputansi sebelumnya :  Ya  Tidak

Jika Ya
- Tahun : ..........................
- Lokasi : .........................
- Lain-lain : .....................................................................................................
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MASALAH KEPERAWATAN :
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G. PENGKAJIAN PSIKOSOSIAL
1. Persepsi klien terhadap penyakitnya
Cobaan Tuhan Hukuman Lainnya
2. Ekspresi klien terhadap penyakitnya
Murung Gelisah Tegang Marah/menangis
3. Reaksi saat interaksi kooperatif tak kooperatif curiga
4. Gangguan konsep diri ya tidak

MASALAH KEPERAWATAN :
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H. PENGKAJIAN SPIRITUAL

a. Kebiasaan beribadah
- Sebelum sakit sering kadang-kadang tidak pernah
- Selama sakit sering kadang-kadang tidak pernah
b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah :
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MASALAH KEPERAWATAN :
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I. PERSONAL HYGIEN
a. Kebersihan diri :
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b. Kemampuan klien dalam pemenuhan kebutuhan :

- Mandi : Dibantu seluruhnya dibantu sebagian mandiri
- Ganti pakaian : Dibantu seluruhnya dibantu sebagian mandiri
- Keramas : Dibantu seluruhnya dibantu sebagian mandiri
- Sikat gigi : Dibantu seluruhnya dibantu sebagian mandiri
- Memotong kuku: Dibantu seluruhnya dibantu sebagian mandiri
- Berhias : Dibantu seluruhnya dibantu sebagian mandiri
- Makan : Dibantu seluruhnya dibantu sebagian mandiri
MASALAH KEPERAWATAN :
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J. PEMERIKSAAN PENUNJANG (Laboratorium, radiologi, EKG, USG)

K. TERAPI

Tuban,.................................
Perawat Primer,

(.............................................)
 ANALISA DATA
DATA ETIOLOGI MASALAH
 DIAGNOSA KEPERAWATAN

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
 INTERVENSI
No Diagnosa Keperawatan Tujuan/ Tgl/jam Intervensi Rasional
Kriteria Hasil
 IMPLEMENTASI DAN EVALUASI
DIAGNOSA IMPLEMENTASI JAM/TGL EVALUASI SOAP TTD