PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa
NIM
Tempat Pengkajian
Tanggal
I. Identitas Klien
Nama
:
Umur
:
Jenis Kelamin :
Agama
:
Pendidikan
:
Alamat
:

:
:
:
:

No. RM
Pekerjaan
Status Perkawinan
Tanggal MRS
Tanggal Pengkajian
Sumber Informasi

:
:
:
:
:
:

II. Riwayat Kesehatan

1. Diagnosa Medik:
...................................
2. Keluhan Utama:
........
.

3. Riwayat penyakit sekarang:

.......................................................................................................................................

............................................

4. Riwayat kesehatan terdahulu:

a. Penyakit yang pernah dialami:
.................................

.................................
b. Alergi (obat, makanan, plester, dll):
.................................

.................................
c.Imunisasi:
...................................

d.Kebiasaan/pola hidup/life style:

.................................

.................................

...................................
e. Obat-obat yang digunakan:
...................................
.
..................................
.................................
5. Riwayat penyakit keluarga:
...................................

Genogram:

III. Pengkajian Keperawatan

1. Persepsi kesehatan & pemeliharaan kesehatan

Interpretasi :

.
2. Pola nutrisi/ metabolik (ABCD)
- Antropometeri

- Interpretasi :

..
-

Biomedical sign :

Interpretasi :

Clinical Sign :

Interpretasi :
.

Diet Pattern (intake makanan dan cairan):

Interpretasi :

3. Pola eliminasi:
BAK
- Frekuensi
- Jumlah
- Warna
- Bau
- Karakter
- BJ
- Alat Bantu
- Kemandirian
- Lain
BAB
-

Frekuensi
Jumlah
Konsistensi
Warna
Bau
Karakter
BJ
Alat Bantu
Kemandirian
Lain

:..
:..
: ..
: ..
: ..
: ..
: ..
: mandiri/dibantu
: ..
:..
:..
: ..
: ..
: ..
: ..
: ..
: ..
: mandiri/dibantu
: ..

Interpretasi :
Balance cairan:

4. Pola aktivitas & latihan

c.1. Aktivitas harian (Activity Daily Living)

Kemampuan perawatan diri
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi / ROM

Ket: 0: tergantung total, 1: dibantu petugas dan alat, 2: dibantu petugas, 3:

dibantu alat, 4: mandiri
Status Oksigenasi :

Fungsi kardiovaskuler :

Terapi oksigen :

Interpretasi :

.
5. Pola tidur & istirahat
Durasi :
Gangguan tidur : .
Keadaan bangun tidur : ..
Lain-lain :
Interpretasi :

.
6. Pola kognitif & perceptual
Fungsi Kognitif dan Memori :

Fungsi dan keadaan indera :

...........................................................................................................................
.....................................................................................................................................................................
Interpretasi :
.

7. Pola persepsi diri

Gambaran diri :

Identitas diri :

Harga diri :

Ideal Diri :

Peran Diri :

Interpretasi :

.
8. Pola seksualitas & reproduksi
Pola seksualitas

Fungsi reproduksi
....................................................................................................................
.......................................................................................................................................................................
......................................................
Interpretasi :

.
9. Pola peran & hubungan
.
.
..............................................
.......................................................................................................................................................................
............................................................................................................................
Interpretasi :

.
10. Pola manajemen koping-stress

Interpretasi :

.
11. System nilai & keyakinan

Interpretasi :

IV. Pemeriksaan Fisik

Keadaan umum:
............................................

Tanda vital:
- Tekanan Darah
:
mm/Hg
- Nadi
:
X/mnt
- RR
:
X/mnt
- Suhu
:
C
Interpretasi :

.
Pengkajian Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi)
1. Kepala

2. Mata

3. Telinga
...............................................

4. Hidung

5. Mulut

6. Leher

7. Dada
.....
...

8. Abdomen

9. Urogenital

10. Ekstremitas

..
11. Kulit dan kuku

12. Keadaan lokal

V. Terapi (jenis terapi, rute, indikasi, KI, implikasi keperawatan)

.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................

VI. Pemeriksaan Penunjang & Laboratorium (bisa dikembangkan)

No

Jenis
pemeriksaan

Nilai normal
(rujukan)
Satuan
nilai

Hasil
(hari/tanggal)

,...........................20...
Pengambil Data,

(__________________________)
NIM

NO

ANALISA DATA
DATA PENUNJANG
ETIOLOGI

MASALAH

DIAGNOSA KEPERAWATAN
Daftar Diagnosa Keperawatan (sesuai prioritas):
No Diagnosa
Tanggal
perumusan

Tanggal
pencapaian

Keterangan

PERENCANAAN KEPERAWATAN
NO

DIAGNOSA

TUJUAN DAN
KRITERIA HASIL

INTERVENSI

RASIONAL

DIAGNOSA:
WAKTU

CATATAN PERKEMBANGAN
IMPLEMENTASI

PARAF

EVALUASI
JAM:

FORMAT RESUME KASUS KELOLAAN HARIAN

S (Subjektif):
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
..
..
..
.
.
.
O (Objektif):
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
..
..
..
..
.
A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan DO):
...............................................................................................................................................................................
...............................................................................................................................................................................
..
P(Perencanaan):
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................

I (Implementasi):
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...
...
...
...
..
E (Evaluasi):
S (Subjektif) :
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
O (Objektif):
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
A (analisa) :
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
P (Perencanaan):
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
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