KEPERAWATAN MEDIKAL BEDAHPROGRAM STUDI ILMU KEPERAWATAN (PSIK)STIKES TRI MANDIRI SAKTI BENGKULU

FORMAT PENGKAJIAN

Nama Mahasiswa :Tanggal praktek :Nomor NPM :Tempat praktek :1. Data BiografiIdentitas Klien:Nama: ..No Register : .Umur: ..Suku/ bangsa: ..Status perkawinan: ..Agama: ..Pendidikan: ..............................Pekerjaan : ..............................Alamat : ..............................Tanggal masuk RS: ..............................Tanggal pengkajian : ..............................Catatan kedatangan : Kursi roda ( ), Ambulans ( ), Brankar ( )

Keluarga Terdekat yang dapat dihubungi :Nama/ Umur: .............................No Telepon : .........................Pendidikan : .............................Pekerjaan : .............................Alamat : .............................

Sumber informasi: .............................2. Riwayat Kesehatan/ Keperawatan1) Keluhan utama/ alasan masuk RS :........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................2) Riwayat kesehatan sekarang :Faktor pencetus : ........................................................................................................................................................................................................................................................Sifat keluhan (mendadak/perlahan- lahan/ terus menerus/ hilang timbul atau berhubungan dengan waktu) : ..............................................................................................................................................................................................................................................................................................................................................................................Lokalisasi dan sifatnya (menjalar/ menyebar/ berpindah- pindah/ menetap) : ...................................................................................................................................................................................................................................................................................Berat ringannya keluhan (menetap/ cenderung bertambah atau berkurang) :....................................................................................................................................................................................................................................................................................Lamanya keluhan : .....................................................................................................................................................................................................................................................Upaya yang telah dilakukan untuk mengatasi : .........................................................................................................................................................................................................Keluhan saat pengkajian : ............Diagnosa medik :.......................................................... Tanggal ....................................................................................................................... Tanggal .............................................................

3) Riwayat Kesehatan DahuluPenyakit yang pernah dialami (jenis penyakit, lama dan upaya untuk mengatasi, riwayat masuk RS) : .............................................................................................................................................................................................................................................................................................................................................................................................Alergi : .......................................................................................................................................................................................................................................................................Obat- obatan (Resep/ obat bebas)DosisDosis terakhirFrekuensi

4) Riwayat Kesehatan Keluarga : Penyakit menular atau keturunan dalam keluarga : .............................................................................................................................................................................................................................................................................................................................................

3. Pola Fungsi Kesehatan (Gordon) :1) Pola persepsi dan pemeliharaan kesehatanPersepsi terhadap penyakit :.................................................................................................................................................................................................................................................................................................................................................................................Penggunaan :Tembakau (bungkus/ hari, pipa, cerutu, berapa lama, kapan berhenti) :....................................................................................................................................................................Alkohol (jenis, jumlah/hari/minggu/bulan) : .............................................................................................................................................................................................................Alergi (obat-obatan, makanan, plester, dll) : ...................................................................Reaksi alergi ....................................................................................................................2) Pola nutrisi dan metabolismeDiet/ suplemen khusus : ...................................................................................................Instruksi diet sebelumnya : ..............................................................................................Nafsu makan (normal, meningkat, menurun) : ..........................................................................................................................................................................................................Penurunan sensasi kecap, mual-muntah, stomatitis : .................................................................................................................................................................................................Fluktuasi BB 6 bulan terakhir (naik/ turun) : .............................................................................................................................................................................................................Kesulitan menelan (disfagia) : .........................................................................................Gigi (lengkap/ tidak, gigi palsu) : ..............................................................................................................................................................................................................................Riwayat masalah kulit/ penyembuhan (ruam, kering, keringat berlebihan, penyembuhan abnormal : ..........................................................................................................................................................................................................................................Jumlah minum/ 24 jam dan jenis (kehausan yang sangat) ........................................................................................................................................................................................Frekuensi makan : ............................................................................................................Jenis makanan : ................................................................................................................Pantangan/ alergi : ............................................................................................................Lain- lain : ..................................................................................................................................................................................................................................................................3) Pola EliminasiBuang air besar (BAB) :Frekuensi : ......................................Waktu : .........................................Warna : ......................................Konsistensi : .................................Kesulitan (diare, konstipasi, inkontinensia) : .....................................................................................................................................................................................Buang air kecil (BAK) :Frekuensi : ......................................Warna : .........................................Kesulitan (disuria, nokturia, hematuria, retensi, inkontinensia) : .......................................................................................................................................................Alat bantu (kateter intermitten, indweling, kateter eksternal) : .................................................................................................................................................................................Lain- lain : ..................................................................................................................................................................................................................................................................

4) Pola aktivitas dan latihanKemampuan perawatan diri :0 = Mandiri3 = Dibantu orang lain dan peralatan1 = Dengan alat bantu4 = Ketergantungan/ tidak mampu2 = Dibantu orang lainKegiatan/ aktivitas01234

Makan/ minum

Mandi

Berpakaian/ berdandan

Toileting

Mobilisasi ditempat tidur

Berpindah

Berjalan

Menaiki tangga

Berbelanja

Memasak

Pemeliharaan rumah

Alat bantu (kruk, pispot, tongkat, kursi roda) : ................................................................Kekuatan otot : ............................................................................................................................................................................................................................................................Kemampuan ROM : ...................................................................................................................................................................................................................................................Keluhan saat beraktivitas : .........................................................................................................................................................................................................................................Lain- lain : ........................................................................................................................5) Pola istirahat dan tidurLama tidur : .................. jam/ malam .................... tidur siang .................. tidur soreWaktu : .............................................................................................................................Kebiasaan menjelang tidur : ............................................................................................Masalah tidur (insomnia, terbangun dini, mimpi buruk) : .........................................................................................................................................................................................Lain- lain (merasa segar/ tidak setelah bangun) : ......................................................................................................................................................................................................

6) Pola kognitif dan persepsiStatus mental (sadar/ tidak, orientasi baik/ tidak) : ...................................................................................................................................................................................................Bicara : Normal ( ), tak jelas ( ), gagap ( ), aphasia ekspresif ( )Kemampuan berkomunikasi : Ya ( ), Tidak ( )Kemampuan memahami : Ya ( ), Tidak ( )Tingkat ansietas : Ringan ( ), Sedang ( ), berat ( ), panik ( )Pendengaran : DBN ( ), tuli ( ) kanan/ kiri, tinitus ( ), alat bantu dengar ( )Penglihatan (DBN, buta, katarak, kacamata, lensa kontak, dll) : ..............................................................................................................................................................................Vertigo : ...........................................................................................................................Ketidaknyamanan/ nyeri (akut/ kronik) : ...................................................................................................................................................................................................................Penatalaksanaan nyeri : .............................................................................................................................................................................................................................................Lain- lain : .......................................................................................................................7) Persepsi diri dan konsep diriPerasaan klien tentang masalah kesehatan ini : .........................................................................................................................................................................................................Lain- lain : .................................................................................................................................................................................................................................................................8) Pola peran hubunganPekerjaan : .......................................................................................................................Sistem pendukung : pasangan ( ), tetangga/ teman ( ), tidak ada ( ), keluarga serumah ( ), keluarga tinggal berjauhan ( )Masalah keluarga berkenaan dengan perawatan di RS : ...........................................................................................................................................................................................Kegiatan sosial : ........................................................................................................................................................................................................................................................Lain- lain : .......................................................................................................................

9) Pola seksual dan reproduksiTanggal menstruasi akhir (TMA) : ..................................................................................Masalah menstruasi : .......................................................................................................Pap Smear terakhir : ........................................................................................................Masalah seksual b.d penyakit : ........................................................................................Lain- lain : .......................................................................................................................

10) Pola koping dan toleransi stressPerhatian utama tentang perawatan di RS atau penyakit (finansial, perawatan diri) : ........................................................................................................................................................................................................................................................................................Kehilangan/ perubahan besar dimasa lalu : .....................................................................Hal yang dilakukan saat ada masalah (sumber koping) : ..........................................................................................................................................................................................Penggunaan obat untuk menghilangkan stress : ..............................................................Keadaan emosi dalam sehari- hari (santai/ tegang) : .......................................................Lain- lain : .......................................................................................................................

11) Keyakinan dan kepercayaanAgama : ...........................................................................................................................Pengaruh agama dalam kehidupan : ..........................................................................................................................................................................................................................4. Pemeriksaan Fisik :1) Keadaan umum :Penampilan umum : .........................................................................................................Klien tampak sehat/ sakit/ sakit berat : ............................................................................Kesadaran : ....................................... GCS ......................BB: ................... KgTB : ................... cm2) Tanda- tanda vital :TD: ..................... mmHgND: ..................... x/menitRR: ..................... x/menitS: ..................... oC3) KulitWarna kulit (sianosis, ikterus, pucat, eritema, dll) : ........................................................Kelembapan : ...................................................................................................................Turgor kulit : ....................................................................................................................Ada/tidaknya oedema : ....................................................................................................4) Kepala/ rambut Inspeksi : ................................................................................................................Palpasi : ................................................................................................................5) MataFungsi penglihatan: .............................................. Palpebra : terbuka / tertutupUkuran pupil: .............................................. Isokor / an isokorKonjungtiva: .............................................. Sklera : ......................................Lensa / iris: ....................................................................................................Oedema palpebra: ....................................................................................................6) TelingaFungsi pendengaran: ................................. Fungsi keseimbangan ..............................Kebersihan : ................................. Sekret .......................................................Daun telinga: ................................. Mastoid ....................................................7) Hidung dan sinusInspeksi : ....................................................................................................Fungsi penciuman : ....................................................................................................Pembengkakan : ...................................... perdarahan : ........................................Kebersihan : ...................................... sekret : ................................................8) Mulut dan tenggorokMembran mukosa : ............................................ kebersihan mulut ................................Keadaan gigi : .................................................................................................................Tanda radang (bibir, gusi, lidah) : ...................................................................................Trismus : ..........................................................................................................................Kesulitan menelan : .........................................................................................................9) Leher Trakea (simetris/ tidak) : .................................................................................................Karotid bruit : ..................................................................................................................JVP : ................................................................................................................................Kelenjar limfe : ...............................................................................................................Kelenjar tiroid : ...............................................................................................................Kaku kuduk : ...................................................................................................................10) Thorak / paruInspeksi : ...............................................................................................................Palpasi: ...............................................................................................................Perkusi: ...............................................................................................................Auskultasi: ...............................................................................................................11) JantungInspeksi : ...............................................................................................................Palpasi: ...............................................................................................................Perkusi: ...............................................................................................................Auskultasi: ...............................................................................................................12) Abdomen Inspeksi : ...............................................................................................................Auskultasi: ...............................................................................................................Perkusi: ...............................................................................................................Palpasi: ...............................................................................................................13) Genetalia : ...............................................................................................................14) Rektal : ...............................................................................................................15) Ekstremitas Ekstremitas atas : ............................................................................................................Ekstremitas bawah : ........................................................................................................ROM : .............................................................................................................................Kekuatan otot : ...............................................................................................................16) Vaskular perifer Capilary Refille: ...................................................................................................Clubbing: ...................................................................................................Perubahan warna (kuku, kulit, bibir) : 17) Neurologis Kesadaran (GCS) : ..Status mental : .....Motorik (kejang, tremor, parese dan paralisis) : .............................................................Sensorik : Tanda rangsang meningeal : ...Saraf kranial : .Reflek fisiologis : Reflek patologis :

5. Pemeriksaan Penunjang(dibuat setiap dilakukan pemeriksaan berdasarkan tanggal dilakukan)Pemeriksaan diagnostik.................................Pemeriksaan laboratorium .............................................

6. Penatalaksanaan Pengobatan...........................