Lampiran 1

FORMAT PENGKAJIAN
KEPERAWATAN MEDIKAL BEDAH (KMB)
1. BIODATA
A. IdentitasPasien
a. Nama
b. JenisKekamin
c. Umur
d. Status Perkawinan
e. Agama
f. pendidikan
g. Pekerjaan
h. Alamat
i. TglMasuk RS
j. Nomor Register
k. Ruangan/Kamar
l. GolonganDarah
m. TglPengkajian
n. TglOperasi
o. DiagnosaMedis
B. PenanggungJawab
a. Nama
b. Hub. dgnPasien
c. Pekerjaan
d. Alamat

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2. KELUHAN UTAMA
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3. RIWAYAT KESEHATAN SEKARANG
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4. RIWAYAT KESEHATAN MASA LALU
a. Penyakit yang pernahdialami
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b. Pengobatan/Tindakan yang dilakukan
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c. Pernahdirawat/operasi
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d. Lamanyadirawat
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e. Alergi
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f. Imunisasi
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5. RIWAYAT KESEHATAN KELUARGA
a. Orang tua
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b. SaudaraKandung
: ......................................................................
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c. Penyakitketurunan yang ada

: ......................................................................
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d. Anggotakeluarga yang meninggal : ......................................................................

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e. Penyebabmeninggal

: ......................................................................
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f. Genogram

Keterangan :

Laki - laki

Perempuan

Klien

Meninggal

Serumah

Cerai

6. RIWAYAT /KEADAAN PSIKOSOSIAL

a. Bahasa yang digunakan
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b. Persepsipasiententangpenyakitnya
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c. Konsepdiri
1) Body image
: .........................................................................................
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d.
e.
f.
g.
h.

2) Ideal diri
: .........................................................................................
3) Hargadiri
: .........................................................................................
4) Perandiri
: .........................................................................................
5) Personal identity : .........................................................................................
Keadaanemosi
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Perhatianterhadap orang lain/lawanbicara
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Hubungandengankeluarga
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Hubungandengansaudara
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Hubungandengan orang lain
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i. Kegemaran
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j. Dayaadaptasi
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k. Mekanismepertahanandiri
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7. PEMERIKSAAN FISIK
a. Keadaanumum
: .....................................................................................
b. Tanda-tanda vital
:
TB : .....................cm
BB : .....................kg
T : ................OC
P : .......x/\i
RR : ........x/i
TD : ..mmhg
c. Pemeriksaankepaladanleher
1) KepaladanRambut
Kepala
a) Bentuk
: ........................................................
b) Ubun-ubun
: ........................................................

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c) Kulitkepala
Rambut
a) Penyebarandankeadaanrambut
b) Bau
c) Warnakulit
Wajah
a) Warnakulit
b) Strukturwajah
2) Mata
a) Kelengkapandankesimetrisan
b) Palpebra
c) Kojungtivadanskelera
d) Pupil
e) Cornea dan iris
f) Visus
g) Tekanan bola mata

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3) Hidung
a) TulangHidungdanposisi septum nasi: ........................................................
b) Lubanghidung
: ........................................................
c) Cupinghidung
: ........................................................
4) Telinga
a) Bentuktelinga
b) Ukurantelinga
c) Lubangtelinga
d) Ketajamanpendengaran
5) Mulutdan faring
a) Keadaanbibir
b) Keadaangusidangigi
c) Keadaanlidah
d) Orofaring
6) Leher
a) Posisitrakea
b) Thyroid
c) Suara
d) Kelenjarlimfe
e) Vena jugularis
f) Denyutnadikarotis
d. Pemeriksaan integument

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1)
2)
3)
4)
5)
6)

Kebersihan
Kehangatan
Warna
Turgor
Kelembaban
Kelainanpadakulit

e. Pemeriksaanpayudaradanketiak
1) Ukurandanbentukpayudara
2) Warnapayudaradan areola
3) Kelainaanpayudaradanputing
4) Aksiladanclavicula
f. Pemeriksaanthoraks/dada
1) Inspeksithoraks
a) BentukThoraks :

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Normal, Burrel Chest, Funnel Chest,

Pigeon Chest, F lail Chest, K
ifosKoiasis

b) Pernafasan
Frekuensi
Irama
c) Tandakesulitanbernafas

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2) Pemeriksaanparu
a) Palpasigetaransuara
b) Perkusi
c) Auskultasi
- Suaranapas
- Suaraucapan
- Suaratambahan

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3) Pemeriksaanjantung
a) Inspeksi
b) Palpasi
- Pulsasi
c) Auskultasi
- bunyijantung
- bunyitambahan
- murmur
- frekuensi

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g. Pemeriksaan abdomen

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1) Inspeksi
a) Bentuk abdomen
b) Benjolan/massa
c) Tanda ascites
d) Hepar
e) Lien
f) TitikMc Burney
2) Perkusi
a) Suara abdomen
b) Pemeriksaan ascites

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h. Pemeriksaankelamindandaerahsekitarnya
1) Genitalia
a) Rambut pubis
: ........................................................
b) Lubang urethra
: ........................................................
c) Kelainanpada genitalia eksternadandaerah inguinal :..................................
2) Anus dan perineum
a) Lubang anus
: ........................................................
b) Kelainanpada anus
: ........................................................
c) Perineum
: ........................................................
i. Pemeriksaanmuskuloskletal/ekstremitas
1) Kesimetrisanotot
:
2) Pemeriksaan edema
:
3) Kekuatanotot
:
4) Kelainanpadaekstremitasdan kuku
:
j. Pemeriksaanneurologi
1) Pemeriksaantingkatkesadaran
GCS
: ,
2) Meningeal sign
:

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E : M : ..V : ..

3) Status mental
a) Kondisiemosi/perasaan
: ........................................................
b) Orientasi
: ........................................................
c) Proses berpikir (ingatan, atensi, keputusan, perhitungan) : ........................
d) Motivasi (kemauan)
: ........................................................
e) Persepsi
: ........................................................
f) Bahasa
: ........................................................
4) Nervuscranialis
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a)
b)
c)
d)
e)
f)
g)
h)

Nervous olfaktorius/ NI
: ........................................................
Nervous optikus/ NII
: ........................................................
Nervous okulomotoris/ NIII, Troklearis/ N IV, Abdusen/ N VI :................
Nervous trigeminus/ N V
: ........................................................
Nervusfasialis/ N VII
: ........................................................
Nervusglossophariengus/ N IX, Vagus / N X : ...........................................
NervusAsesorius / N XI
: ........................................................
Nervushipoglossus/ N XII
: ........................................................

5) FungsiMotorik
a) Cara berjalan
b) Romberg test
c) Tesjari-hidung
d) Pronasi-supinasi test
e) Heel to shin test

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6) FungsiSensori
a) Identifikasisentuhanringan
b) Test tajam-tumpul
c) Test panasdingin
d) Test getaran
e) Streognosis test
f) Graphetesia test
g) Membedakanduatitik
h) Topognosis test

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7) Reflek
a)
b)
c)
d)
e)
f)

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ReflekBisep
ReflekTrisep
ReflekBrachioradialis
ReflekPatelar
Reflek Tendon Achialis
Reflek Plantar

8. POLA KEBIASAAN SEHARI-HARI

a. Polatidurdankebiasaan
1) Waktutidur
2) Waktubangun
3) Masalahtidur
4) Hal-hal yang mempermudahtidur
5) Hal-hal yang mempermudahbangun

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b. PolaEliminasi
1) BAB
a) Pola BAB
: .........Penggunaanlaksatif : ya / tidak
b) Karakterfeses
: ....... .BAB Terakhir : ....
c) Riwayatperdarahan
: ................................Diare : ya / tidak
2) BAK
a) Pola BAK
: ...................Inkontinensia : ya / tidak
b) Karakter urine
: .............................Retensi : ya / tidak
c) Nyeri/rasa terbakar/kesulitan BAK
: Ya / Tidak
d) Riwayatpenyakitginjal/kandungkemih : Ya / Tidak
e) Penggunaandiuretika
: Ya / Tidak
f) Upayamengatasimasalah
: ...........................................................
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c. PolaMakan Dan Minum
1) Gejala (subyektif)
a) Diit (type)
: ................jmlhmakananperhari....
b) PolaDiit
: ......................................................................
c) Kehilanganseleramakan : .................mual / muntah :
d) Nyeriuluhati
: ......................................................................
e) Yang berhubungandengan: ......................................................................
f) Disembuhkandengan
: ......................................................................
g) Alergi/intoleransimakanan: ......................................................................
h) Beratbadanbiasa
: ......................................................................
2) Randa (obyektif)
Beratbadansekarang
: ..........kg, TinggiBadan : cm,
Bentuktubuh
: ......................................................................
3) Waktupemberianmakanan
: ......................................................................
4) Jumlahdanjenispemberian
: ......................................................................
5) Waktupemberiancairan
: ......................................................................
6) Masalahmakandanminum
a) Kesulitanmengunyah
: ......................................................................
b) Kesulitanmenelan
: ......................................................................
c) Tidakdapatmakansendiri :
7) Upayamengatasimasalah
: ......................................................................
d. Kebersihandiri/personal hygiene
a) Pemeliharaanbadan
: ......................................................................
b) Pemeliharaangigidanmulut : ......................................................................
c) Pemeliharaan kuku
: ......................................................................
e. Polakegiatan / aktivitas
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9. HASIL PEMERIKSAAN PENUNJANG / DIAGNOSTIK
a. Diagnosamedis
: ..................................................................................
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b. Pemeriksaan diagnostic/penunjangmedis :
1) Laboratorium :
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2) Rontgen :
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3) ECG :
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4) USG :
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5) Lain lain :
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10. PENATALAKSANAAN / TERAPI
No.

NamaObat

Dosis

Kegunaan

EfekSamping

11. ANALISA DATA

No
.

Data Fokus

Etiologi

12. PRIORITAS DIAGNOSA KEPERAWATAN

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MasalahKeperawata
n

No
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DiagnosaKeperawatan

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13. RENCANA ASUHAN KEPERAWATAN

No
.

Diagnosakeperawata
n

PerencanaanKeperawatan
TujuanKeperawatan

Intervensi

Rasional

14. CATATAN PERKEMBANGAN

No

Hari / Tanggal

DX

Implementasi

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Evaluasi

Paraf