STIKES HAFSHAWATY PESANTREN ZAINUL HASAN PROBOLINGGO

FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa : …………………………………………………………………….

NIM : …………………………………………………………………….
Tempat Pengkajian : …………………………………………………………………….

PENGKAJIAN KEPERAWATAN

I. Identitas Klien
Nama : ……………………………………. No. RM : …………………………………..
Tanggal lahir : ……………………………………. Pekerjaan : …………………………………..
Jenis Kelamin : ……………………………………. Status Perkawinan : …………………………………..
Agama : ……………………………………. Tanggal MRS :………………… Jam : ……….
Pendidikan : ……………………………………. Tanggal Pengkajian :………………… Jam : ……….
Alamat : ……………………………………. Sumber Informasi : …………………………………..
……………………………………. …………………………………..

II. Riwayat Kesehatan

1. Diagnosa Medik: ……………..………………………………………………………………………….………....
……………………….……

2. Keluhan Utama: ……………..………………………………………………………………………….………....

……………………….…………………..………………………………………………………………………….………....
……………………….……

3. Riwayat penyakit sekarang: ……………..

………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
……………..………………………………………………………………………….………....……………………….……

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 1

 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:
Keterangan :
: Laki-laki
: Perempuan
: Menikah
// : Cerai
: Anak kandung
: Anak angkat

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 2

 : Anak kembar
: Pasien
: Meninggal
: Tinggal serumah

III. Pengkajian Keperawatan

1. Persepsi kesehatan & pemeliharaan kesehatan
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
Interpretasi : ……………..………………………………………………………………………….………....
……………………….…………………..………………………………………………………………………….………....
……………………….……
2. Pola nutrisi/ metabolik (ABCD) (saat sebelum sakit dan saat di rumah sakit)
Antropometry……………..………………………………………………………………………….………....
……………………….…………………..………………………………………………………………………….………....
……………………….…………………..………………………………………………………………………….………....
……………………….……
Interpretasi : ……………..………………………………………………………………………….………....
……………………….…………………..………………………………………………………………………….………....
……………………….……
Biomedical sign :
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
Interpretasi :
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
Clinical Sign :
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
Interpretasi :

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 3

 ……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
Diet Pattern (intake makanan dan cairan):
Pola makan Sebelum sakit Saat di rumah sakit

……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
Interpretasi :
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……

3. Pola eliminasi: (saat sebelum sakit dan saat di rumah sakit)

BAK Sebelum sakit Saat di rumah sakit
Frekuensi
Jumlah
Warna
Bau
Karakter
BJ
Alat bantu
Kemandirian
(mandiri/dibantu)
Lainnya
Interpretasi:
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……

BAB Sebelum sakit Saat di rumah sakit

Frekuensi
Jumlah
Warna
Bau
Karakter
Alat bantu
Kemandirian
(mandiri/dibantu)
Lainnya

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 4

 Interpretasi:
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
Balance cairan:
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Interpretasi:
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
4. Pola aktivitas & latihan (saat sebelum sakit dan saat di rumah sakit)
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Aktivitas harian (Activity Daily Living)
Kemampuan perawatan diri 0 1 2 3 4
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 SkorADL : ……………………………………………………………………………………………………….
Status Oksigenasi : ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……
Fungsi kardiovaskuler : ……………..………………………………………………………………………….
………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Terapi oksigen : ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……
Interpretasi :
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……

5. Pola tidur & istirahat (saat sebelum sakit dan saat di rumah sakit)
Istirahat dan Tidur Sebelum sakit Saat di rumah sakit
Durasi
Gangguan tidur

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 5

 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 : ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Ideal diri :
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Harga diri : ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Peran Diri : ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Identitas Diri : ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 6

 Interpretasi :
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……

8. Pola seksualitas & reproduksi

Pola seksualitas ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……
Fungsi reproduksi ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Interpretasi :
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……

9. Pola peran & hubungan

……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Interpretasi : ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……

10. Pola manajemen koping-stress

……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Interpretasi : ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……

11. Sistem nilai & keyakinan

……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Interpretasi : ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……

IV. Pemeriksaan Fisik

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 7

 Keadaan umum:
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Tanda vital:
- Tekanan Darah : mm/Hg
- Nadi : X/mnt
- RR : X/mnt
- Suhu : C

Interpretasi :
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Pengkajian Fisik Head to toe (Inspeksi, Palpasi, Perkusi, Auskultasi)
1. Kepala
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
2. Mata
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
3. Telinga
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
4. Hidung
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
5. Mulut ……………..………………………………………………………………………….………....
……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
6. Leher
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
7. Dada
Jantung
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 8

 ……………..………………………………………………………………………….………....……………………….……
Paru
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Payudara dan Ketiak
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Posterior
……………..………………………………………………………………………….………....……………………….
…………………..………………………………………………………………………….………....……………………….
……
8. Abdomen
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
9. Genetalia dan Anus
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
10. Ekstremitas
Ekstremitas atas
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Ekstremitas bawah
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
11. Kulit dan kuku
Kulit
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
Kuku
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 9

 ……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
12. Keadaan lokal
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 10

V. Terapi

Farmako dinamik Indikasi dan Implikasi

NO Jenis Terapi Dosis Rute Efek samping
dan farmako kinetik Kontra Indikasi keperawatan

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 11

VI. Pemeriksaan Penunjang & Laboratorium
Nilai normal Hasil(Tanggal/Jam)
N
Jenis pemeriksaan Satua
o Nilai
n

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 12

Pemeriksaan Radiologi
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……

Pemeriksaan Penunjang Lainnya

……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……
……………..………………………………………………………………………….………....……………………….……

……………,….................................
Pengambil Data,

(_________________________________________)
NIM.

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 13

 ANALISIS DATA

Tanggal/Jam :
N Paraf &
DATA PENUNJANG ETIOLOGI MASALAH
O Nama

DIAGNOSA KEPERAWATAN

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 14

 Tanggal Tanggal
No Diagnosis Keperawatan Keterangan
perumusan pencapaian

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 15

 PERENCANAAN KEPERAWATAN
Tanggal/Jam :
N DIAGNOSIS PARAF &
TUJUAN DAN KRITERIA HASIL INTERVENSI
O KEPERAWATAN NAMA

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 16

 CATATAN PERKEMBANGAN
Diagnosa :
Tanggal Jam IMPLEMENTASI Paraf EVALUASI Paraf

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 17

STIKES Hafshawaty Pesantren Zaiunl Hasan Problinggo / 2020 18