Format Pengkajian Kmb

Lampiran 3 FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH Pengkajian tgl.

:

Jam

:

MRS tanggal

:

No. RM

:

Diagnosa Masuk : Ruangan/kelas

Hari Rawat Ke :

:

A. IDENTITAS PASIEN Nama

:

Penanggung jawab biaya

Usia

:

Nama

:

Jenis kelamin :

Alamat

:

Suku /Bangsa :

Hub. Keluarga

:

Agama

:

Telepon

:

Pendidikan

:

:

Status perkawinan Pekerjaan

:

Alamat

:

B. RIWAYAT PENYAKIT SEKARANG 1. Keluhan Utama : ....................................................................................................................... 2. 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

5.

- Kapan

: ...............................

- Jenis Operasi

: ...............................

Lain-lain :

................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. 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. Tanda-tanda vital Kesadaran S:

Compos mentis N:

Apatis TD :

Somnolen

Sopor

Koma

RR :

MASALAH KEPERAWATAN : ................................................................................................................................................. .................................................................................................................................................

2. Sistem Pencernaan

a. TB

: ............. cm

b. IMT

: .............

BB : ..............kg Interpretasi : ....................................

MASALAH KEPERAWATAN : .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... c. Mulut :

Bersih

d. Mukosa mulut :

Kotor

Lembab

Kering

e. Tenggorokan Nyeri telan Abdomen

stomatitis

Sulit menelan

Pembesaran Tonsil f.

Merah

Supel

Nyeri Tekan Tegang nyeri tekan, lokasi :

Luka operasi

Jejas

Pembesaran hepar

ya

tidak

Pembesaran lien

ya

tidak

Ascites

ya

tidak

Drain

Ada

Tidak

lokasi :

-

Jumlah

: ......................

-

Warna

: ......................

-

Kondisi area sekitar insersi : .....................................

Mual

ya

tidak

Muntah

ya

tidak

Terpasang NGT

ya

tidak

lunak

cair

Bising usus :..........x/mnt g. BAB :........x/hr, konsistensi : konstipasi h. Diet

padat

lendir/darah

inkontinensia

kolostomi

lunak

cair

Diet Khusus : ...................................................................................................................... Nafsu Makan

Baik

Menurun

Frekuensi :...............x/hari

jumlah:...............

jenis : .......................

Lain –lain : .......................................................................................................................... MASALAH KEPERAWATAN : .................................................................................................................................................... ....................................................................................................................................................

.................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... G. PENGKAJIAN PSIKOSOSIAL 1. Persepsi klien terhadap penyakitnya cobaan Tuhan

hukuman

lainnya

2. Ekspresi klien terhadap penyakitnya murung

gelisah

3. Reaksi saat interaksi

tegang

kooperatif

4. Gangguan konsep diri

ya

marah/menangis tak kooperatif

curiga

tidak

MASALAH KEPERAWATAN : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... 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 : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... MASALAH KEPERAWATAN : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... I.

PERSONAL HYGIEN

a.

Kebersihan diri : ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................

b. -

Kemampuan klien dalam pemenuhan kebutuhan : Mandi : Dibantu seluruhnya dibantu sebagian Ganti pakaian : Dibantu seluruhnya dibantu sebagian Keramas : Dibantu seluruhnya dibantu sebagian Sikat gigi : Dibantu seluruhnya dibantu sebagian Memotong kuku: Dibantu seluruhnya dibantu sebagian Berhias : Dibantu seluruhnya dibantu sebagian Makan : Dibantu seluruhnya dibantu sebagian

mandiri mandiri mandiri mandiri mandiri mandiri mandiri

MASALAH KEPERAWATAN : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... J. PEMERIKSAAN PENUNJANG (Laboratorium, radiologi, EKG, USG)

K. TERAPI

Meulaboh ,............................2018 Perawat

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