FAKULTAS KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL

Nama Mahasiswa :
NIM :
Tempat Pengkajian :
Tanggal :

I. Identitas Klien
Nama : Ny Mujiati No. RM : 11408844
Umur : 55 Pekerjaan :-
Jenis kelamin : Perempuan Status perkawinan : Kawin
Agama : Islam Tanggal MRS : 3-10-2018
Pendidikan : SMP Tanggal : 10-10-2018
pengkajian
Alamat :Ds Karangturi Kec Sumber informasi : Rekam Medik
Munjungan Kab dan Keluarga
Trenggalek Pasien

II. Riwayat Kesehatan

1. Diagnosa medik:
Suspect Cancer Pankreas

2. Keluhan utama:
Nyeri perut kanan atas

3. Riwayat penyakit sekarang:

Nyeri perut di kanan atas dengan Hepatomegali

4. Riwayat kesehatan terdahulu:

a. Penyakit yang pernah dialami:
Nyeri perut sejak 5 bulan yang lalu
b. Alergi (obat, makanan, plester, dll):
-
c. Imunisasi:

Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

 -
d. Kebiasaan/pola hidup/life style:
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e. Obat-obat yang digunakan:
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5. Riwayat penyakit keluarga:

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6. Genogram:
Keterangan :

: Laki-laki
: Perempuan
: Menikah
// : Cerai
: Anak kandung
: Anak angkat
: Anak kembar
: Pasien
: Meninggal
: Tinggal
serumah

III. Pengkajian Keperawatan

1. Persepsi & pemeliharaan kesehatan

Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

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Interpretasi:
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2. Pola nutrisi/ metabolik (ABCD) (saat sebelum dan saat di rumah sakit)
- Antropometri:
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Interpretasi:
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- Biomedical Sign:
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Interpretasi:
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- Clinical Sign:
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Interpretasi:
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- Diet Pattern:
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Interpretasi:
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3. Pola eliminasi: (saat sebelum sakit dan saat di rumah sakit)

Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

 BAK
- Frekuensi : ....................................................................................................
- Jumlah : ....................................................................................................
- Warna : ....................................................................................................
- Bau : ....................................................................................................
- Karakter : ....................................................................................................
- BJ : ....................................................................................................
- Alat Bantu : ....................................................................................................
- Kemandirian : mandiri/dibantu
- Lain : ....................................................................................................
BAB
- Frekuensi : ....................................................................................................
- Jumlah : ....................................................................................................
- Warna : ....................................................................................................
- Bau : ....................................................................................................
- Karakter : ....................................................................................................
- BJ : ....................................................................................................
- Alat Bantu : ....................................................................................................
- Kemandirian : mandiri/dibantu
- Lain : ....................................................................................................

Interpretasi:
Balance cairan:
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4. Pola aktivitas & latihan (saat sebelum sakit dan saat di rumah sakit)
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c.1. Aktivitas harian (Activity Daily Living)

Kemampuan perawatan diri 0 1 2 3 4
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur

Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

 Berpindah
Ambulasi / ROM
Ket: 0: tergantung total, 1: bantuan petugas dan alat, 2: bantuan petugas,
3: bantuan alat, 4: mandiri
Status Oksigenasi:
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Fungsi kardiovaskuler:
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Terapi oksigen:
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Interpretasi:
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5. Pola tidur & istirahat (saat sebelum sakit dan saat di rumah sakit)
Durasi : ....................................................................................................
Gangguan tidur : ....................................................................................................
Keadaan bangun tidur : ....................................................................................................
Lain-lain : ....................................................................................................

Interpretasi:
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6. Pola kognitif & perceptual

Fungsi Kognitif dan Memori:
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Fungsi dan keadaan indera:
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Interpretasi:
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Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

7. Pola persepsi diri
Gambaran diri:
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Identitas diri:
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Harga diri:
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Ideal diri:
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Peran diri:
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Interpretasi:
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8. Pola seksualitas & reproduksi

Pola seksualitas:
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Fungsi reproduksi:
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Interpretasi:
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9. Pola peran & hubungan

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Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

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Interpretasi:
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10. Pola manajemen koping-stress:

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Interpretasi:
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11. System nilai & keyakinan:

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Interpretasi:
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IV. Pemeriksaan Fisik

Keadaan umum:
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Tanda vital:
- Tekanan Darah : mm/Hg
- Nadi : X/mnt
- RR : X/mnt

Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

 - Suhu : C

Interpretasi:
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Pengkajian Fisik Head to toe (Inspeksi, Palpasi, Perkusi, Auskultasi)

1. Kepala
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2. Mata:
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3. Telinga:
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4. Hidung:
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5. Mulut:
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6. Leher:
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Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

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7. Dada:
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8. Abdomen:
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9. Urogenital:
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10. Ekstremitas:
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11. Kulit dan kuku:
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12. Keadaan lokal:
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Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

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V. Terapi
No Jenis Farmako Dosis dan Indikasi Efek Implikasi
Terapi dinamik Rute dan samping Keperawatan
dan Pemberian Kontra
Farmako Indikasi
kinetik
1.
2.
3.
4.
5.
dst

VI. Pemeriksaan Penunjang & Laboratorium

No Jenis Nilai normal Hasil
Pemeriksaan (rujukan) (hari/tanggal)
Nilai Satuan
1.
2.
3.
4.
5.
6.
7.
8.
dst

……………, ….......................... 20….

Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

 Pengambil Data

( _____________________ )
NIM.

ANALISA DATA
NO DATA PENUNJANG ETIOLOGI MASALAH

Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

 DIAGNOSA KEPERAWATAN

Daftar Diagnosa Keperawatan Sesuai Prioritas

TANGGAL TANGGAL
NO DIAGNOSA KETERANGAN
PERUMUSAN PENCAPAIAN

Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018
 PERENCANAAN KEPERAWATAN

NO DIAGNOSA TUJUAN DAN KRITERIA HASIL INTERVENSI RASIONAL

CATATAN PERKEMBANGAN

DIAGNOSA:

Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018

 WAKTU IMPLEMENTASI PARAF EVALUASI
JAM:

Panduan Profesi Ners Keperawatan Medikal Fkep UNEJ 2018