FORM KEP MEDIKAL BEDAH

DEPARTEMEN KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI NERS KEPERAWATAN
FAKULTAS ILMU KESEHATAN UNIVERSITAS MUHAMMADIYAH JEMBER

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Tgl / jam MRS : ………………………………. Ruang : ………………….…

Tgl. Pengkajian :……………………………….. No. Register : ………………….…
Diagnosa Medis : …………………………………………………………………………..

A. IDENTITAS KLIEN
Nama : ………………………………... Suami / Istri / Orang tua :
Umur : ………………………………... Nama :.…………………..
Jenis Kelamin : ………………………………… Pekerjaan :…………………..
Agama : ………………………………… Alamat :…………………...
Suku / Bangsa : …………………………………
Bahasa :………………………. ……….. Penanggung jawab :
Pendidikan : …………………………… Nama :…………………..
Pekerjaan : ………………………………… Alamat :…………………..
Status : …………………………………
Alamat : …………………………………

B. KELUHAN UTAMA
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C. RIWAYAT PENYAKIT SEKARANG

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Upaya yang telah dilakukan :…………………………………………………………….................
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Terapi yang telah diberikan :…………………………………………………………….................
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D. RIWAYAT KESEHATAN DAHULU
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E. RIWAYAT KESEHATAN KELUARGA
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Dok Prodi Ners Kep 1

FIKes UNMUH Jember
FORM KEP MEDIKAL BEDAH

Genogram :

F. Keadaan Lingkungan Yang Mempengaruhi Timbulnya Penyakit

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G. POLA FUNGSI KESEHATAN

1. Pola persepsi dan tata laksana kesehatan
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2. Pola nutrisi dan metabolisme
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3. Pola eliminasi
BAK………………………………………………………………………………..
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BAB…………………………………………………………………………………
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4. Pola aktifitas
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5. Pola istirahat – tidur
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6. Pola kognitif dan persepsi sensori
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Dok Prodi Ners Kep 2
FIKes UNMUH Jember
FORM KEP MEDIKAL BEDAH

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7. Pola konsep diri
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8. Pola hubungan – peran
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9. Pola fungsi seksual – seksualitas
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10. Pola mekanisme koping
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11. Pola nilai dan kepercayaan
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H. STATUS MENTAL ( PSIKOLOGIS)

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I. PEMERIKSAAN FISIK
1. Status kesehatan umum
Keadaan / penampilan umum :
Kesadaran :…………………………. GCS :
BB sebelum sakit :…………………………. T B : ..…………………….
BB saat ini :…………………………. BB ideal:………………………
Tanda– tanda Vital :
TD : ……………………… mmHg Suhu :……………….. C
N : ……………………… x/mnt RR : ……………... x/mnt
2. Kepala
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Dok Prodi Ners Kep 3

FIKes UNMUH Jember
FORM KEP MEDIKAL BEDAH

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3. Leher
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4. Thorax (dada)
Pemeriksaan Paru
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Pemeriksaan Jantung
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5. Abdomen
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6. Tulang belakang
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7. Ekstrimitas
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8. Integumen
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9. Genetalia dan anus

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10. Pemeriksaan neurologis
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Dok Prodi Ners Kep 4
FIKes UNMUH Jember
FORM KEP MEDIKAL BEDAH

J. PEMERIKSAAN DIAGNOSTIK
Tgl Jenis Pemeriksaan Hasil

K. TERAPI
Nama Obat Rute Dosis Efek Samping Nama Obat Rute Dosis Efek Samping
1 6
2 7
3 8
4 9
5 10

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Mahasiswa,

NIM : …………………….

Dok Prodi Ners Kep 5

FIKes UNMUH Jember