format pengkajian bedah a4
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7/26/2019 Format Pengkajian Bedah a4
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Kurikulum PelatihanJabatan Fungsional Perawat Ahli
FORMAT PENGKAJIAN KEPERAWATAN BEDAH
Ruangan :.....................................................NO Reg :.....................................................
PENGKAJIAN DIAMBIL :
TANGGAL :..................................JAM ...................................
I. IDENTITAS
1. Nama : .................................................................
2. Umur : .................................................................
3. Jenis Keamin : .................................................................
!. "u#u $%angsa : .................................................................
&. Agama : .................................................................'. Pe#er(aan : .................................................................
). Pen*i*i#an : .................................................................
+. Aama, : .................................................................
-. Aasan *iraa, : .................................................................
1/. Keu0an U,ama :..................................................................
11. Riaa, Keu0an U,ama :..................................................................
12. Uaa ang Tea0 *ia#u#an :..................................................................
13. Terai erasi ang ,ea0 *ia#u#an :..................................................................
II. RIWAYAT PERAWATAN.( NURSING HISTORY ).
1. Riaa, ena#i, se%eumna : .................................................................2. Riaa, ena#i, se#arang : .................................................................
3. Riaa, #ese0a,an #euarga : .................................................................
!. Kea*aan #ese0a,an ing#ungan : .................................................................
&. Riaa, #ese0a,an ainna : .................................................................
III. OBSERVASI DAN PEMERIKSAAN FISIK
1. Kea*aan Umum : ...............................................................................................
2. Tan*a ,an*a 4i,a
"u0u :..................567 Na*i :......................8$mn,7 Tensi :............................mm9g
A8ia Tera,ur Lengan #iri
Re6,a Ti*a# ,era,ur Lengan #anan
Ora Kua, Ber%aring
Du*u#
RR :.............................8$mn, 9R .......................8$mn,
Nrma Tera,ur
;ansis Ti*a# ,era,ur.
;0enes,#e
Kusmau
Lainna < se%u,#an = > :....................................................................................
Pusdiklat Aparatur Kesehatan - Kemenkes RI-2011
Hal : 1
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7/26/2019 Format Pengkajian Bedah a4
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Kurikulum PelatihanJabatan Fungsional Perawat Ahli
3. B* "s,em
PERNAPA"AN < B1 : BREAT9ING >.
9i*ung :......................................................................................
Tra60ea :......................................................................................
Neri Dsnea Or,0nea
;ansis Ba,u# Dara0 Naas Dang#a
"u,um Re,ra#si *a*a
Tra60es,m Resira,r
"uara Tam%a0an :
?0e@ing L#asi................................................................................
Rn60i L#asi................................................................................
Raes L#asi................................................................................
;ra6#es L#asi................................................................................
Ben,u# Da*a :
"ime,ris :...........................................................................
Ti*a# "ime,ris :...........................................................................
Lainna < se%u,#an >...................................................................................
;ARDIOA";ULAR < B2 : BLEEDING >
Neri Da*a Pusing Keaa
Kram #a#i Pai,asi
"a#i, #eaa ;u%%ing inger.
"uara Jan,ung :
Nrma
A*a #eainan < se%u,#an >..................................................................
E*ema :
Pae%rae E#s,remi,as a,as As6i,es
Anasar6a E#s,remi,as %aa0 Ti*a# a*a
Lainna < se%u,#an > ..............................................................................
PER"CARAAN < B3 : BRAIN >
;ms men,is Aa,is
"r "mnens
Kma Geisa0
G;" < Gas6 ;ma "6ae >:
Resn Ees..................Resn er%a................M,ri#......................
T,a niai :........................................................................
Keaa *an ?a(a0 :........................................................................
Ma,a
"#era : Pu,i0 Mera0
Per*ara0an I6,erus
;n(ung,i4a : Pu6a, Mera0 Mu*a
Is6r Anis6r Misis Me*riasis
Pusdiklat Aparatur Kesehatan - Kemenkes RI-2011
Hal : 2
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Kurikulum PelatihanJabatan Fungsional Perawat Ahli
Le0er :.....................................................................................
Ree#s :.....................................................................................
Lainna se%u,#an :.....................................................................................
PERKEMI9AN ELIMINA"I URIN < B! : BLADDER >
Pr*u#si Urine :..............................m:................................8$0ari
?arna :.............................Bau :.......................................
Ti*a# a*a masaa0 Mene,es In6n,inensia
Oiguri Neri Re,ensi urine
Piuria Panas 9ema,uria
Disuria "ering N6,uria
Diasang 6a,0e,er ;s,s,m
Lainna se%u,#an :......................................................................................
PEN;ERNAAN ELIMINA"I ALI < B& : BO?EL >
Muu, *an Tenggr#an :........................................................................A%*men :........................................................................
Re6,um :........................................................................
BAB :.....................8$0ari Knsis,ensi:..............................................
Ti*a# a*a masaa0 Diare ;ns,iasi
ae6es %er*ara0 Ti*a# ,erasa Kesui,an
Meena ;s,m ?asir
O%a, Pen6a0ar Ca Ti*a#
La4emen, Ca Ti*a#
Lainna se%u,#an :.......................................................................................
TULANGF OTOTF INTEGUMEN < B' : BONE >.
Kemamuan ergera#an sen*i :
Parese : Ca Ti*a#
Paraisis : Ca Ti*a#
9emiarese : Ca Ti*a#
Lainna se%u,#an :......................................................................................
E#s,remi,as :
A,as : Ti*a# a*a #eainan Pera*angan
Pa,a0 Tuang Peru#aan
L#asi ................................................................................. Baa0 : Ti*a# a*a #eainan Pera*angan
Pa,a0 Tuang Peru#aan
L#asi .................................................................................
Tuang Bea#ang :........................................................................
Kui,
?arna Kui, A6ra :
I#,eri# 9anga,
;an,i# Panas
Pu6a, Dingin Kering
Kemera0an Dingin %asa0
Pigmen,asi Turgr : Eas,is Jee#
Pusdiklat Aparatur Kesehatan - Kemenkes RI-2011
Hal : 3
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Kurikulum PelatihanJabatan Fungsional Perawat Ahli
IV. POLA FUNGSI KESEHATAN
!.1 Persesi ,er0a*a #ese0a,an ena#i, :................................................................
!.2 Nu,risi Fme,a%isme
TB .................6m BB se%eum sa#i,.........................................
BB saa, sa#i,................................................
Die, K0usus :
Ti*a# a*a
Ca ;air Ren*a0 garam
Luna# "aring
Dia%e,.................#ari
Ren*a0 ema#
TKTP Ren*a0 urin
Lainna se%u,#an :.....................................................................
Pan,angan se%u,#an...........................................................................................Ke%iasaan ma#an
re#ensi :..........................................8$0ari
Mema#ai sen*# Ca Ti*a# Ka*ang #a*ang
Ja(an *iuar Ca Ti*a# Ka*ang #a*ang
Jenis ma#anan *i ruma0 :..................................................................................
Nasu ma#an :...........................................................................................
Minum :...........................................................................................
Juma0 :......................................................................66$2! (am.
Jenis :............................................................................................
Ke%iasaan :............................................................................................Keu0an masaa0
Mua Mun,a0 Rasa 0aus
"a#i, muu, Kesu#aran menean Masaa0 6erna
Lainna se%u,#an :.............................................................................................
!.3. Pa ,i*ur *an Is,ira0a, :..................................................................................
!.!. Kgni,iFerse,ua :..................................................................................
!.&. Persesi #nse *iri :
B* Image :......................................................................................
I*en,i,as *iri :......................................................................................
I*ea *iri :......................................................................................
9arga *iri :......................................................................................
Peran :......................................................................................
E#sresi Ae# *an Emsi :
"enang "e*i0 Mara0
Ta#u, Mu*a0 ,ersinggung Geisa0
Lainna se%u,#an :.............................................................................................
!.'. Peran F %er0u%ungan
Ber#muni#asi :
Ba0asa "e0ari 0ari :...........................................................................................
Ber%i6ara :
Nrma Gaga Parau Ti*a# *aa, menamai#an Dengan isara, Aasia
Pusdiklat Aparatur Kesehatan - Kemenkes RI-2011
Hal : 4
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Kurikulum PelatihanJabatan Fungsional Perawat Ahli
9u%ungan *engan #euarga :............................................................................
9u%ungan *engan e,ugas $,enaga #ese0a,an :................................................
!.). A#,ii,as *an #e%ersi0an *iri :...........................................................................
!.+. KingF ,eransi s,ress < me#anisme em%eaan eg > :..................................!.-. Niai a #ea#inan
Men(aan#an I%a*a0 :............................................................................
Persesi ,en,ang #ema,ian :............................................................................
Lainna se%u,#an :............................................................................
V. KEBIASAAN WAKTU LUANG.
VI. DATA PENUNJANG.
Tan*a Tangan Nurse
Nama Terang
Pusdiklat Aparatur Kesehatan - Kemenkes RI-2011
Hal : 5
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