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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 = > :....................................................................................

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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

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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#

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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

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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

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