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STIKes Eka Harap Palangka Raya

YAYASAN EKA HARAP PALANGKA RAYASEKOLAH TINGGI ILMU KESEHATANPROGRAM STUDI S1 KEPERAWATAN

Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536) 3327707

FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa : ……………………………………………………….NIM : ……………………………………………………….Ruang Praktek : ……………………………………………………….Tanggal Praktek : ……………………………………………………….Tanggal & Jam Pengkajian : ……………………………………………………….

I. PENGKAJIANA. IDENTITAS PASIEN

Nama : ……………………………………………………………..Umur : ……………………………………………………………..Jenis Kelamin : ……………………………………………………………..Suku/Bangsa : ……………………………………………………………..Agama : ……………………………………………………………..Pekerjaan : ……………………………………………………………..Pendidikan : ……………………………………………………………..Status Perkawinan : ……………………………………………………………..Alamat : ……………………………………………………………..Tgl MRS : ……………………………………………………………..Diagnosa Medis : ……………………………………………………………..

B. RIWAYAT KESEHATAN /PERAWATAN1. Keluhan Utama :

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2. Riwayat Penyakit Sekarang:...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …......................................................................................................................................................................……............................................................................................................................................................... …...................................................................................................................................................................... …......................................................................................................................................................................……............................................................................................................................................................... …...................................................................................................................................................................... …......................................................................................................................................................................……............................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …......................................................................................................................................................................……............................................................................................................................................................... …

3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi)

Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013

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4. Riwayat Penyakit Keluarga...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …......................................................................................................................................................................

GENOGRAM KELUARGA:

C. PEMERIKASAAN FISIK1. Keadaan Umum:

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2. Status Mental :a. Tingkat Kesadaran : ………………….b. Ekspresi wajah : ………………….c. Bentuk badan : ………………….d. Cara berbaring/bergerak : ………………….e. Berbicara : ………………….f. Suasana hati : ………………….g. Penampilan : ………………….h. Fungsi kognitif :

Orientasi waktu : …………………. Orientasi Orang : …………………. Orientasi Tempat : ………………….

i. Halusinasi : Dengar/Akustic Lihat/Visual Lainnya ...........................................................j. Proses berpikir : Blocking Circumstansial Flight oh ideas Lainnya


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k. Insight : Baik Mengingkari Menyalahkan orang lainm. Mekanisme pertahanan diri : Adaptif Maladaptifn. Keluhan lainnya : ………………….

3. Tanda-tanda Vital :a. Suhu/T : ……………….0C Axilla Rektal Oralb. Nadi/HR : ………………x/mtc. Pernapasan/RR : …..…………..x/tmd. Tekanan Darah/BP : ……...………..mm Hg

4. PERNAPASAN (BREATHING)Bentuk Dada : .................................................................................................Kebiasaan merokok : …………………………………...Batang/hari Batuk, sejak .............................................................................……………………………………… Batuk darah, sejak .................................................................……………………………………… Sputum, warna .......................................................................……………………………………… Sianosis Nyeri dada Dyspnoe nyeri dada Orthopnoe Lainnya …….……….. Sesak nafas saat inspirasi Saat aktivitas Saat istirahatType Pernafasan Dada Perut Dada dan perut

Kusmaul Cheyne-stokes Biot Lainnya

Irama Pernafasan Teratur Tidak teraturSuara Nafas Vesukuler Bronchovesikuler

Bronchial TrakealSuara Nafas tambahan Wheezing Ronchi kering

Ronchi basah (rales) Lainnya……………Keluhan lainnya : ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

5. CARDIOVASCULER (BLEEDING) Nyeri dada Kram kaki Pucat Pusing/sinkop Clubing finger Sianosis Sakit Kepala Palpitasi Pingsan Capillary refill > 2 detik < 2 detik Oedema : Wajah Ekstrimitas atas

Anasarka Ekstrimitas bawah Asites, lingkar perut ……………………. cm Ictus Cordis Terlihat Tidak melihatVena jugularis Tidak meningkat MeningkatSuara jantung Normal,………………….

Ada kelainan

Keluhan lainnya : ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :......................................................................................................................................................................


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6. PERSYARAFAN (BRAIN)Nilai GCS : E : …………………. V : ………………….

M : ………………….Total Nilai GCS : ……………………Kesadaran : Compos Menthis Somnolent Delirium

Apatis Soporus ComaPupil : Isokor Anisokor

Midriasis Meiosis Refleks Cahaya : Kanan Positif Negatif

Kiri Positif Negatif Nyeri, lokasi ……………………………….. Vertigo Gelisah Aphasia Kesemutan Bingung Disarthria Kejang Trernor PeloUji Syaraf Kranial :Nervus Kranial I : .....................................................................................................................Nervus Kranial II : .....................................................................................................................Nervus Kranial III : .....................................................................................................................Nervus Kranial IV : .....................................................................................................................Nervus Kranial V : .....................................................................................................................Nervus Kranial VI : .....................................................................................................................Nervus Kranial VII : .....................................................................................................................Nervus Kranial VIII : .....................................................................................................................Nervus Kranial IX : .....................................................................................................................Nervus Kranial X : .....................................................................................................................Nervus Kranial XI : .....................................................................................................................Nervus Kranial XII : .....................................................................................................................Uji Koordinasi :Ekstrimitas Atas : Jari ke jari Positif Negatif

Jari ke hidung Positif NegatifEkstrimitas Bawah : Tumit ke jempul kaki Positif NegatifUji Kestabilan Tubuh : Positif NegatifRefleks :Bisep : Kanan +/- Kiri +/- Skala…………. Trisep

: Kanan +/- Kiri +/- Skala…………. Brakioradialis : Kanan +/- Kiri +/- Skala…………. Patella

: Kanan +/- Kiri +/- Skala…………. Akhiles: Kanan +/- Kiri +/- Skala…………. Refleks

Babinski Kanan +/- Kiri +/- Refleks lainnya : .....................................................................................................................Uji sensasi : .....................................................................................................................

.....................................................................................................................Keluhan lainnya : ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

7. ELIMINASI URI (BLADDER) :Produksi Urine : ………….ml…………x/hrWarna : Bau : Tidak ada masalah/lancer Menetes Inkotinen Oliguri Nyeri Retensi Poliuri Panas Hematuri Dysuri Nocturi


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Kateter Cystostomi

Keluhan Lainnya : ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

8. ELIMINASI ALVI (BOWEL) :Mulut dan FaringBibir : ..................................................................................................................................Gigi : ..................................................................................................................................Gusi : ..................................................................................................................................Lidah : ..................................................................................................................................Mukosa : ..................................................................................................................................Tonsil : ..................................................................................................................................Rectum :Haemoroid :BAB : ……….x/hr Warna :..……… . Konsistensi : ……………. Tidak ada masalah Diare Konstipasi Kembung Feaces berdarah Melena Obat pencahar LavementBising usus : ......................................................................................................................Nyeri tekan, lokasi : ......................................................................................................................Benjolan, lokasi : ......................................................................................................................Keluhan lainnya : ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9. TULANG - OTOT – INTEGUMEN (BONE) : Kemampuan pergerakan sendi Bebas Terbatas Parese, lokasi Paralise, lokasi Hemiparese, lokasi Krepitasi, lokasi Nyeri, lokasi Bengkak, lokasi Kekakuan, lokasi Flasiditas, lokasi Spastisitas, lokasi Ukuran otot Simetris

Atropi Hipertropi Kontraktur Malposisi

Uji kekuatan otot : Ekstrimitas atas……….. Ekstrimitas bawah…….. Deformitas tulang, lokasi............................................................................................................................ Peradangan, lokasi Perlukaan, lokasi Patah tulang, lokasiTulang belakang Normal Skoliosis

Kifosis Lordosis

10. KULIT-KULIT RAMBUTRiwayat alergi Obat......................................................................................................


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Makanan............................................................................................... Kosametik............................................................................................. Lainnya.................................................................................................

Suhu kulit Hangat Panas DinginWarna kulit Normal Sianosis/ biru Ikterik/kuning

Putih/ pucat Coklat tua/hyperpigmentasiTurgor Baik Cukup KurangTekstur Halus KasarLesi : Macula, lokasi

Pustula, lokasi....................................................................................... Nodula, lokasi....................................................................................... Vesikula, lokasi..................................................................................... Papula, lokasi........................................................................................ Ulcus, lokasi..........................................................................................

Jaringan parut lokasiTekstur rambut ..................................................................................................................................Distribusi rambutBentuk kuku Simetris Irreguler

Clubbing Finger LainnyaMasalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

11. SISTEM PENGINDERAAN :a. Mata/Penglihatan

Fungsi penglihatan : Berkurang Kabur Ganda Buta/gelap

Gerakan bola mata : Bergerak normal Diam Bergerak spontan/nistagmus

Visus : Mata Kanan (VOD) :...........................................................................................Mata kiri (VOS) :............................................................................................

Selera Normal/putih Kuning/ikterus Merah/hifema Konjunctiva Merah muda Pucat/anemic

Kornea Bening KeruhAlat bantu Kacamata Lensa kontak Lainnya…….Nyeri : Keluhan lain :

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b. Telinga / Pendengaran :Fungsi pendengaran : Berkurang Berdengung Tuli

c. Hidung / Penciuman:Bentuk : Simetris Asimetris Lesi Patensi Obstruksi Nyeri tekan sinus TransluminasiCavum Nasal Warna………………….. Integritas……………..Septum nasal Deviasi Perforasi Peradarahan Sekresi, warna ……………………… Polip Kanan Kiri Kanan dan Kiri

Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

12. LEHER DAN KELENJAR LIMFE


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Massa Ya TidakJaringan Parut Ya TidakKelenjar Limfe Teraba Tidak terabaKelenjar Tyroid Teraba Tidak terabaMobilitas leher Bebas Terbatas

13. SISTEM REPRODUKSIa. Reproduksi Pria

Kemerahan, LokasiGatal-gatal, LokasiGland Penis .....................................................................................Maetus Uretra .................................................................................Discharge, warnaSrotum .........................................................................................Hernia .........................................................................................Kelainan ……………………………………………Keluhan lain ………………………………………….

a. Reproduksi WanitaKemerahan, LokasiGatal-gatal, LokasiPerdarahan .....................................................................................Flour Albus .................................................................................Clitoris .............................................................................................Labis .........................................................................................Uretra .........................................................................................Kebersihan : Baik Cukup KurangKehamilan : ……………………………………Tafsiran partus : ……………………………………Keluhan lain.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Payudara : Simetris Asimetris Sear Lesi Pembengkakan Nyeri tekanPuting : Menonjol Datar Lecet Mastitis

Warna areola ..........................................................................................................................................

ASI Lancar Sedikit Tidak keluarKeluhan lainnya.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Masalah Keperawatan : .................................................................................................................................................................

D. POLA FUNGSI KESEHATAN1. Persepsi Terhadap Kesehatan dan Penyakit :

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......................................................................................................................................................................2. Nutrisida Metabolisme

TB : CmBB sekarang : KgBB Sebelum sakit : Kg

Diet : Biasa Cair Saring LunakDiet Khusus : Rendah garam Rendah kalori TKTP Rendah Lemak Rendah Purin Lainnya……….


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Mual

Muntah…………….kali/hariKesukaran menelan Ya TidakRasa hausKeluhan lainnya....................................................................................................................................................................................................................................

Pola Makan Sehari-hari Sesudah Sakit Sebelum Sakit

Frekuensi/hari

Porsi

Nafsu makan

Jenis Makanan

Jenis Minuman

Jumlah minuman/cc/24 jam

Kebiasaan makan

Keluhan/masalah

Masalah Keperawatan…………………………………………………………………………………………………

3. Pola istirahat dan tidur…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………

4. Kognitif :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………

5. Konsep diri (Gambaran diri, ideal diri, identitas diri, harga diri, peran ) :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………

6. Aktivitas Sehari-hari…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………

7. Koping –Toleransi terhadap Stress…………………………………………………………………………………………………


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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………

8. Nilai-Pola Keyakinan………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………

E. SOSIAL - SPIRITUAL1. Kemampuan berkomunikasi

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2. Bahasa sehari-hari……………………………………………………………………………………………………………………………………………………………………………………………………

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3. Hubungan dengan keluarga :…………………………………………………………………………………………………

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4. Hubungan dengan teman/petugas kesehatan/orang lain :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

5. Orang berarti/terdekat :………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

6. Kebiasaan menggunakan waktu luang :………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

7. Kegiatan beribadah :……………………………………………………………………………………………………………………………………………………………………………………………………

F. DATA PENUNJANG (RADIOLOGIS, LABORATO RIUM, PENUNJANG LAINNYA)

G. PENATALAKSANAAN MEDIS


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…. …………..……………..Mahasiswa

( ………………………………)

Lampiran 12 Format Diagnosa Keperawatan



ANALISIS DATA

DATA SUBYEKTIF DAN DATA OBYEKTIF KEMUNGKINAN PENYEBAB MASALAH


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Prioritas Masalah


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Lampiran 13 Format Intervensi Keperawatan


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RENCANA KEPERAWATAN

Nama Pasien : ……………………..

Ruang Rawat : ……………………..

Diagnosa Keperawatan Tujuan (Kriteria hasil) Intervensi Rasional


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Lampiran 14 Format Implementasi Dan Evaluasi Keperawatan




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IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/TanggalJam

Implementasi Evaluasi (SOAP)Tanda tangan

danNama Perawat


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