STIKes Eka Harap

Palangka Raya

YAYASAN EKA HARAP PALANGKA RAYA
SEKOLAH TINGGI ILMU KESEHATAN
PROGRAM 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

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I. PENGKAJIAN
A.
IDENTITAS PASIEN
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Jenis Kelamin
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Suku/Bangsa
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Pekerjaan
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Pendidikan
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Status Perkawinan
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Alamat
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Tgl MRS
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Diagnosa Medis
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B.
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2.

RIWAYAT KESEHATAN /PERAWATAN
Keluhan Utama :
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Riwayat Penyakit Sekarang:
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3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi)
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4. Riwayat Penyakit Keluarga
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GENOGRAM KELUARGA:

Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013

1

.......................................... f.. Tingkat Kesadaran : …………………............. Masalah Keperawatan : ......... : …………………………………........................................................ Nadi/HR c......................................................................................................... • Orientasi Orang : …………………............ e........ 5............................ Keluhan lainnya : …………………........................ c......................................... Insight :  Baik  Mengingkari  Menyalahkan orang lain m.......................................................................................... Penampilan : …………………........STIKes Eka Harap Palangka Raya C...........………..........................................………….... Halusinasi :  Dengar/Akustic  Lihat/Visual  Lainnya .......... Berbicara : …………………............................................. 2012/2013  Pucat 2 ..................... Tanda-tanda Vital : a.................... Suhu/T b...................................................................................................................... ……… ............................................................ Sesak nafas  saat inspirasi  Saat aktivitas  Saat istirahat Type Pernafasan  Dada  Perut  Dada dan perut  Kusmaul  Cheyne-stokes  Biot  Lainnya Irama Pernafasan  Teratur  Tidak teratur Suara Nafas  Vesukuler  Bronchovesikuler  Bronchial  Trakeal Suara Nafas tambahan  Wheezing  Ronchi kering  Ronchi basah (rales)  Lainnya…………… Keluhan lainnya : ........... 2............. warna ............................x/tm : ……........................... • Orientasi Tempat : ………………….............................................. ..... Mekanisme pertahanan diri :  Adaptif  Maladaptif n. g............ sejak Sputum.... h...........................0C  Axilla  Rektal  Oral : ………………x/mt : ….............. Proses berpikir :  Blocking  Circumstansial  Flight oh ideas  Lainnya k....................................................................Batang/hari ................................. i............................................ Suasana hati : …………………...................................... ..................................................................................................……………………………………… ................. Ekspresi wajah : ………………….... Cara berbaring/bergerak : …………………......................................................................... Pernapasan/RR d...................... PERNAPASAN (BREATHING) Bentuk Dada Kebiasaan merokok        Batuk.................mm Hg 4....................... PEMERIKASAAN FISIK Keadaan Umum: ................. b........ CARDIOVASCULER (BLEEDING)  Nyeri dada  Kram kaki Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA..................................... Tekanan Darah/BP : ……………….................... Bentuk badan : …………………. ……… ...................................................................................... ....... ……… Status Mental : a............................... j...........................……………………………………… Sianosis Nyeri dada Dyspnoe nyeri dada  Orthopnoe  Lainnya ……............. d............................... ……… ............................................……….............................. 3......................……………………………………… Batuk darah................................. sejak : .............................. Fungsi kognitif : • Orientasi waktu : …………………......................................................... 1..............................

............................. Masalah Keperawatan : .................................................................................................... ............................................................................................... 6.................................................................. Trisep :  Kanan +/ Kiri +/............................................................................................................. 2012/2013 3 ............................................................................. ............................................................................................................................. lingkar perut ……………………....................................................... .......................... Patella :  Kanan +/ Kiri +/Skala………….......................................................................................................................................................................................................................................................... Total Nilai GCS : …………………… Kesadaran :  Compos Menthis  Somnolent  Apatis  Soporus Pupil :  Isokor  Anisokor  Midriasis  Meiosis Refleks Cahaya :  Kanan  Positif  Kiri  Positif      Delirium  Coma  Negatif  Negatif Nyeri.....................................................Skala…………................ Refleks  Kanan +/ Kiri +/: ............ ...................................................... ............................ V : …………………......................................................... PERSYARAFAN (BRAIN) Nilai GCS : E : ………………….............................. Vertigo  Gelisah  Aphasia Bingung  Disarthria Pelo Uji 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 Ekstrimitas Bawah Uji Kestabilan Tubuh Refleks : Bisep Brakioradialis Babinski Refleks lainnya Uji sensasi  Kejang : : : : : : : : : : : :  Kesemutan  Trernor ........................... .....STIKes Eka Harap Palangka Raya     Pusing/sinkop  Clubing finger  Sianosis Sakit Kepala  Palpitasi  Pingsan Capillary refill  > 2 detik  < 2 detik Oedema :  Wajah  Anasarka  Ekstrimitas atas  Ekstrimitas bawah   Asites......................................................................................................... : ......................................... ............................................... cm Ictus Cordis Vena jugularis Suara jantung     Terlihat Tidak meningkat Normal..................................... ........................................... ......................... .......................................................………………….................................................................................................... :  Kanan +/ Kiri +/Skala………….................................... Keluhan lainnya : Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA.................................................................................................................... lokasi ………………………………..................... : Jari ke jari Jari ke hidung : Tumit ke jempul kaki :  Positif  Positif  Positif  Positif  Negatif  Negatif  Negatif  Negatif :  Kanan +/ Kiri +/Skala………….................................................................................................................................................................................................................................................................................................................................................................................................................................... Akhiles :  Kanan +/ Kiri +/Skala………….... M : …………………........................................... ................................................................... ...................... ......................................................................... Ada kelainan  Tidak melihat  Meningkat Keluhan lainnya : ................... .................................................................................................. ..................

........................ Gigi : ...................................... lokasi  Paralise.............................................................................................................................. lokasi  Spastisitas...........STIKes Eka Harap Palangka Raya 7............................ ELIMINASI URI (BLADDER) : Produksi Urine : …………................................................................................... lokasi  Kekakuan....................................................................................... TULANG .............. Keluhan lainnya : .................................................................. Nyeri tekan............................................................... lokasi : ................................................................................  Ekstrimitas bawah……........ml…………x/hr Warna : Bau :  Tidak ada masalah/lancer  Menetes  Inkotinen  Oliguri  Nyeri  Retensi  Poliuri  Panas  Hematuri  Dysuri  Nocturi  Kateter  Cystostomi Keluhan Lainnya : ............................... Tonsil : ......................... 8......................................................... Lidah : .................................................................................................................................................................... lokasi  Perlukaan............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... lokasi  Flasiditas............................................................................................................  Peradangan..................................................................................................................... Rectum : Haemoroid : BAB : ………...... lokasi : .... Masalah Keperawatan : ................. lokasi...................................................................................................................... ................................................................... ........................................................ Masalah Keperawatan : .. lokasi  Hemiparese................................................................................................................................................ ............................... ELIMINASI ALVI (BOWEL) : Mulut dan Faring Bibir : .............................. lokasi  Krepitasi....................................................................................... ............................................................................................ lokasi Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA...   Tidak ada masalah  Diare  Konstipasi  Kembung Feaces berdarah  Melena  Obat pencahar  Lavement Bising usus : ................................................................... Konsistensi : ……………..……… ..................................... lokasi  Ukuran otot  Simetris  Atropi  Hipertropi  Kontraktur  Malposisi Uji kekuatan otot :  Ekstrimitas atas………......... Benjolan...............................................................................................................................................  Deformitas tulang.................................................................................................................................................................................................................................. Masalah Keperawatan : .......................................................... lokasi  Bengkak......................... Mukosa : .......................................................................... .. ......................................................................................... lokasi  Nyeri.......................................................................................................................... Gusi : ................................................. 9....... ............. ....................................................................................................................................................................................................OTOT – INTEGUMEN (BONE) :  Kemampuan pergerakan sendi  Bebas  Terbatas  Parese......... 2012/2013 4 .....................x/hr Warna :...............

................................................................................................................................................................................ KULIT-KULIT RAMBUT Riwayat alergi                Suhu kulit Warna kulit Turgor Tekstur Lesi :  Skoliosis  Lordosis Obat....................................................... lokasi.......................................................................................................................STIKes Eka Harap Palangka Raya  Patah tulang.......... Hidung / Penciuman: Bentuk :  Simetris  Asimetris       Merah/hifema Konjunctiva  Lainnya…….................................................. lokasi................. lokasi.......................................... Jaringan parut lokasi Tekstur rambut ....................................................... Nodula................................................................... lokasi........................................................... Hangat  Panas  Dingin Normal  Sianosis/ biru  Ikterik/kuning Putih/ pucat  Coklat tua/hyperpigmentasi Baik  Cukup  Kurang Halus  Kasar Macula........................................................................... Makanan..................................................................................................................... lokasi.......... Kosametik............................................................... Mata/Penglihatan Fungsi penglihatan :  Berkurang  Kabur  Ganda  Buta/gelap Gerakan bola mata :  Bergerak normal  Diam  Bergerak spontan/nistagmus Visus : Mata Kanan (VOD) :............................................................................................... lokasi Pustula............................................ Distribusi rambut Bentuk kuku  Simetris  Irreguler  Clubbing Finger  Lainnya Masalah Keperawatan : ....... Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA. Ulcus..................... Selera Kornea Alat bantu Nyeri Keluhan lain     Normal/putih Merah muda Bening Kacamata     Kuning/ikterus Pucat/anemic Keruh Lensa kontak : : ………………………………………………………………… b............................................................................................................... Integritas……………..................................... lokasi Tulang belakang  Normal  Kifosis 10.............................. Lainnya.................................................................... ......................... 2012/2013 5 ............................ SISTEM PENGINDERAAN : a................. ........................ warna ………………………  Polip  Kanan  Kiri  Kanan dan Kiri Masalah Keperawatan : .......................... Telinga / Pendengaran : Fungsi pendengaran :  Berkurang  Berdengung c................................................. Vesikula............................................................................................  Tuli Lesi Patensi Obstruksi Nyeri tekan sinus Transluminasi Cavum Nasal Warna…………………. Papula........................................................................................... 11................... Septum nasal  Deviasi  Perforasi  Peradarahan  Sekresi..................................................... Mata kiri (VOS) :...................................................................

........................................ ........................................................................................................................................................................ Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA..................................... Kebersihan :  Baik  Cukup  Kurang Kehamilan : …………………………………… Tafsiran partus : …………………………………… Keluhan lain............................................................................................... a....................................................................................... ......... Nutrisida Metabolisme TB : Cm BB sekarang : Kg BB Sebelum sakit : Kg Diet :  Biasa  Cair  Saring  Lunak Diet Khusus :  Rendah garam  Rendah kalori  TKTP  Rendah Lemak  Rendah Purin  Lainnya………................................................................................. Maetus Uretra .............................................................................................................................................................. ............................................................................ ...................................................................................... 2012/2013 6 .................................................... Lokasi Perdarahan ........................................... D......................................................... POLA FUNGSI KESEHATAN Persepsi Terhadap Kesehatan dan Penyakit : ...................................................................................................................... Lokasi Gatal-gatal............  Mual  Muntah……………..................... ........................................... LEHER DAN KELENJAR LIMFE Massa  Ya  Tidak Jaringan Parut  Ya  Tidak Kelenjar Limfe  Teraba  Tidak teraba Kelenjar Tyroid  Teraba  Tidak teraba Mobilitas leher  Bebas  Terbatas 13.................................................................................... Hernia ..................................................................................................................................................................................................................................................................................................... Clitoris .................................................................................................................................................. ............................................................................................................... SISTEM REPRODUKSI a.................. Lokasi Gatal-gatal...................................... Uretra .............................................................................. Reproduksi Pria Kemerahan........... Payudara :  Simetris  Asimetris  Sear  Lesi  Pembengkakan  Nyeri tekan Puting :  Menonjol  Datar  Lecet  Mastitis Warna areola ............................... Discharge..................................... Lokasi Gland Penis ...............................................kali/hari Kesukaran menelan  Ya  Tidak Rasa haus Keluhan lainnya..................... 1............................................................. .................................................................................................................................................................................................................................................................STIKes Eka Harap Palangka Raya 12............................ 2...................... .................................................................................................................. Masalah Keperawatan : ....................................................................................................................... ASI  Lancar  Sedikit  Tidak keluar Keluhan lainnya..... Reproduksi Wanita Kemerahan............................. Kelainan …………………………………………… Keluhan lain …………………………………………................................. Labis .................................................................................................................................................................................... Flour Albus ... warna Srotum ...................................

8. 2012/2013 . 2.SPIRITUAL Kemampuan berkomunikasi ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… ……………………………………………………………… Bahasa sehari-hari ………………………………………………………………………………………………… 7 Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA. Masalah Keperawatan ………………………………………………………………………………………………… Pola istirahat dan tidur ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Masalah Keperawatan ………………………………………………………………………………………………… Kognitif : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………Masalah Keperawatan ………………………………………………………………………………………………… Konsep diri (Gambaran diri. 1. 6. 4. E. identitas diri. harga diri.STIKes Eka Harap Palangka Raya 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 3. ideal diri. 5. peran ) : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………Masalah Keperawatan ………………………………………………………………………………………………… Aktivitas Sehari-hari ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………Masalah Keperawatan ………………………………………………………………………………………………… Koping –Toleransi terhadap Stress ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………Masalah Keperawatan ………………………………………………………………………………………………… Nilai-Pola Keyakinan ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Masalah Keperawatan ………………………………………………………………………………………………… SOSIAL . 7.

LABORATO RIUM. 2012/2013 8 . PENUNJANG LAINNYA) G.. Mahasiswa ( ………………………………) Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA. PENATALAKSANAAN MEDIS …. 4. 6.. …………………………………………………………………………………………………………………………………… ……………………………………………………………… Hubungan dengan keluarga : ………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… ……………………………………………………………… ………………………………………………………………………………………………… Hubungan dengan teman/petugas kesehatan/orang lain : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Orang berarti/terdekat : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Kebiasaan menggunakan waktu luang : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Kegiatan beribadah : ………………………………………………………………………………………………… ………………………………………………………………………………………………… F. ………….……………. DATA PENUNJANG (RADIOLOGIS. 5. 7.STIKes Eka Harap Palangka Raya ………………………………………………………………………………………………… 3.

(0536) 3327707 ANALISIS DATA DATA SUBYEKTIF DAN DATA OBYEKTIF KEMUNGKINAN PENYEBAB MASALAH Prioritas Masalah Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA. 2012/2013 9 .STIKes Eka Harap Palangka Raya Lampiran 12 Format Diagnosa Keperawatan YAYASAN EKA HARAP PALANGKA RAYA SEKOLAH TINGGI ILMU KESEHATAN PROGRAM STUDI S1 KEPERAWATAN Jalan Beliang No.110 Palangka Raya Telp/Fax.

2012/2013 Intervensi Rasional 10 . Ruang Rawat : ……………………. (0536) 3327707 RENCANA KEPERAWATAN Nama Pasien : …………………….110 Palangka Raya Telp/Fax...STIKes Eka Harap Palangka Raya Lampiran 13 Format Intervensi Keperawatan YAYASAN EKA HARAP PALANGKA RAYA SEKOLAH TINGGI ILMU KESEHATAN PROGRAM STUDI S1 KEPERAWATAN Jalan Beliang No. Diagnosa Keperawatan Tujuan (Kriteria hasil) Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA.

2012/2013 Evaluasi (SOAP) Tanda tangan dan Nama Perawat 11 . (0536) 3327707 IMPLEMENTASI DAN EVALUASI KEPERAWATAN Hari/Tanggal Jam Implementasi Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA.STIKes Eka Harap Palangka Raya Lampiran 14 Format Implementasi Dan Evaluasi Keperawatan YAYASAN EKA HARAP PALANGKA RAYA SEKOLAH TINGGI ILMU KESEHATAN PROGRAM STUDI S1 KEPERAWATAN Jalan Beliang No.110 Palangka Raya Telp/Fax.

2012/2013 12 .STIKes Eka Harap Palangka Raya Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA.

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