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
Nama
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Umur
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Jenis Kelamin
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Suku/Bangsa
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Agama
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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.
1.

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

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

................................................................................................................................................................................................................ Akhiles :  Kanan +/ Kiri +/Skala………….... M : …………………................................ ......................................................................... ................................ : .................... Ada kelainan  Tidak melihat  Meningkat Keluhan lainnya : ............................………………….................... ............................. ....................................................................................... ........................................... cm Ictus Cordis Vena jugularis Suara jantung     Terlihat Tidak meningkat Normal......................................................................................................................................................... ................ ........................................................................................... V : …………………..................................................................................... .. Masalah Keperawatan : ................................................................................................................... lingkar perut ……………………...................................................................... PERSYARAFAN (BRAIN) Nilai GCS : E : …………………........... : Jari ke jari Jari ke hidung : Tumit ke jempul kaki :  Positif  Positif  Positif  Positif  Negatif  Negatif  Negatif  Negatif :  Kanan +/ Kiri +/Skala…………............................................................................................ ... .................. Patella :  Kanan +/ Kiri +/Skala…………...................... 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 ................................................................................... Keluhan lainnya : Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA......................................... ................... 2012/2013 3 ........................................................................................................................................................ :  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........... ....................................................... Trisep :  Kanan +/ Kiri +/................Skala…………....................................................................................................................... Refleks  Kanan +/ Kiri +/: ................................................................................................................................ 6.....................................................................................................................................................................................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......................................................................................................................................................... lokasi ……………………………….............................................................. .................................................................................................................................................................................................................

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

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

............................. 2...................................................................................... ........................... 2012/2013 6 ............................... D.. Lokasi Gland Penis ...................... POLA FUNGSI KESEHATAN Persepsi Terhadap Kesehatan dan Penyakit : ................................................................................ .......................................................... .................... Maetus Uretra ........................................... Kelainan …………………………………………… Keluhan lain ………………………………………….............. ............... Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA......................................................................................STIKes Eka Harap Palangka Raya 12............................................................................... Hernia ........................... a............................................... ASI  Lancar  Sedikit  Tidak keluar Keluhan lainnya................................................... ............................................................................................................................................................................................ Lokasi Gatal-gatal................................................................................................................................................................................................................................... Reproduksi Pria Kemerahan................................. Lokasi Perdarahan ................... Payudara :  Simetris  Asimetris  Sear  Lesi  Pembengkakan  Nyeri tekan Puting :  Menonjol  Datar  Lecet  Mastitis Warna areola .. Clitoris ........................................ Masalah Keperawatan : .................................................................................................................................................................................................................................... SISTEM REPRODUKSI a...................................................................................................................................................................................................................................................................... .............................................................. Flour Albus ...................................................................................................... Kebersihan :  Baik  Cukup  Kurang Kehamilan : …………………………………… Tafsiran partus : …………………………………… Keluhan lain.............kali/hari Kesukaran menelan  Ya  Tidak Rasa haus Keluhan lainnya.................. warna Srotum ......................................................................................... ..................................................................................  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.................................................................................................................................... 1.............................................................................................................................................................. Discharge............................................................................................................................... Labis ......................... Uretra ....... Lokasi Gatal-gatal............................................. 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………......................................................................................................................................................................................................... Reproduksi Wanita Kemerahan..............................

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

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

110 Palangka Raya Telp/Fax. (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.

. (0536) 3327707 RENCANA KEPERAWATAN Nama Pasien : …………………….. Diagnosa Keperawatan Tujuan (Kriteria hasil) Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA.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. 2012/2013 Intervensi Rasional 10 .110 Palangka Raya Telp/Fax. Ruang Rawat : …………………….

110 Palangka Raya Telp/Fax. 2012/2013 Evaluasi (SOAP) Tanda tangan dan Nama Perawat 11 .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. (0536) 3327707 IMPLEMENTASI DAN EVALUASI KEPERAWATAN Hari/Tanggal Jam Implementasi Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA.

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

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