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.
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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

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

............................................................... Trisep :  Kanan +/ Kiri +/.............................................. : ............ ................................................................................. ..................................................................................................... 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 .............................................................. lingkar perut ……………………............... ....................................................... ................................................................................................................. : 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…………...................... Akhiles :  Kanan +/ Kiri +/Skala…………................................................................................................................................................................................................... M : ………………….................................................................................................... .................................................................................................................................................................................................................................................. ..................................................................... lokasi ………………………………..........................................................................................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...................................................................................................................................................................................................... ..............................................................................Skala………….................................. .................... 6.................................................................................................. 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......... V : ………………….................................................................................................... .................................... 2012/2013 3 .................................... ................................ Keluhan lainnya : Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA............................................... Ada kelainan  Tidak melihat  Meningkat Keluhan lainnya : ................... Masalah Keperawatan : ... :  Kanan +/ Kiri +/Skala…………................................................................ ...................... Refleks  Kanan +/ Kiri +/: ...... ........................... PERSYARAFAN (BRAIN) Nilai GCS : E : …………………............................................................................................ ...............................................................................................................…………………............................................................................................

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

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

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

2. 8.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. 2012/2013 . peran ) : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………Masalah Keperawatan ………………………………………………………………………………………………… Aktivitas Sehari-hari ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………Masalah Keperawatan ………………………………………………………………………………………………… Koping –Toleransi terhadap Stress ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………Masalah Keperawatan ………………………………………………………………………………………………… Nilai-Pola Keyakinan ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Masalah Keperawatan ………………………………………………………………………………………………… SOSIAL . 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. 5. 6. harga diri. 1. identitas diri. 7. 4. ideal diri. E.

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

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. 2012/2013 9 . (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.110 Palangka Raya Telp/Fax.

110 Palangka Raya Telp/Fax. Ruang Rawat : …………………….. (0536) 3327707 RENCANA KEPERAWATAN Nama Pasien : ……………………. Diagnosa Keperawatan Tujuan (Kriteria hasil) Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA. 2012/2013 Intervensi Rasional 10 .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 Evaluasi (SOAP) Tanda tangan dan Nama Perawat 11 .110 Palangka Raya Telp/Fax. (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.

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

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