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

: ……………………………………………………….
: ……………………………………………………….
: ……………………………………………………….
: ……………………………………………………….
: ……………………………………………………….

I. PENGKAJIAN
A.
IDENTITAS PASIEN
Nama
: ……………………………………………………………..
Umur
: ……………………………………………………………..
Jenis Kelamin
: ……………………………………………………………..
Suku/Bangsa
: ……………………………………………………………..
Agama
: ……………………………………………………………..
Pekerjaan
: ……………………………………………………………..
Pendidikan
: ……………………………………………………………..
Status Perkawinan
: ……………………………………………………………..
Alamat
: ……………………………………………………………..
Tgl MRS
: ……………………………………………………………..
Diagnosa Medis
: ……………………………………………………………..
B.
1.

2.

RIWAYAT KESEHATAN /PERAWATAN
Keluhan Utama :
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
Riwayat Penyakit Sekarang:
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………

3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi)
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
4. Riwayat Penyakit Keluarga
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
GENOGRAM KELUARGA:

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

1

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

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

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

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

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

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

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

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 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.

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

(0536) 3327707 IMPLEMENTASI DAN EVALUASI KEPERAWATAN Hari/Tanggal Jam Implementasi Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA. 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.110 Palangka Raya Telp/Fax.

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