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

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

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

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

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

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

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

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

110 Palangka Raya Telp/Fax. 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.

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

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. 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 Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA. 2012/2013 12 .

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