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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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

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

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

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

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

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

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

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

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.STIKes Eka Harap Palangka Raya Lampiran 12 Format Diagnosa Keperawatan YAYASAN EKA HARAP PALANGKA RAYA SEKOLAH TINGGI ILMU KESEHATAN PROGRAM STUDI S1 KEPERAWATAN Jalan Beliang No.110 Palangka Raya Telp/Fax.

(0536) 3327707 RENCANA KEPERAWATAN Nama Pasien : ……………………. 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.. Ruang Rawat : …………………….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.110 Palangka Raya Telp/Fax.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 .

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