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

: AMIYANI KRISTINA
: 2011.C.03a.0151
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sd

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

RIWAYAT KESEHATAN /PERAWATAN

1. Keluhan Utama :
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2. 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 :

C.

PEMERIKASAAN FISIK
1. Keadaan Umum:
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2. Status Mental :
a. Tingkat Kesadaran
: .
b. Ekspresi wajah
: .
c. Bentuk badan
: .
d. Cara berbaring/bergerak
: .
e. Berbicara
: .
f. Suasana hati
: .
g. Penampilan
: .
h. Fungsi kognitif :
Orientasi waktu
: .
Orientasi Orang
: .
Orientasi Tempat
: .
i. Halusinasi :
Dengar/Akustic Lihat/Visual Lainnya ................................
j. Proses berpikir : Blocking
Circumstansial Flight oh ideas
Lainnya
k. Insight : Baik
Mengingkari
Menyalahkan orang lain
m. Mekanisme pertahanan diri :
Adaptif
Maladaptif
n. Keluhan lainnya
: .
3. Tanda-tanda Vital :
a. Suhu/T
: .0C Axilla Rektal Oral
b. Nadi/HR
: x/mt
c. Pernapasan/RR
: ....x/tm
d. Tekanan Darah/BP
: .....mm Hg
4. PERNAPASAN (BREATHING)
Bentuk Dada
: ...................................................................................
Kebiasaan merokok
: ...Batang/hari
Batuk, sejak

Batuk darah, sejak

Sputum, warna

Sianosis
Nyeri dada
Dyspnoe nyeri dada
Orthopnoe Lainnya ...
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 :
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Masalah Keperawatan :
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5. CARDIOVASCULER (BLEEDING)
Nyeri dada
Kram kaki
Pucat
Pusing/sinkop
Clubing finger
Sianosis
Sakit Kepala
Palpitasi
Pingsan
Capillary refill
> 2 detik
< 2 detik
Oedema :
Wajah
Ekstrimitas atas
Anasarka
Ekstrimitas bawah
Asites, lingkar perut . cm
Ictus Cordis
Terlihat
Tidak melihat
Vena jugularis
Tidak meningkat
Meningkat
Suara jantung
Normal,.
Ada kelainan
Keluhan lainnya :
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Masalah Keperawatan :
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6.

PERSYARAFAN (BRAIN)
Nilai GCS :
E
: .
V
: .
M
: .
Total Nilai GCS
:

Kesadaran
: Compos Menthis
Somnolent
Apatis
Soporus
Pupil
: Isokor
Anisokor
Midriasis
Meiosis
Refleks Cahaya : Kanan
Positif
Kiri
Positif
Nyeri, lokasi ..
Vertigo Gelisah
Aphasia
Bingung
Disarthria
Kejang
Pelo
Uji Syaraf Kranial :

Delirium
Coma

Negatif
Negatif
Kesemutan
Trernor

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
:

:
:
:
:
:
:
:
:
:
:
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:

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Jari ke jari
Positif
Negatif
Jari ke hidung
Positif
Negatif
Ekstrimitas Bawah : Tumit ke jempul kaki
Positif
Negatif
Uji Kestabilan Tubuh
: Positif
Negatif
Refleks :
Bisep
: Kanan +/ Kiri +/Skala.
Trisep
:
Kanan +/ Kiri +/Skala. Brakioradialis
:
Kanan +/ Kiri +/Skala. Patella
:
Kanan +/ Kiri +/Skala.
Akhiles
: Kanan +/ Kiri +/Skala.
Refleks Babinski
Kanan +/ Kiri +/Refleks lainnya
: ....................................................................................................
Uji sensasi
: ....................................................................................................
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Keluhan lainnya :
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Masalah Keperawatan :
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7.

ELIMINASI URI (BLADDER) :

Produksi Urine
: .mlx/hr
Warna
:
Bau
:
Tidak ada masalah/lancer
Menetes
Inkotinen
Oliguri
Nyeri
Retensi
Poliuri
Panas
Hematuri
Dysuri
Nocturi
Kateter
Cystostomi
Keluhan Lainnya :
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Masalah Keperawatan :

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8. ELIMINASI ALVI (BOWEL) :
Mulut dan Faring
Bibir
: ..............................................................................................................
Gigi
: ..............................................................................................................
Gusi
: ..............................................................................................................
Lidah
: ..............................................................................................................
Mukosa
: ..............................................................................................................
Tonsil
: ..............................................................................................................
Rectum
:
Haemoroid
:
BAB
: .x/hr Warna :.. . Konsistensi : .
Tidak ada masalah
Diare
Konstipasi
Kembung
Feaces berdarah
Melena
Obat pencahar
Lavement
Bising usus
: ....................................................................................................
Nyeri tekan, lokasi
: ....................................................................................................
Benjolan, lokasi
: ....................................................................................................
Keluhan lainnya :
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Masalah Keperawatan :
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9.

TULANG - OTOT INTEGUMEN (BONE) :

Kemampuan pergerakan sendi
Bebas
Terbatas
Parese, lokasi
Paralise, lokasi
Hemiparese, lokasi ..........................................................................................................
Krepitasi, lokasi
Nyeri, lokasi
Bengkak, lokasi
Kekakuan, lokasi .............................................................................................................
Flasiditas, lokasi ..............................................................................................................
Spastisitas, lokasi ............................................................................................................
Ukuran otot
Simetris
Atropi
Hipertropi
Kontraktur
Malposisi
Uji kekuatan otot : Ekstrimitas atas.. Ekstrimitas bawah..
Deformitas tulang, lokasi..................................................................................................
Peradangan, lokasi...........................................................................................................
Perlukaan, lokasi..............................................................................................................
Patah tulang, lokasi..........................................................................................................
Tulang belakang
Normal
Skoliosis

 Kifosis

Lordosis

10. KULIT-KULIT RAMBUT

Riwayat alergi

Obat.....................................................................................
Makanan..............................................................................
Kosametik............................................................................
Lainnya................................................................................
Suhu kulit
Hangat
Panas
Dingin
Warna kulit
Normal
Sianosis/ biru
Ikterik/kuning
Putih/ pucat
Coklat tua/hyperpigmentasi
Turgor
Baik
Cukup
Kurang
Tekstur
Halus
Kasar
Lesi :
Macula, lokasi
Pustula, lokasi.....................................................................
Nodula, lokasi......................................................................
Vesikula, lokasi....................................................................
Papula, lokasi......................................................................
Ulcus, lokasi........................................................................
Jaringan parut lokasi............................................................................................................
Tekstur rambut ..............................................................................................................
Distribusi rambut
Bentuk kuku
Simetris
Irreguler
Clubbing Finger Lainnya
Masalah Keperawatan :
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11. SISTEM PENGINDERAAN :

a. Mata/Penglihatan
Fungsi penglihatan :
Berkurang
Kabur
Ganda
Buta/gelap
Gerakan bola mata : Bergerak normal
Diam
Bergerak spontan/nistagmus
Visus :
Mata Kanan (VOD) :........................................................................
Mata kiri (VOS)
:.........................................................................
Selera
Normal/putih
Kuning/ikterus
Merah/hifema
Konjunctiva
Merah muda
Pucat/anemic
Kornea
Bening
Keruh
Alat bantu
Kacamata
Lensa kontak
Lainnya.
Nyeri
:
Keluhan lain :

b. Telinga / Pendengaran :
Fungsi pendengaran : Berkurang
Berdengung
Tuli
c. Hidung / Penciuman:
Bentuk :
Simetris
Asimetris
Lesi

Patensi
Obstruksi
Nyeri tekan sinus
Transluminasi
Cavum Nasal
Warna..
Integritas..
Septum nasal
Deviasi
Perforasi
Peradarahan
Sekresi, warna
Polip
Kanan
Kiri Kanan dan Kiri
Masalah Keperawatan :
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12. 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. SISTEM REPRODUKSI
a. Reproduksi Pria
Kemerahan, Lokasi
Gatal-gatal, Lokasi
Gland Penis
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Maetus Uretra .....................................................................
Discharge, warna
Srotum
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Hernia
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Kelainan
Keluhan lain .
a. Reproduksi Wanita
Kemerahan, Lokasi
Gatal-gatal, Lokasi
Perdarahan ........................................................................
Flour Albus
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Clitoris ...............................................................................
Labis
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Uretra
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Kebersihan
: Baik
Cukup
Kurang
Kehamilan :

Tafsiran partus :
Keluhan lain.....................................................................................................................
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Payudara :
Simetris
Asimetris
Sear
Lesi
Pembengkakan
Nyeri tekan
Puting :
Menonjol
Datar
Lecet
Mastitis
Warna areola ..................................................................................................................

ASI
Lancar
Sedikit
Tidak keluar
Keluhan lainnya...............................................................................................................
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Masalah Keperawatan :
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D.

POLA FUNGSI KESEHATAN

1. Persepsi Terhadap Kesehatan dan Penyakit :
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2. 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.kali/hari
Kesukaran menelan
Ya
Tidak
Rasa haus
Keluhan lainnya....................................................................................................................
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Pola Makan Sehari-hari

Frekuensi/hari
Porsi
Nafsu makan
Jenis Makanan
Jenis Minuman
Jumlah minuman/cc/24 jam
Kebiasaan makan
Keluhan/masalah

Sesudah Sakit

Sebelum Sakit

Masalah Keperawatan

3. Pola istirahat dan tidur

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Masalah Keperawatan

4. Kognitif :

Masalah Keperawatan

5. Konsep diri (Gambaran diri, ideal diri, identitas diri, harga diri, peran ) :

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Masalah Keperawatan

6. Aktivitas Sehari-hari

Masalah Keperawatan

7. Koping Toleransi terhadap Stress

Masalah Keperawatan

8. Nilai-Pola Keyakinan

Masalah Keperawatan


E.
1.

2.

3.

4.

5.

6.

7.

SOSIAL - SPIRITUAL
Kemampuan berkomunikasi

Bahasa sehari-hari

Hubungan dengan keluarga :

Hubungan dengan teman/petugas kesehatan/orang lain :

Orang berarti/terdekat :

Kebiasaan menggunakan waktu luang :

Kegiatan beribadah :

F.

DATA PENUNJANG (RADIOLOGIS, LABORATO RIUM, PENUNJANG LAINNYA)

G.

PENATALAKSANAAN MEDIS

Palangka Raya,
Mahasiswa

(AMIYANI KRISTINA)

ANALISIS DATA
DATA SUBYEKTIF DAN DATA OBYEKTIF

KEMUNGKINAN PENYEBAB

MASALAH

PRIORITAS MASALAH

RENCANA KEPERAWATAN
Nama Pasien : ..
Ruang Rawat : ..
Diagnosa Keperawatan

Tujuan (Kriteria hasil)

Intervensi

Rasional

IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/Tanggal,
Jam

Implementasi

Evaluasi (SOAP)

Tanda tangan dan

Nama Perawat