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 :
......................................................................................................................................................................
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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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Program Studi S1 Keperawatan
TA. 2012/2013

STIKes Eka Harap

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GENOGRAM KELUARGA:

C.
1.

2.

PEMERIKASAAN FISIK
Keadaan Umum:
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
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
b. Nadi/HR
c. Pernapasan/RR
d. Tekanan Darah/BP

: .0C Axilla Rektal Oral

: x/mt
: ....x/tm
: .....mm Hg

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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 :
......................................................................................................................................................................
......................................................................................................................................................................
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
Anasarka
Asites, lingkar perut . cm

Ictus Cordis
Vena jugularis
Suara jantung

Terlihat
Tidak meningkat
Normal,.
Ada kelainan

Ekstrimitas atas
Ekstrimitas bawah
Tidak melihat
Meningkat

Keluhan lainnya :
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
Masalah Keperawatan :
......................................................................................................................................................................
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Pedoman Penyususnan & Penulisan Laporan Studi Kasus

Program Studi S1 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

Negatif
Negatif

Nyeri, 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

7.

Delirium
Coma

Kejang

:
:
:
:
:
:
:
:
:
:
:
:

Kesemutan
Trernor

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: Jari ke jari
Jari ke hidung
: Tumit ke jempul kaki
: Positif

Positif
Positif
Positif
Negatif

Negatif
Negatif
Negatif

: Kanan +/ Kiri +/Skala. Trisep

:
Kanan +/ Kiri +/- Skala.
:
Kanan +/ Kiri +/Skala. Patella
:
Kanan +/ Kiri +/Skala. Akhiles
:
Kanan +/ Kiri +/Skala. Refleks
Kanan +/ Kiri +/: .....................................................................................................................
: .....................................................................................................................
.....................................................................................................................

Keluhan lainnya :
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......................................................................................................................................................................
Masalah Keperawatan :
......................................................................................................................................................................
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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

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STIKes Eka Harap

Palangka Raya

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

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Program Studi S1 Keperawatan
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STIKes Eka Harap

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10. KULIT-KULIT RAMBUT

Riwayat alergi

Suhu kulit
Warna kulit
Turgor
Tekstur
Lesi :

Obat......................................................................................................
Makanan...............................................................................................
Kosametik.............................................................................................
Lainnya.................................................................................................
Hangat
Panas
Dingin
Normal
Sianosis/ biru
Ikterik/kuning
Putih/ pucat
Coklat tua/hyperpigmentasi
Baik
Cukup
Kurang
Halus
Kasar
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 :
......................................................................................................................................................................
......................................................................................................................................................................
11.

SISTEM PENGINDERAAN :
a. Mata/Penglihatan
Fungsi penglihatan :

Berkurang

Kabur

Ganda
Buta/gelap
Bergerak normal
Diam
Bergerak spontan/nistagmus
Mata Kanan (VOD) :...........................................................................................
Mata kiri (VOS)
:............................................................................................

Gerakan bola mata :

Visus :

Selera
Kornea
Alat bantu
Nyeri
Keluhan lain

Normal/putih
Merah muda
Bening
Kacamata

Kuning/ikterus
Pucat/anemic
Keruh
Lensa kontak

:
:

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

Merah/hifema Konjunctiva

Lainnya.

Tuli

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 :
......................................................................................................................................................................
......................................................................................................................................................................

Pedoman Penyususnan & Penulisan Laporan Studi Kasus

Program Studi S1 Keperawatan
TA. 2012/2013

STIKes Eka Harap

Palangka Raya

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
.....................................................................................
Maetus Uretra
.................................................................................
Discharge, warna
Srotum
.........................................................................................
Hernia
.........................................................................................
Kelainan
Keluhan lain .
a. Reproduksi Wanita
Kemerahan, Lokasi
Gatal-gatal, Lokasi
Perdarahan
.....................................................................................
Flour Albus
.................................................................................
Clitoris
.............................................................................................
Labis
.........................................................................................
Uretra
.........................................................................................
Kebersihan
: Baik
Cukup
Kurang
Kehamilan :

Tafsiran partus
:
Keluhan lain.............................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Payudara :
Simetris
Asimetris
Sear
Lesi
Pembengkakan
Nyeri tekan
Puting :
Menonjol
Datar
Lecet
Mastitis
Warna areola ..........................................................................................................................................
ASI
Lancar
Sedikit
Tidak keluar
Keluhan lainnya.......................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Masalah Keperawatan :
.................................................................................................................................................................
D.

POLA FUNGSI KESEHATAN

Persepsi Terhadap Kesehatan dan Penyakit :
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
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
1.

Muntah.kali/hari
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
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Kesukaran menelan
Ya
Tidak
Rasa haus
Keluhan lainnya.............................................................................................................................................
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.

4.

5.

6.

7.

8.

Masalah Keperawatan

Pola istirahat dan tidur

Masalah Keperawatan

Kognitif :

Masalah Keperawatan

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

Masalah Keperawatan

Aktivitas Sehari-hari

Masalah Keperawatan

Koping Toleransi terhadap Stress

Masalah Keperawatan

Nilai-Pola Keyakinan

Masalah Keperawatan

Pedoman Penyususnan & Penulisan Laporan Studi Kasus

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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

. ....
Mahasiswa

( )

Pedoman Penyususnan & Penulisan Laporan Studi Kasus

Program Studi S1 Keperawatan
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STIKes Eka Harap

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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
ANALISIS DATA
DATA SUBYEKTIF DAN DATA
OBYEKTIF

KEMUNGKINAN PENYEBAB

Pedoman Penyususnan & Penulisan Laporan Studi Kasus

Program Studi S1 Keperawatan
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MASALAH

10

STIKes Eka Harap

Palangka Raya

Prioritas Masalah

Pedoman Penyususnan & Penulisan Laporan Studi Kasus

Program Studi S1 Keperawatan
TA. 2012/2013

11

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. (0536)
3327707
RENCANA KEPERAWATAN
Nama Pasien : ..
Ruang Rawat : ..
Diagnosa Keperawatan

Tujuan (Kriteria hasil)

Pedoman Penyususnan & Penulisan Laporan Studi Kasus

Program Studi S1 Keperawatan
TA. 2012/2013

Intervensi

Rasional

12

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. (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

13

STIKes Eka Harap

Palangka Raya

Pedoman Penyususnan & Penulisan Laporan Studi Kasus

Program Studi S1 Keperawatan
TA. 2012/2013

14