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ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa

Nim

Tempat Praktik

Tanggal

PENGKAJIAN
Identitas
1.

2.

Identitas Klien
Nama
Tempat & tgl Lahir
Golongan Darah
Agama
Suku
Status Perkawinan
Pendidikan Terakhir
Pekerjaan
TB/ BB
Alamat

:...........................................................................L/P Usia (......)


:.....................................................................................................
: O/ A/ B/ AB
: Islam/ Protestan/ Katolik/ Hindu/ Budha/ Konghuchu
:.....................................................................................................
: Kawin/ Belum kawin/ Janda/ Duda (Cerai: Hidup/ Mati)
: .....................................................................................................
:.....................................................................................................
:..........................Cm ..............................Kg..................................
:.....................................................................................................
.......................................................................................................
Telp. ................................/.....................................
Identitas Penanggungjawab
Nama

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

Umur

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

Jenis Kelamin

: P/L

Agama

: Islam/ Protestan/ Katolik/ Hindu/ Budha/ Konghuchu

Suku

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

Hubungan dg Pasien

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

Pendidikan Terakhir

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

Pekerjaan

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

Alamat

:.....................................................................................................
.......................................................................................................
Telp. ................................/.....................................

RIWAYAT KELUARGA
Genogram

Keterangan:

RIWAYAT LINGKUNGAN HIDUP


Tipe Tempat tinggal
: .....................................................................................................
Jumlah Kamar
: .....................................................................................................
Kondisi Tempat Tinggal
:......................................................................................................
Jumlah Orang Yang Tinggal Di Rumah: Laki-Laki :............orang Perempuan :......... orang
STATUS KESEHATAN
Status Kesehatan Saat Ini
Alasan Masuk Rumah Sakit/ Keluhan Utama :
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Faktor Pencetus:...........................................................................................................................
......................................................................................................................................................
Timbulnya Keluhan
: ( ) Bertahap
( ) Mendadak
Faktor yang memperberat: ...........................................................................................................
......................................................................................................................................................
Pemahaman & Penatalaksanaan Masalah Kesehatan
Upaya Yang Dilakukan Untuk Mengatasinya:
Diagnosa Medik
:
Tanggal
:
Tanggal
:
Tanggal
:
Status Kesehatan Masa Lalu
Penyakit yang Pernah Dialami : ..................................................................................................
Kecelakaan
:
Pernah Dirawat
:
Penyakit
:
Waktu
:

Operasi
Alergi

:
: Agen:
Reaksi Spesifik:
:
:
:
:
:
influinza:
:
: Merokok/ kopi/ obat/ alkohol, lain-lain yang merugikan
kesehatan:.................................................................................

Obat-obatan
Makanan
Faktor Lingkungan
Satus Imunisasi
Tetanus, Desentri
Pnemovaks
Kebiasaan
Obat-Obatan
No

Nama

TINJAUAN SISTEM
Keadaan Umum
Tingkat kesadaran
Skala GCS
Tanda- Tanda Vital
1. Sistem Pernafasan
Gejala (Subjektif):
a. Dispnea:
b.
c.
d.

Dosis

Keterangan

:..................................................................................................
...................................................................................................
:Composmentis, Apatis, Somnolen, Suporus, Coma
: Eye .................. Verbal .............. Motorik................
: TD:................. N:............... RR:................. S:.......................

Riwayat Penyakit Sistem pernafasan


: (
) Bronkhitis
( ) Asma
(
) TBC ( )Emfisema (
) Pneumonia
( ) Lain-lain..................
Perokok
: ..................... Pak/ Hari Lama: ..................
(Bulan/ Tahun)
Penggunaan
Alat
bantu
:.........................................................................................

Tanda (Objektif)
a. Pernafasan : 1) Frekwensi:............. 2) Kedalaman: ............... 3) Simetris :.................
b. Penggunaan Otot bantu nafas: ..................................... Cuping Hidung:......................
c. Batuk :.................. Sputum (Karakteristik Sputum):.....................................................
d. Bunyi Nafas :................................................................................................................
e. Sianosis:........................................................................................................................
f. Gelisah :.......................................................................................................................
..
2. Sistem Kardiovaskuler
a. Tekanan Darah (TD)
b. Nadi Palpasi :

c. Bunyi jantung :................Irama:....................... Kualiltas...................... Murmur............


d. Ekstrimitas: Akral:.................... Warna................ CRT.................... Plebitis.................
e. Warna: Membran Mukosa:..................... Bibir................. Konjungtiva..................
Punggung kuku........................... Skela................................
3. Sistem Integumen
Gejala ( Subjektif)
a. Riwayat gangguan kulit:
b. Keluhan klien:
Tanda (Objektif)
a. Lesi kulit:
b. Jumlah lesi:
c. Penyebaran lesi:
d. Abnormalitas kuku:
e. abnormalitas
4. Sistem Perkemihan
Gejala Subjektif
a. Riwayat penyakit ginjal/ kandung kemih: .................................................................
b. Riwayat penggunaan deuritik:....................................................................................
c. Rasa nyeri/ rasa terbakar saat kencing:......................................................................
d. Konsultasi BAK:........................................................................................................
Tanda (objektif)
a. Pola BAK: .............................. Frekuensi:.............................Retensi.....................
b. Perubahan kandung kemih:.......................... Distensi Kandung Kemih:...................
c. Karakteristik urine: Warna...................... Jumlah.................... Bau...........................
5. Sistem Gastrointestinal
Gejala (subjektif)
a. Diit biasa (tipe):.......................................... Jumlah makan per hari:.......................
b. Pola diit:....................................................... Makan terakhir:...................................
c. Nafsu/ selera makan:...................................Mual/ Muntah:.....................................
d. Nyeri Ulu Hati:............................................................................................................
e. Alergi Makanan:...........................................................................................................
f. Masalah mengunyah/ menelan:....................................................................................
Tanda (objektif)
a. BB:.................................................TB:.....................................
b. Turgor kulit:............................................. Tonus Otot:...............................................
c. Edema:....................................................... Acites:.......................................................
d. Kondisi Mulut: Gigi.................. Mukosa Mulut: ............................Lidah:..................
e. Bising Usus:.................................................................................................................

6. Sistem Eliminasi
Gejala (subjektif)
a. Pola BAB:..................................................................................................................

b. Kesulitan BAB: Konstipasi:................................. Diare:...........................................


c. Penggunaan Laksantif:...............................................................................................
d. BAB terakhir:.............................................................................................................
e. Riwayat perdarahan:...................................................................................................
f. Riwayat inkontinensia alvi:........................................................................................
Tanda (objektif)
a. Abdomen : Nyeri tekan:................................... Lunak/ Keras:.............................
Massa:............................. Lingkar Abdomen: ............... Bising Usus:.................
Integritas kulit perut:.............................................................................................
b. Hemoroid:
7. Sistem Endokrin
Gejala (subjektif)
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Tanda (objektif)
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
8. Sistem Imune
Gejala (subjektif)
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Tanda (objektif)
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
9. Sistem Muskuloskeletal
Gejala (subjektif)
Keluhan:...........................................................................................................................
...........................................................................................................................................
Tanda (objektif)
Kekuatan otot
Tonus otot
Kemampuan aktifitas
Deformitas
10. Sistem Reproduksi
Gejala (subjektif)

:
:
:
:

Tanda (objektif)
11. Sistem Persyarafan

Gejala (subjektif)

Tanda (objektif)
GCS
Nervous Cranial 1-12
Reflek normal
Reflek Patologis

:
:
:
:

12. Sistem Penglihatan


Gejala (subjektif)
Tanda (objektif)
Konjungtiva
Pupil
Sklera
Penampilan Bola Mata
Pergerakan bola Mata

:
:
:
:
:

13. Sistem Pendengaran


Gejala (subjektif)
Tanda (objektif)
Daun Telinga
Liang telinga
Fungsi Pendengaran

:
:
:

14. Sistem Pengecapan


Gejala (subjektif)
Tanda (objektif)
Membedakan rasa:
Warna lidah:
15. Sistem Penciuman
Gejala (subjektif)
Tanda (objektif)
Membedakan Bau:
DATA TAMBAHAN
POLA
Pola istirahat tidur

SEBELUM DI RS

SESUDAH DI RS

Waktu
Lama Tidur
Kebiasaan Pengantar Tidur
Kesulitan Tidur
Pola Aktifitas Dan Latihan
Kegiatan Sehari-hari
Olah raga
Kegiatan waktu luang
Pola Bekerja
Jenis Pekerjaan
Jumlah Jam Kerja
Jadwal Kerja
ASPEK PSIKOSOSIAL
Pola Pikir dan Persepsi:
Konsep Diri:
Komunikasi/ hubungan:
Mekanisme koping:
Sistem dan nilai kepercayaan:

PERSEPSI KLIEN TENTANG PENYAKIT


A. Harapan Klien:
B. Analisa Data
No

Data

Etiologi

Problem

C. RENCANA KEPERAWATAN
No RM:
Nama:
No.
Hari&
Tujuan
Dx
Tanggal
Kep
Pukul

Usia:
Tindakan

Rasional

D. IMPLEMENTASI DAN EVALUASI


No RM:
Nama:
No.
Hari&
Dx
Tanggal
Tindakan
Kep
Pukul

Tanda
Tangan

Usia:
Hari&
Tanggal
Pukul

Evaluasi

Tanda
Tangan