ASUHAN KEPERAWATAN

KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa

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

NIM

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

Ruang

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

INFORMASI UMUM
Nama:............................................................

Usia:..............................................................

Tanggal Lahir:...............................................

Jenis Kelamin:...............................................

Suku Bangsa:................................................

Tanggal masuk:.............................................

Sumber Informasi: .......................................

ISTIRAHAT
Pekerjaan: ...................................................................................................................................
Perasaan bosan: ..........................................................................................................................
Keterbatasan karena kondisi :.....................................................................................................
Tidur Jam:........................... Tidur siang: .Kebiasaan tidur ..
Lain-lain: ....................................................................................................................................
Massa/ tonus otot : .....................................................................................................................
Deformitas : ...............................................................................................................................
Masalah lainnya: ........................................................................................................................
SIRKULASI
Riwayat tentang : Hipertensi : ................................................................................................
Masalah jantung : ......................................................................................
Demam rematik :.......................................................................................
Edema mata kaki/ kaki: .................................. Flebitis:............................................................
Ekstremitas : Kesemutan :............................... Kebas : ............................................................
Batuk/ hemoptisis :.....................................................................................................................
Perubahan frekuensi/ jumlah urine :...........................................................................................
TD :................mmHg.

Tekanan nadi:.................................... Frekuensi Nadi:.x/menit

Bunyi jantung:............................................................................................................................

Ekstremitas : Suhu: .................................................................................................................

Abnormalitas kuku ...........................................................................................
Penyebaran/ kualitas rambut :...........................................................................
Warna : Membran mukosa:.......................................................................................................
Bibir:...........................................................................................................................
Punggung kuku :.........................................................................................................
Konjungiva :...............................................................................................................
Sklera :........................................................................................................................
Diaforesis :..................................................................................................................................
Masalah lainnya :........................................................................................................................
INTEGRITAS EGO
Agama:.......................................................... Gaya hidup:.........................................................
Keputusasaan:............................................... Ketidak berdayaan :............................................
Masalah lainnya..........................................................................................................................
Status emosional (beri tanda cek untuk yang sesuai) :
Tenang

Cemas

Marah

Takut

Mudah tersinggung

Tidak sabar

Menarik diri

Respons-respons fisiologis yang terobservasi ...........................................................................

Masalah lainnya .........................................................................................................................
ELIMINASI
POLA BAB:
Penggunaan laksatif ..................................... Karakter fases ................................................
BAB terakhir ................................................ Riwayat perdarahan .......................................
Hemoroid ..................................................... Konstipasi ......................................................
Diare .............................................................
POLA BAK:
Karakter urine...........................................................................................................................
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 Nyeri/ rasa terbakar/ kesulitan BAK .......................................................................................

Riwayat penyakit ginjal/ kandung kemih ................................................................................
Penggunaan diuretik ................................................................................................................
Abdomen : Nyeri tekan

Lunak

Keras

Bising usus :..............x/menit

Masalah lainnya :. ......................

MAKANAN/ CAIRAN
Diit biasa (tipe) : ............................................. Jumlah makanan per hari .................................
Makan terakhir/ masukan ............................... Pola diit ............................................................
Kehilangan selera makan ................................ Mual/ muntah ...................................................
Nyeri ulu hati ..................................................Yang berhubungan dengan................................
Alergi/ intoleransi makanan .......................................................................................................
Masalah-masalah mengunyah/ menelan ....................................................................................
Berat badan biasa ........................................... Perubahan berat badan .....................................
Berat badan sekarang ..................................... Tinggi badan ....................................................
Bentuk tubuh ..............................................................................................................................
Turgor kulit :...............................................................................................................................
Kelembaban/ kering membran mukosa :....................................................................................
Kondisi gigi/ gusi :......................................................................................................................
Penampilan lidah :.......................................................................................................................
Masalah lainnya :........................................................................................................................
HIGIENE
Aktivitas sehari-hari (Tergantung/ Mandiri)
Mobilitas :............................................................... Makan :.................................................
Hegiene Berpakaian :............................................. Toileting :..............................................
Bantuan diberikan oleh:............................................................................................................
Penampilan umum :....................................................................................................................
Waktu mandi yang diinginkan:...................................................................................................
Cara berpakaian :........................................................................................................................
Kebiasaan pribadi :.....................................................................................................................
Bau badan: .................................................................................................................................
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Kondisi kulit kepala :..................................................................................................................

Adanya kutu :..............................................................................................................................
Masalah lainnya :........................................................................................................................
NEUROSENSORI
Rasa ingin pingsan/ pusing:........................................................................................................
Sakit kepala : Lokasi nyeri :..............................Frekuensi :.......................................................
Kesemutan/ kebas/ kelemahan (lokasi) :.....................................................................................
Stroke (gejala sisa) :....................................................................................................................
Mata :
Kehilangan penglihatan:................................. Pemeriksaan terakhir :..................................
Glaukoma :...................................................... Katarak:.........................................................
Telinga:
Kehilangan pendengaran :............................... Pemeriksaan terakhir :..................................
Epistaksis:..........................................................
Status mental :...................................................
Terorientasi/ disorientasi :
Waktu :............................................................
Tempat :...........................................................
Orang :.............................................................
Kesadaran :
Mengantuk

Letargi

Stupor

Koma

Kooperatif

Menyerang

Delusi

Halusinasi

Afek (gambarkan)....................................................................................................................
Kaca mata :........................................................Kontak lensa :..................................................
Alat bantu dengar :.............................................Rekasi pupil : Ka/ Ki ......................................
Genggaman tangan/ lepas : Ka/ Ki:............................................................................................
Postur .........................................................................................................................................
Masalah lainnya .........................................................................................................................

NYERI/ KETIDAKNYAMANAN
Faktor-faktor pencetus ........................................ Kualitas........................................................
Lokasi................................................................... intensitas (1-10)...........................................
Frekuensi.............................................................. Durasi ..........................................................
Penjalaran:...................................................................................................................................
Cara menghilangkan: Mengkerutkan muka

Menjaga area yang sakit

Respons emosional .....................................................................................................................

Masalah lainnya :........................................................................................................................
PERNAPASAN
Dispnea yang berhubungan dengan batuk/ sputum :..................................................................
Riwayat bronkitis:.............................................. Asma :............................................................
Tuberkulosis :.................................................... Emifisema :....................................................
Pneumonia kambuhan :...............................................................................................................
Pemanjanan terhadap udara berbahaya :.....................................................................................
Merokok :.....................................

Banyak:.hari

Lama: .......................tahun

Penggunaan alat bantu pernapasan:............................................................................................

Frekuensi :x/menit

Kedalaman:...................................................................

Simetris : ..........................................

Penggunaan otot-otot asesori .......................................

Masalah lainnya :........................................................................................................................

KEAMANAN
Alergi/ sensitivitas :...........................................Reaksi :............................................................
Perubahan sistem imun sebelumnya :................Penyebab :.......................................................
Tranfusi darah/ jumlah :.....................................Kapan :............................................................
Gambaran reaksi :.......................................................................................................................
Riwayat cedera kecelakaan :.......................................................................................................
Fraktur/ dislokasi :......................................................................................................................
Artritis/ sendi tak stabil :.............................................................................................................
Masalah punggung :....................................................................................................................
Kerusakan penglihatan, pendengaran :.......................................................................................
Suhu tubuh :.......................................................Diaforesis :......................................................
Integritas kulit :...........................................................................................................................
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Jaringan parut :..................................................Kemerahan :....................................................

Laserasi:.............................................................Ulserasi :..........................................................
Ekimosis :..........................................................Lepuh :............................................................
Luka bakar : (derajat/ persen):...........................Drainase:.........................................................
Tandai lokasi pada diagram di bawah ini :

Kekuatan Umum :..............................................Tonus otot:.......................................................

Cara berjalan :....................................................ROM :..............................................................
Parestesia/ paralisis :...................................................................................................................
Masalah lainnya :........................................................................................................................
INTERAKSI SOSIAL
Status perkawinan :.....................................................................................................................
Hidup dengan :............................................................................................................................
Masalah-masalah/ stres :.............................................................................................................
Orang pendukung lain :...............................................................................................................
Masalah-masalah yang berhubungan dengan penyakit/ kondisi :...............................................
Bicara : Jelas

Tak Jelas

Tidak Dapat Dimengerti

Afasia .

Masalah lainnya :........................................................................................................................

PENYULUHAN/ PEMBELAJARAN
Bahasa dominan (khusus) :................................Melek huruf :...................................................
Tingkat pendidikan :...................................................................................................................
Keterbatasan kognitif :................................................................................................................
Masalah lainnya :........................................................................................................................
Obat yang diresepkan :

ANALISA DATA
No
Data Senjang
Etiologi
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Masalah
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RENCANA ASUHAN KEPERAWATAN

No
Diagnosa Keperawatan
Tujuan / sasaran
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Intervensi
Paraf
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TINDAKAN KEPERAWATAN

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No.
Dx
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Waktu

Catatan tindakan dan evaluasi hasil tindakan

Paraf

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CATATAN PERKEMBANGAN
Tanggal

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S O AP

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Mengetahui,

CI/Kepala Ruangan..

Mahasiswa

...

Dosen Pembimbing

24