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PENGKAJIAN KEPERAWATAN

KEPERAWATAN MEDIKAL BEDAH


PROGRAM STUDI PROFESI NERS
Nama mahasiswa yang mengkaji : Sulfiana

NIM : 15.04.044

Ruangan : Lontara 3 atas belakang

Tanggal Pengkajian : 11 11 - 2011

Kamar

Waktu Pengkajian : 14.30

Tanggal masuk RS : 10 11 2015

Auto Anamnese
Allo Anamnese

I.

IDENTITAS
A. Klien
Nama Initial

: Tn. K

Tempat/Tanggal Lahir (Umur)

: Belawa, 1 - 7 - 1963

Jenis Kelamin

Laki-laki

Perempuan

Status Perkawinan

Kawin/Tidak

Janda / Duda

Jumlah Anak

: -

Agama/Suku

: Islam, bugis

Warga Negara

Bahasa yang digunakan

Pendidikan

Indonesia

Asing

Indonesia
SD

Daerah

SMP

SMA

Tidak/Belum Sekolah
Pekerjaan

Swasta

Asing
S-1

Lainnya

Pegawai Negeri

petani
Alamat

: Jl. Belawa, Sidrap

B. Penanggung Jawab

II.

Nama

: Tn. B

Alamat

: Perdos, tamalanrea

DATA MEDIK
A. Dikirim Oleh

B. Diagnosa Medik

UGD

Saat Masuk

: Os. Ulkus Kornea

Saat Pengkajian

: Os. Ulkus Kornea

S-2

Dokter Praktek

Lainnya,

III.

KEADAAN UMUM
A. Keadaan Sakit

: Klien tampak sakit ringan/ sedang/ berat/ tidak tampak

sakit/ tidak bereaksi/ baring lemah/ duduk/ aktif/ pucat/ sianosis/ sesak nafas.
Penggunaan alat medik : ............................................................................................
............................................................................................
............................................................................................
............................................................................................
Keluhan Utama

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

B. Tanda-tanda Vital
1. Kesadaran

Kualitatif

Compos Mentis

Somnolens

Apatis
Kuantitatif

Koma

Soporcoma

Skala Coma Glasgow : 15

Respon Motorik

:6

Respon Bicara

:5

Respon Membuka Mata : 4


Kesimpulan : Kesadaran penuh
Tremor
2. Tekanan Darah

Positif

Negatif

:120/80 mmHg

Kesimpulan : Normal
3. Suhu

: 36,5 C

4. Nadi

: 80 x/ menit

5. Pernapasan

: 20 x/ menit

Oral

Axilla

Irama

Teratur

Kusmaul

Jenis

Dada

Perut

Rectal

Cheyne-Stokes

C. Pengukuran
1. Lingkar lengan atas : ................. cm

Tinggi Badan : 165 cm

2. Lipat kulit triceps

Berat Badan : 58 kg

: ................. cm

Indeks Massa Tubuh (IMT)

: 21,3 Kg/ m2

Kesimpulan

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

Catatan

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

D. Genogram

Tn. K

IV.

PENGKAJIAN POLA KESEHATAN


A. Kajian Persepsi Kesehatan Pemeliharaan Kesehatan
Riwayat penyakit yang pernah dialami : sakit berat/ dirawat/ kecelakaan, operasi,
gangguan kehamilan/ persalinan/ abortus/ transfusi/ reaksi alergi.
Kapan : .........................................................
Catatan :........................................................
........................................................
........................................................
........................................................
Kapan : .........................................................
Catatan : ........................................................
........................................................
........................................................
........................................................

Riwayat Kesehatan Sekarang :


Klien mengeluh nyeri pada mata sebelah kiri naik ke kepala.
1. Data Subyektif :
a. Keadaan sebelum sakit :
Klien mampu beraktivitas penuh tanpa bantuan
b. Keadaan sejak sakit/ sakit saat ini :
Klien mengeluh penglihatan kabur
Klien mengeluh nyeri pada mata kiri disertai sakit kepala
2. Data Obyektif
Observasi :
Kebersihan rambut : bersih
Kulit Kepala

: bersih

Kebersihan Mulut : bersih


B. Kajian Nutrisi Metabolik
1. Data Subyektif
a. Keadaan sebelum sakit :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.......................
b. Keadaan sejak sakit/ sakit saat ini :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.......................
2. Data Obyektif
a. Observasi :
.....................................................................................................................................
.....................................................................................................................................
....................................................................................................
b. Pemeriksaan Fisik
Keadaan Rambut : ..........................................................................................
..........................................................................................
Hidrasi Kulit

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

Conjungtiva

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

Hidung

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

Rongga Mulut

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

Gusi

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

Kemampuan mengunyah keras : ...................................................................


..........................................................................................
Lidah

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

Pharing

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

Kelenjar getah bening :..................................................................................


.........................................................................................
Kelenjar tyroid : ..........................................................................................
..........................................................................................
Abdomen
Inspeksi Bentuk : ..........................................................................................

...........................................................................................
Bayangan Vena
Auscultasi
Palpasi :

Benjolan Massa

: Peristaltik : ................ x/ menit


Tanda nyeri umum : ...............................................................
..............................................................
..............................................................
..............................................................
..............................................................
..............................................................
Massa

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

Hidrasi Kulit

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

Perkusi :
Ascites

Negatif

Positif

Lingkar Perut : ............. cm


Kelenjar Lympe Inguinale :
Kulit :
Oedema

Negatif

Positif

Ichterik

Negatif

Positif

Tanda Radang...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
...........................................................................................
Lesi ............................................................................................................
....................................................................................................................
....................................................................................................................
.....................................................................................................................
Lain-lain .....................................................................................................
....................................................................................................................
....................................................................................................................
Kesimpulan .....................................................................................................

....................................................................................................................
...................................................................................................................
....................................................................................................................
....................................................................................................................
c. Pemeriksaan Diagnostik
Laboratorium
WBC : 14.2 mm3
HGB : 9.5 g/dL
MCHC : 22.2 g/dL
Lainlain ..............................................................................................................................
.....................................................................................................................................
...........................................................................................................
d. Terapi
Infus RL 16tts/menit
c.LFx EDMD 1 tetes/4jam/OS
c.Tobro 1 tetes/4jam/OS
c.Reepitel EDMD 1 tetes/4jam/OS
Nevanac ED 1tetes/8jam/OS
c. Tropin 1% ED 1tetes/12jam/OS
C. Kajian Pola Eliminasi
1. Data Subyektif
a. Keadaan sebelum sakit :
b. Keadaan sejak sakit/ sakit saat ini :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.
2. Data Obyektif
a. Observasi ....................................................................................................................
.....................................................................................................................................

.....................................................................................................................................
..........................................................................................................
b. Pemeriksaan Fisik
Peristaltik usus .......... x/ menit
Palpasi supra pubic : Kandung kemih

Penuh

Kosong

Nyeri ketuk ginjal : Kiri

Negatif

Positif

Kanan

Negatif

Positif

Anus :
Peradangan

Negatif

Positif

Fissura

Negatif

Positif

Hemorhoid

Negatif

Positif

Prolapsus Recti

Negatif

Positif

Fistula Ani

Negatif

Positif

Massa Tumor

Negatif

Positif

Kesimpulan :
...........................................................................................................................
..........................................................................................................................
..........................................................................................................................
D. Kajian Pola Aktivitas dan Latihan
1. Data Subyektif
a. Keadaan sebelum sakit :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
....................................................................................................................................
b. Keadaan sejak sakit/ sakit saat ini :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

2. Data Objektif
a. Observasi
Aktivitas harian
Makan

: Mandiri

Mandi

Berpakaian

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

...............................................................................................
Kerapian

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

...............................................................................................
BAB

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

...............................................................................................
BAK

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

...............................................................................................
Mobilisasi ditempat tidur : dibantu sebagian
Ambulasi

: Mandiri

Postur tubuh

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

...............................................................................................
Anggota gerak yang cacat : ..................................................
...............................................................................................
Fixasi

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

...............................................................................................
Kesimpulan :
.....................................................................................................................................
.....................................................................................................................................
....................................................................................................
Perfusi pembuluh perifer kuku :
.....................................................................................................................................
...............................................................................................................
..........................................................................................................................
Thorax dan Pernapasan
Inspeksi

Bentuk Thoraks : .................................................................


Stridor

Negatif

Positif

Dyspnea deffort

Negatif

Positif

Syanosis

Negatif

Positif

Palpasi

Vocal Fremitus : ...................................................................


...............................................................................................
...............................................................................................

Perkusi

Sonor

Redup

Pekak

Batas Paru Hepar : ................................................................


...............................................................................................
...............................................................................................
...............................................................................................
...............................................................................................
Auskultasi
Suara Napas : ........................................................................
...............................................................................................
...............................................................................................
...............................................................................................
Suara Ucapan : .....................................................................
...............................................................................................
...............................................................................................
...............................................................................................
Suara Tambahan : .................................................................
...............................................................................................
...............................................................................................
...............................................................................................
Jantung
Inspeksi

: Ictus Cordis :......................................................................


.............................................................................................
.............................................................................................
Klien menggunakan alat pacu jantung :

Negatif
Positif

Palpasi

: Ictus Cordis : .....................................................................


..............................................................................................
..............................................................................................

Perkusi
Batas Atas Jantung : ............................................................
..............................................................................................
Batas Kanan Jantung : .........................................................

..............................................................................................
Batas Bawah Jantung : ........................................................
..............................................................................................
Batas Kiri Jantung : .............................................................
.............................................................................................
Auskultasi
Bunyi Jantung II A : ............................................................
..............................................................................................
Bunyi Jantung II P : ............................................................
..............................................................................................
Bunyi Jantung I T : ..............................................................
..............................................................................................
Bunyi Jantung I M : .............................................................
..............................................................................................
Bunyi Jantung III Irama Gallop :
Negatif
Mur-mur

Positif
Negatif

Positif
Tempat : ..............
.............................
Grade : ................
.............................

HR : .......... x/ menit
Bruit Aorta

Negatif

Positif

A. Renalis

Negatif

Positif

A. Femoralis

Negatif

Positif

Lengan dan Tungkai


Atrofi Otot

Negatif

Positif

Rentang Gerak : ...................................................................


..............................................................................................
Mati Sendi : .......................................................
............................................................................
Kaku Sendi : .....................................................
...........................................................................
Refleks Fisiologi : ................................................................
..............................................................................................

E. Kajian Pola Tidur dan Istirahat


1. Data Subyektif
a. Keadaan Sebelum Sakit ..................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
b. Keadaan Sejak Sakit ......................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
........................................................

2. Data Obyektif
a. Observasi :
Ekspresi wajah mengantuk

Negatif

Positif

Banyak menguap

Negatif

Positif

Palpabrae inferior berwarna gelap

Negatif

Positif

b. Terapi :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
...................................................................

F. Kajian Pola Persepsi Kognitif


1. Data Subyektif
a. Keadaan Sebelum Sakit
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................
........................................................................................................................
b. Keadaan Sejak Sakit
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.............................................
2. Data Obyektif
a. Observasi
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
..............................................................................
b. Pemeriksaan Fisik
Penglihatan
Cornea : ................................................................................
..............................................................................................
Visus :..................................................................................
..............................................................................................
Pupil : ...................................................................................

..............................................................................................
Lensa Mata : ........................................................................
.............................................................................................
Tekanan Intra Okuler : ........................................................
.............................................................................................
Pendengaran
Pina : ....................................................................................
.............................................................................................
Canalis : ..............................................................................
............................................................................................
Membran Timpani : ............................................................
.............................................................................................
Test Pendengaran : .............................................................
.............................................................................................
............................................................................................
G. Kajian Pola Persepsi dan Konsep Diri
1. Data Subyektif
a. Keadaan Sebelum Sakit
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.......................
b. Keadaan Sejak Sakit
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.......................
2. Data Obyektif
a. Observasi
Kontak Mata :
.....................................................................................................................................
...............................................................................................................
Rentang Penglihatan :
.....................................................................................................................................
...............................................................................................................
Suara dan Tata bicara :
.....................................................................................................................................
.....................................................................................................................................
....................................................................................................
Postur Tubuh :
.....................................................................................................................................
.....................................................................................................................................
....................................................................................................
b. Pemeriksaan Fisik
Abdomen :
Bentuk :..........................................................................
........................................................................................
........................................................................................
........................................................................................
Bayangan Vena : ...........................................................
........................................................................................
.........................................................................................
.........................................................................................
Bayangan Massa : ...........................................................
.........................................................................................
........................................................................................
........................................................................................

Kulit :
Lesi Kulit : ......................................................................
.........................................................................................
.........................................................................................
.........................................................................................
H. Kajian Pola Peran dan Hubungan Dengan Sesama
1. Data Subyektif
a. Sebelum keadaan sakit
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
b. Keadaan sejak sakit
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
2. Data Obyektif
Observasi
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
I. Kajian Pola Reproduksi-Seksualitas
1. Data Subyektif
a. Keadaan sebelum sakit :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
b. Keadaan sejak sakit :
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

2. Data Obyektif
a. Observasi
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
b. Pemeriksaan Fisik
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
c. Pemeriksaan Diagnostik
Laboratorium
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.......................
Lain-lain
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
d. Terapi
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
....................................................................................................................................

J. Kajian Mekanisme Koping dan Toleransi Terhadap Stress


1. Data Subyektif
a. Keadaan sebelum sakit
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.......................
b. Keadaan sejak sakit
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.......................
2. Data Obyektif
a. Observasi
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

b. Pemeriksaan Fisik
Tekanan Darah :

Berbaring :

mmHg

Duduk :

mmHg

Berdiri :

mmHg

Kesimpulan Hipotensi Ortostatik :


HR

x/menit

Kulit

Keringat

Negatif

Positif

Dingin

Basah

c. Terapi
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.......................

K. Kajian Pola Sistem Nilai Kepercayaan


1. Data Subyektif
a. Keadaan sebelum sakit
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
b. Keadaan sejak sakit
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

2. Data Obyektif
Observasi
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.................................................................
Yang Mengkaji

PENGELOMPOKAN DATA

DATA OBYEKTIF
Klien

mengeluh

DATA SUBYEKTIF
nyeri

pada

Ekspresi wajah nampak meringis

daerah matanya

Nampak memegang area mata

P : Mata merah

Penurunan

ketajaman

Q : Nyeri Tajam

penurunan visus

R : Mata Kiri

Hasil :

S:4

VOD : 20/40

T : Intermiten

VOS : 1/300

Klien mengeluh sakit kepala


Klien

mengeluh

beraktivitas

tidak

seperti

dapat

biasanya

Nampak mengecilkan mata bila


ada respon cahaya
Mata nampak merah

karena gangguan penglihatan


Klien mengeluh penglihatannya
kabur
Klien mengeluh penglihatan silau

DIAGNOSA KEPERAWATAN
Nama / Umur

: Tn. K / 52 tahun

mata,

Ruang / Kamar
N
O.
1.

: Lontara 3 Atas Belakang / K5 bed 6

DIAGNOSA KEPERAWATAN

NAMA

Nyeri berhubungan dengan agens penyebab cedera fisik ;

JELAS
Nyeri

tertusuk kulit buah coklat.


2.

Gangguan Persepsi Sensori (Penglihatan) berhubungan


dengan perubahan dan atau penurunan integrasi sensori.

Gangguan
persepsi
sensori

RENCANA ASUHAN KEPERAWATAN


Nama/ Umur

: Tn. K / 52 tahun

Ruang / Kamar

: Lontara 3 Atas Belakang

DIAGNOSA

TUJUAN/ HASIL YANG

RENCANA

RASIONAL

KEPERAWATAN

DIHARAPKAN

TINDAKAN

TINDAKAN

D
/
N
A
M
A

Nyeri berhubungan

dengan
penyebab

agens
cedera

fisik ; tertusuk kulit

buah coklat.

1. Kaji skala nyeri dengan


Setelah

dilakukan

tindakan

keperawatan selama 1 x 24 jam


pasien

mengatakan

nyeri

berkuranang deng dengan kriteria


hasil:

Mampu mengontrol nyeri

(tahu penyebab nyeri, mampu

menggunakan

farmakologi untuk mengurangi

nyeri)

tehnik

non

menggunakan PQRST
2. Observasi Tanda
tanda vital
3. Kontrol

lingkungan

yang

dapat

mempengaruhi

nyeri

seperti suhu ruangan,


pencahayaan

dan

kebisingan

4. Ajarkan

tentang teknik

non farmakologi: napas

Melaporkan

bahwa

nyeri

berkurang dengan menggunakan


manajemen nyeri

Tanda vital dalam rentang


normal

dalam.
5. Berikan analgetik untuk
mengurangi nyeri.

1. Mengetahui

derajat

nyeri yang dirasakan


klien

sehingga

memudahkan

dalam

menentukan tindakan
selanjutnya.
2. Suplay okesigen ke
jaringan
maka

barkurang
akan

menyebabkan nyeri
3. lingkungan
yang
nyaman

dapat

mengurangi nyeri.
4. Untuk
mengurangi
rasa nyeri.

DIAGNOSA

TUJUAN/

KEPERAWATAN

YANG

HASIL

DIHARAPKAN

RENCANA

RASIONAL

TINDAKAN

TINDAKAN

T
D
/
N
A
M
A

1
1

Gangguan Persepsi

Setelah

dilakukan

Sensori

tindakan keperawatan

penglihatan,

(Penglihatan)

selama 1 x 24 jam

apakah satu atau kedua

berhubungan

pasien

mampu

dengan perubahan

mengenal

dan atau penurunan

sensori

integrasi sensori.

berkompensasi

2
0
1
5

gangguan
dan

terhadap perubahan.

1. Tentukan

ketajaman 1. Kebutuhan individu dan


catat

mata terlibat.
2. Orientasi

intervensi

bervariasi

sebab

kehilangan
pasien

terhadap lingkungan.
3. Observasi tanda dan
gejala

pilihan

disorientasi

terjadi

penglihatab
lambat

dan

progresif.
2. Memberikan peningkatan

kenyamanan.
pagar 3. Menurunkan resiko jatuh

pertahankan

tempat tidur.
bila pasien bingung.
4. Berikan
pendidikan 4. Untuk
mencegah
kesehatan
pemberian
(Jika ada).

tentang
obat

mata

kemungkinan
kesalahan
pemberian obat.

terjadinya
dalam

PELAKSANAAN ASUHAN KEPERAWATAN


Nama / Umur

: Tn. K / 52 tahun

Ruang / Kamar

: Lontara 3 Atas Belakang

TAN

PELAKSANAAN

NAMA

GG

KEPERAWATAN

JELAS

AL

D
1

P
1

14

1. Mengkaji

nov

menggunakan PQRST
2. Mengobservasi tanda tanda vital
3. Mengontrol lingkungan yang dapat

2015

skala

nyeri

dengan

mempengaruhi nyeri seperti suhu


ruangan,

pencahayaan

dan

kebisingan

4. Mengajarkan

tentang teknik non

farmakologi: napas dalam.

5. Memberikan

analgetik

untuk

mengurangi nyeri

WA

PELAKSANAAN

NAMA

KTU

KEPERAWATAN

JELAS

.
D

P
2

14
nov
2015

1. Menentukan ketajaman penglihatan,


catat apakah satu atau kedua mata
terlibat.
2. Mengorientasi

pasien

terhadap

lingkungan.
3. Mengobservasi tanda dan gejala
disorientasi

pertahankan

pagar

tempat tidur.
4. Memberikan pendidikan kesehatan
tentang pemberian obat mata (Jika
ada).

EVALUASI ASUHAN KEPERAWATAN


Nama / Umur

: Tn. K / 52 tahun

Ruang / Kamar

: Lontara 3 Atas Belakang / K5 bed 6

N
O

DP

TAN

EVALUASI KEPERAWATAN

NAM

GG

AL

JELA
S

Ny

S : Klien mengatakan nyeri mata kiri

eri

berkurang
O : Keadaan umum baik
Kesadaran Compos mentis
Skala nyeri 2
A : Masalah belum teratasi
P : Lanjutkan intervensi 1,2,4,5

S : Klien mengatakan penglihatannya kabur


Ga

O : Klien Nampak memegang area mata


VOD : 20/40
VOS : 1/300
A : Masalah belum teratasi

ng
gua
n

P : Lanjutkan intervensi 2, 3, 4

per
sep
si
sen
sor
i

N
O

DP

TAN

EVALUASI KEPERAWATAN

NAM

GG

AL

JELA
S