YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN

Jl. Beliang No. 110 Telp / Fax (0536) 3227707

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. RIWAYAT KESEHATAN /PERAWATAN

1. Keluhan Utama :
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2. Riwayat Penyakit Sekarang :
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3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi)
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4. Riwayat Penyakit Keluarga

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GENOGRAM KELUARGA :
C. PEMERIKASAAN FISIK
1. Keadaan Umum :
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2. Status Mental :
a. Tingkat Kesadaran : .
b. Ekspresi wajah : .
c. Bentuk badan : .
d. Cara berbaring/bergerak : .
e. Berbicara : .
f. Suasana hati : .
g. Penampilan : .
h. Fungsi kognitif :
Orientasi waktu : .
Orientasi Orang : .
Orientasi Tempat : .
i. Halusinasi : Dengar/Akustic Lihat/Visual Lainnya .................
j. Proses berpikir : Blocking Circumstansial Flight oh ideas
Lainnya
k. Insight : Baik Mengingkari Menyalahkan orang lain
m. Mekanisme pertahanan diri : Adaptif Maladaptif
n. Keluhan lainnya : .

3. Tanda-tanda Vital :
a. Suhu/T : .0C Axilla Rektal Oral
b. Nadi/HR : x/mt
c. Pernapasan/RR : ....x/tm
d. Tekanan Darah/BP : .....mm Hg

4. PERNAPASAN (BREATHING)
Bentuk Dada : ..........................................................................
Kebiasaan merokok : ...Batang/hari
Batuk, sejak ...........................................................

Batuk darah, sejak .................................................

Sputum, warna ......................................................

Sianosis

Nyeri dada

Dyspnoe nyeri dada Orthopnoe Lainnya ...

Sesak nafas saat inspirasi Saat aktivitas Saat istirahat

Type Pernafasan Dada Perut Dada dan perut
Kusmaul Cheyne-stokes Biot
Lainnya
Irama Pernafasan Teratur Tidak teratur
Suara Nafas Vesukuler Bronchovesikuler
Bronchial Trakeal
Suara Nafas tambahan Wheezing Ronchi kering
Ronchi basah (rales) Lainnya
Keluhan lainnya :
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Masalah Keperawatan :
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5. CARDIOVASCULER (BLEEDING)
Nyeri dada Kram kaki Pucat

Pusing/sinkop Clubing finger Sianosis

Sakit Kepala Palpitasi Pingsan

Capillary refill > 2 detik < 2 detik

Oedema : Wajah Ekstrimitas atas

Anasarka Ekstrimitas bawah
Asites, lingkar perut . cm

Ictus Cordis Terlihat Tidak melihat

Vena jugularis Tidak meningkat Meningkat
 Suara jantung Normal,.
Ada kelainan
Keluhan lainnya :
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Masalah Keperawatan :
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6. PERSYARAFAN (BRAIN)
Nilai GCS : E : .
V : .
M : .
Total Nilai GCS :
Kesadaran : Compos Menthis Somnolent Delirium
Apatis Soporus Coma
Pupil : Isokor Anisokor
Midriasis Meiosis
Refleks Cahaya : Kanan Positif Negatif
Kiri Positif Negatif
Nyeri, lokasi ..

Vertigo Gelisah Aphasia Kesemutan

Bingung Disarthria Kejang Trernor

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 : Jari ke jari Positif Negatif
Jari ke hidung Positif Negatif
Ekstrimitas Bawah : Tumit ke jempul kaki Positif Negatif
Uji Kestabilan Tubuh : Positif Negatif
Refleks :
Bisep : Kanan +/- Kiri +/- Skala. Trisep :
Kanan +/- Kiri +/- Skala. Brakioradialis:
Kanan +/- Kiri +/- Skala. Patella :
Kanan +/- Kiri +/- Skala. Akhiles :
Kanan +/- Kiri +/- Skala. Refleks Babinski
Kanan +/- Kiri +/-
Refleks lainnya : ..........................................................................................
Uji sensasi : ..........................................................................................
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Keluhan lainnya :
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Masalah Keperawatan :
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7. ELIMINASI URI (BLADDER) :
Produksi Urine : .mlx/hr
Warna :
Bau :
Tidak ada masalah/lancer Menetes Inkotinen
Oliguri Nyeri Retensi
Poliuri Panas Hematuri
 Dysuri Nocturi
Kateter Cystostomi
Keluhan Lainnya :
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Masalah Keperawatan :
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8. ELIMINASI ALVI (BOWEL) :
Mulut dan Faring
Bibir : ...................................................................................................
Gigi : ...................................................................................................
Gusi : ...................................................................................................
Lidah : ...................................................................................................
Mukosa : ...................................................................................................
Tonsil : ...................................................................................................
Rectum :
Haemoroid :
BAB : .x/hr Warna :.. . Konsistensi : .
Tidak ada masalah Diare Konstipasi Kembung

Feaces berdarah Melena Obat pencahar Lavement

Bising usus : ..........................................................................................
Nyeri tekan, lokasi : ..........................................................................................
Benjolan, lokasi : ..........................................................................................
Keluhan lainnya :
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Masalah Keperawatan :
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9. TULANG - OTOT INTEGUMEN (BONE) :
Kemampuan pergerakan sendi Bebas Terbatas
Parese, lokasi
Paralise, lokasi ...................................................................................................
Hemiparese, lokasi ............................................................................................
 Krepitasi, lokasi .................................................................................................
Nyeri, lokasi
Bengkak, lokasi .................................................................................................
Kekakuan, lokasi ...............................................................................................
Flasiditas, lokasi ................................................................................................
Spastisitas, lokasi ..............................................................................................
Ukuran otot Simetris
Atropi
Hipertropi
Kontraktur
Malposisi
Uji kekuatan otot : Ekstrimitas atas.. Ekstrimitas bawah..
Deformitas tulang, lokasi...................................................................................
Peradangan, lokasi..............................................................................................
Perlukaan, lokasi................................................................................................
Patah tulang, lokasi............................................................................................
Tulang belakang Normal Skoliosis
Kifosis Lordosis

10. KULIT-KULIT RAMBUT

Riwayat alergi Obat............................................................................
Makanan....................................................................
Kosametik..................................................................
Lainnya......................................................................
Suhu kulit Hangat Panas Dingin
Warna kulit Normal Sianosis/ biru Ikterik/kuning
Putih/ pucat Coklat tua/hyperpigmentasi
Turgor Baik Cukup Kurang
Tekstur Halus Kasar
Lesi : Macula, lokasi
Pustula, lokasi............................................................
 Nodula, lokasi............................................................
Vesikula, lokasi..........................................................
Papula, lokasi.............................................................
Ulcus, lokasi..............................................................
Jaringan parut lokasi..............................................................................................
Tekstur rambut ...................................................................................................
Distribusi rambut...................................................................................................
Bentuk kuku Simetris Irreguler
Clubbing Finger Lainnya....................
Masalah Keperawatan :
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11. SISTEM PENGINDERAAN :
a. Mata/Penglihatan
Fungsi penglihatan : Berkurang Kabur
Ganda Buta/gelap
Gerakan bola mata : Bergerak normal Diam
Bergerak spontan/nistagmus
Visus : Mata Kanan (VOD) :............................................................
Mata kiri (VOS) :.............................................................

Selera Normal/putih Kuning/ikterus Merah/hifema Konjunctiva

Merah muda Pucat/anemic
Kornea Bening Keruh
Alat bantu Kacamata Lensa kontak Lainnya.
Nyeri : .................................................................................................
Keluhan lain :..................................................................................................

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

Patensi

Obstruksi

Nyeri tekan sinus

Transluminasi
Cavum Nasal Warna.. Integritas..
Septum nasal Deviasi Perforasi Peradarahan
Sekresi, warna
Polip Kanan Kiri Kanan dan Kiri
Masalah Keperawatan :
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12. LEHER DAN KELENJAR LIMFE

Massa Ya Tidak
Jaringan Parut Ya Tidak
Kelenjar Limfe Teraba Tidak teraba
Kelenjar Tyroid Teraba Tidak teraba
Mobilitas leher Bebas Terbatas
13. SISTEM REPRODUKSI
a. Reproduksi Pria
Kemerahan, Lokasi......................................................
Gatal-gatal, Lokasi.......................................................
Gland Penis .................................................................
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......................................................................................................
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Payudara :
Simetris Asimetris
Sear Lesi
Pembengkakan Nyeri tekan
Puting : Menonjol Datar Lecet Mastitis
Warna areola .....................................................................................................
ASI Lancar Sedikit Tidak keluar
Keluhan lainnya.................................................................................................
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Masalah Keperawatan :
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D. POLA FUNGSI KESEHATAN
1. Persepsi Terhadap Kesehatan dan Penyakit :
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2. Nutrisida Metabolisme
TB : Cm
BB sekarang : Kg
BB Sebelum sakit : Kg
Diet :
 Biasa Cair Saring Lunak
Diet Khusus :
Rendah garam Rendah kalori TKTP
Rendah Lemak Rendah Purin Lainnya.
Mual
Muntah.kali/hari
Kesukaran menelan Ya Tidak
Rasa haus
Keluhan lainnya.....................................................................................................
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
Masalah Keperawatan

3. Pola istirahat dan tidur




Masalah Keperawatan

4. Kognitif :




Masalah Keperawatan

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




Masalah Keperawatan

6. Aktivitas Sehari-hari




Masalah Keperawatan

7. Koping Toleransi terhadap Stress




Masalah Keperawatan

8. Nilai-Pola Keyakinan



Masalah Keperawatan

E. SOSIAL - SPIRITUAL
1. Kemampuan berkomunikasi




2. Bahasa sehari-hari

3. Hubungan dengan keluarga :

4. Hubungan dengan teman/petugas kesehatan/orang lain :




5. Orang berarti/terdekat :



6. Kebiasaan menggunakan waktu luang :



7. Kegiatan beribadah :


F. DATA PENUNJANG (RADIOLOGIS, LABORATURIUM, PENUNJANG LAINNYA)

G. PENATALAKSANAAN MEDIS
 . ....
Mahasiswa

( )

ANALISIS DATA
DATA SUBYEKTIF DAN
KEMUNGKINAN PENYEBAB MASALAH
DATA OBYEKTIF
PRIORITAS MASALAH
 RENCANA KEPERAWATAN

Nama Pasien : ..

Ruang Rawat : ..

Diagnosa Keperawatan Tujuan (Kriteria hasil) Intervensi Rasional

 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/Tanggal Tanda tangan dan

Implementasi Evaluasi (SOAP)
Jam Nama Perawat