FORMAT ASUHAN KEPERAWATAN KEPERAWATAN MEDIKAL BEDAH

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PROGRAM STUDI NERS STIKES WIYATA HUSADA SAMARINDA

Kelompok : Kelompok 6
Tempat praktek :
Tanggal :

I. Identitas diri klien

Nama :Ny. S Suku : …………………………………............

Umur : Pendidikan :..........................................................

Jemis kelamin : Perempuan Pekerjaan :..........................................................

Alamat :........................................... Lama bekerja :..........................................................
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…………………………………………………....................... Tanggal masuk RS :........................................

Status perkawinan ............................................................ Tanggal Pengkajian : ……………………...........

Agama: .................................................................................. Sumber Informasi : ……………………….......

II. Riwayat penyakit

1. Keluhan utama saat masuk RS:

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2. Riwayat penyakit sekarang:
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Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
3. Riwayat Penyakit Dahulu
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4. Diagnosa medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah dilakukan:
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Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
III. Pengkajian saat ini (mulai hari pertama saudara merawat klien)
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1. Persepsi dan pemeliharaan kesehatan

Pengetahuan tentang penyakit/perawatan

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2. Pola nutrisi/metabolic
Program diit RS:
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Intake makanan:
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Intake cairan:
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3. Pola eliminasi
a. Buang air besar

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b. Buang air kecil

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Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
4. Pola aktifitas dan latihan:
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Kemampuan perawatan diri 0 1 2 3 4
Makan/minum

Mandi

Toileting

Berpakaian

Mobilitas di tempat tidur

Berpindah

Ambulasi/ROM

0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung
total Oksigenasi:
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5. Pola tidur dan istirahat
(lama tidur, gangguan tidur, perawasan saat bangun tidur)

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6. Pola persepsual
(penglihatan, pendengaran, pengecap, sensasi):
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7. Pola persepsi diri
(pandangan klien tentang sakitnya, kecemasan, konsep diri)
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Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
 8. Pola seksualitas dan reproduksi
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(fertilitas, libido, menstuasi, kontrasepsi, dll.)

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9. Pola peran hubungan

(komunikasi, hubungan dengan orang lain, kemampuan keuangan):
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10. Pola managemen koping-stess

(perubahan terbesar dalam hidup pada akhir-akhir ini):

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11. Sistem nilai dan keyakinan
(pandangan klien tentang agama, kegiatan keagamaan, dll)
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IV. Pemeriksaan fisik

(cephalocaudal) yang meliputi : Inspeksi, Palpasi, Perkusi dan Auskultasi
keluhan yang dirasakan saat ini

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TD: mm/H P: x/m N: x/m S: oC BB/TB…………………………………………

Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
Kepala:
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Mata dan Telinga (Penglihatan dan pendengaran)

a. Penglihatan

Berkurang Ganda Kabur Buta/ gelap

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▪ Visus: dioptri

▪ Sklera ikterik : (ya/tidak)

▪ Konjungtiva : (anemis/ tidak anemis)

▪ Nyeri : (ya/tidak), intensitas :

▪ Kornea : jernih/keruh/berbintik

▪ Alat bantu : tidak ada/lensa kontak/kaca mata

b. Pendengaran

Normal Berdengung Berkurang Alat bantu Tuli

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Keluhan lain:
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Hidung:
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Mulut/Gigi/Lidah:
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Leher :

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Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
Respiratori
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a. Dada :

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b. Batuk : ya/tidak; produktif/tidak produktif

Karakteristik Sputum .........................................................................................................................................

c. Napas bunyi : vesikuler/lainnya, jelaskan

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▪ Sesak napas saat :

➢ Ekspirasi ➢ Inspirasi ➢ Istirahat ➢ Aktivitas

Tipe pernapasan :

Perut Dada Biot

Kussmaul Cynestokes Lainnya

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Frekuensi nafas : x/mnt
Penggunaan otot-otot asesori: (ya/tidak), Napas Cuping Hidung:......................................

Fremitus: ......................................................................................................................................................
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Sianosis : (ya/ tidak)

▪ Keluhan Lain:
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Kardiovaskular
Riwayat Hipertensi: ............................................................... Masalah jantung……………..

Demam Rematik: ...................................................................

Bunyi Jantung: Frekuensi: ................................................. Irama………………….

Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
 Kualitas……………………………….. Murmur ………………………..
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Nyeri dada, Intensitas : Palpitasi

Pusing Cianosis
▪ Capillary refill :

Riwayat Keluhan lainnya

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▪ Edema, lokasi : grade :

▪ Hematoma, lokasi :

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Neurologis
Rasa ingin pingsan/ pusing: ........................................................................................................................

Sakit Kepla: Lokasi nyeri ........................................................................ Frekuensi ...................................

▪ GCS : Eye = Verbal = Motorik =

▪ Pupil : isokor/unisokor

▪ Reflek cahaya :

• Sinistra : +/- cepat/lambat

• Dextra : +/- cepat/lambat

▪ Bicara :

Komunikatif Aphasia Pelo

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▪ Keluhan lain :

Kesemutan Bingung Tremor Gelisah Kejang

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▪ Koordinasi ekastemitas

Normal Paralisis, Lokasi : Plegia, Lokasi :

Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
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▪ Keluhan lain:
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Integumen
▪ Warna kulit

Kemerahan Pucat Sianosis Jaundice Normal

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▪ Kelembaban :

Lembab Kering
▪ Turgor : elastis / tidak elastic

> 2 detik < 2 detik

Keluhan lain :

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Abdomen
Nyeri Tekan: ..........................................................................................................................................................
Lunak/keras: ..........................................................................................................................................................
Massa:……………………………..ukuran/ Lingkar Perut: .................................................................................

Bising usus:............................................................................................................................................................
Asites : .....................................................................................................................................................................
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Keluhan lain: .........................................................................................................................................................

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Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
 Muskuloskeletal
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Nyeri otot/tulang, lokasi : intensitas :
Kaku sendi, lokasi :
Bengkak sendi, lokasi :
Fraktur (terbuka/tertutup), lokasi :
Alat bantu, jelaskan :

Pergerakan terbatas, jelaskan :

Keluhan lain, jelaskan :

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Seksualitas
Aktif melakukan hubungan seksual: ..................................................................................................................
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Penggunaan alat kontrasepsi: ..............................................................................................................................

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Masalah/kesulitan seksual: ....................................................................................................................................
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Perubahan terakhir dalam frekuensi: ................................................................................................................

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Wanita:

Usia Menarche :…………… lamanya siklus:……………..durasi:………………..

Periode menstruasi terakhir:……………………..Menopouse:……………………

Melakukan pemeriksaan payudara sendiri: ....................................................................................................
PAP smear terakhir: ..................................................................................................................................................

Pria
Rabas penis :……………………….Gangguan prostat:……………………………
Sirkumsisi :…………………………Vasektomi:…………………………………..

Impoten :…………………………….Ejakulasi dini:………………………………

Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
V. Program terapi:
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Hasil Pemeriksaan Penunjang dan Laboratorium

(dimulai saat anda mengambil sebagai kasus kelolaan, cantumkan tanggal pemeriksaan,

dan kesimpulan hasilnya)

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Samarinda, ................... 2015
Perawat

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Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
VI. Analisa Data
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No Data Penunjang Kemungkinan Penyebab Masalah
1. Data Subjektif :
dst

Data Objektif :

VII. Diagnosa Keperawatan

1. …………………………………………………………………………………………………………………………………………………………
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3. …………………………………………………………………………………………………………………………………………………………
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Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
 RENCANA KEPERAWATAN
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DIAGNOSA KEPERAWATAN
NO TUJUAN (NOC) INTERVENSI (NIC)
/MASALAH KOLABORASI

Dst

Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
 Catatan Perkembangan
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Nama
Klien : Umur :
Ruang
No RM : :

Hari/Tgl No. Dx Implementasi Evaluasi Paraf

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Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah