FORMAT PENGKAJIAN

Nama Pasien : Ny. Boinem No. Rekam Medis : 435549

Tanggal Lahir/Umur : 30-06-1948 / 70 Tahun Tanggal Masuk : 06 April 2018
Alamat : Ds. Kemuning Kec. Sambit Ponorogo Tanggal Pengkajian : 16 April 2018
Jenis Kelamin : Perempuan Diagnosa Masuk : Tetanus
Pekerjaan : - ..............................................................................................

Penanggung Jawab
Keluhan Utama MRS
Nama : Tn. Miskandar
Pasien mengatakan kaku pada rahang dan perut
Alamat : Ds. Kemuning RT/RW 01/01 Kec.
..............................................................................................
Sambit Ponorogo
..............................................................................................
Jenis Kelamin : Laki - laki
..............................................................................................
Pekerjaan : Petani
..............................................................................................
Hubungan Dengan Pasien : Anak Kandung
Riwayat Penyakit Sekarang
Keluarga mengatakan pasien terkena lancupan kayu saat
disawah, kemudian pasien merasa kaku pada rahang dan
perut. Setelah itu oleh keluarga dibawa berobat ke
Keluhan Utama Pengkajian
posyandu lansia dan sudah mendapat suntikan. Setelah 5
Keluarga pasien mengatakan pasien belum bisa bicara dan
hari kaku pada rahang dan perut belum berkurang,
sering kejang dengan durasi kejang 15-30 menit
akhirnya oleh keluarga dibawa ke RSU Aisyiyah
Ponorogo melalui IGD dan dirawat di ruang Siti Fadilah
(Ruang Isolasi) sudah 10 hari. Pada saat pengkajian pasien
belum bisa bicara dan masih kejang 15-30 menit.

Riwayat Penyakit Dahulu Riwayat Kesehatan Keluarga

Keluarga mengatakan pasien tidak memiliki penyakit
seperti HT, DM, dll
..............................................................................................
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Keluarga pasien mengatakan tidak ada anggota keluarga
lain yang pernah menderita penyakit seperti yang dialami
pasien dan juga tidak memiliki penyakit keturunan
..............................................................................................
..............................................................................................

Pola Nutrisi dan Cairan Pola Eliminasi

Setelah MRS : Sebelum MRS : Setelah MRS :
Sebelum MRS :
Makan :3 gelas susu x/hari
Makan : 3 x /hari
1 gelas juz, bubur sum sum BAK : 4-6 x/hari BAK : ±500 cc/hari
Komposisi nasi, lauk pauk,
±150 cc, energen ± 100cc ............................................. ............................................
sayur, makan 1 porsi habis
........................................... ............................................. ............................................
Minum : ± 1.500 cc/hari
Minum : ............... cc/hari BAB : 1 x/hari BAB : 3 x dlm 10 hari
√ Air Putih/Mineral
√ Air Putih/Mineral Konsistensi lembek, bau Konsistensi lembek, bau
 Alkohol
 Alkohol khas feces khas feces
 Soda
 Soda ............................................. ............................................
Pola Istirahat/Tidur Pola Aktivitas
Sebelum MRS :
Sebelum MRS : Setelah MRS : Setelah MRS :
Keluarga mengatakan
Tidur Jam : 21.00 WIB Tidur Jam : .......... WIB Bedrest, aktivitas dibantu
pasien beraktivitas normal;
Bangun Jam : 05.00 WIB Bangun Jam : .......... WIB oleh keluarga dan perawat
berkebun dan jalan-jalan
√ Istirahat Siang  Istirahat Siang .............................................
.............................................
13.00 – 14.00Jam/hari ..................... Jam/hari .............................................
.............................................
Personal Hygiene Keadaan Umum
Sebelum MRS : Setelah MRS : S : 36,3 oC
TD : 170/100 mmHg
Mandi : 3 x /hari Mandi :Sibin 2x/hari RR : 21 x/menit
N : 86 x/menit
Sikat Gigi : 2 x /hari Sikat Gigi : - x/hari Kesadaran : Sopor
Keramas : 3 x /mgg Keramas : - x/mgg
..............................................................................................
Potong Kuku : 1 x /mgg Potong Kuku : - x/mgg
..............................................................................................
√ Mandiri  Mandiri
..............................................................................................
 Dibantu Sebagian  Dibantu Sebagian
..............................................................................................
 Dibantu Seluruhnya √ Dibantu Seluruhnya

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

 PEMERIKSAAN FISIK

Kepala Keterangan
Bentuk  Normal □ Abnormal Hidung terpasang NGT (kiri) selama 10 hari
Mata  Normal □ Abnormal ..............................................................................................
Hidung  Normal □ Abnormal ..............................................................................................
Telinga  Normal □ Abnormal ..............................................................................................
Mulut  Normal □ Abnormal Kotor, darah +, luka +
Gigi  Normal □ Abnormal Kotor
Leher Keterangan
Vena Jugularis  Normal □ Abnormal ..............................................................................................
Thyroid  Normal □ Abnormal ..............................................................................................
Nodus Limfe  Normal □ Abnormal ..............................................................................................
Thorax
Paru Jantung
I : inspirasi dan ekspirasi simetris I : pulsasi ictus cordis tidak tampak
........................................................................................... ...........................................................................................
P : Vokal fremitus getaran dekstra sinistra sama ...........................................................................................
........................................................................................... P : pulsasi ictus cordis teraba di ICS 5 midclavicula
........................................................................................... sinistra
........................................................................................... ...........................................................................................
P : Resonan diseluruh lapang paru diantara 2 costa ...........................................................................................
........................................................................................... P : pekak ICS 3-5 Sinistra
........................................................................................... ...........................................................................................
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A : Vesikuler, tidak ada suara tambahan seperti ronkhi, ...........................................................................................
wheezing pada ICS 2 dextra sejajar sinistra A : BJ 1 dan 2 terdengar tunggal, tidak ada suara
........................................................................................... tambahan
........................................................................................... ...........................................................................................
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Abdomen Ekstremitas
Akral Hangat Edema
I : simetris, tidak ada massa, tidak ada benjolan
...........................................................................................
........................................................................................... + + - -
A : bising usus 17x/menit
...........................................................................................
+ + + +
...........................................................................................
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P : tympani Fraktur Kekuatan Otot
...........................................................................................
...........................................................................................
........................................................................................... - - 2 2
P : nyeri tekan tidak terkaji, perut kaku pada regio 1-9
........................................................................................... - - 2 2
...........................................................................................

Genetalia
Terpasang DK, nyeri tidak terkaji
...........................................................................................
...........................................................................................
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Integumen
Warna kulit sawo matang, sama dengan bagian kulit
lainnya.
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Ponorogo, 16 April 2018

Tanda Tangan Perawat

(...............................................................)

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

 PEMERIKSAAN LABORATORIUM

Nama : Ny. Boinem No. Rekam Medis : 435545

Tanggal Lahir/Umur : 30-06-1948/70Tahun Tanggal : ........................................................

Jenis Pemeriksaan Nilai Satuan Nilai Normal

Hb 12,9 g/dL 12,0-16,0
Leukosit 9,3 4x103-11x103
Eritrosit 4,21 4,3-5,4
Trombosit 226 150x103-450x103
Hematokrit 41% 35-47%
GDA sewaktu 91 Mg/dL <200
Kolesterol Total 244 <200
Trigliserida 135 <150
SGOT 21 <31
SGPT 18 µ/L <35
Serum Kreatinin 0,71 Mg/dL 0,7-1,2
BUN 19 Mg/dL 7-21
Urin Acid 3,96 Mg/dL 1,9-5,1

Ponorogo,..............................
Tanda Tangan Perawat

(.................................................................)

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

 PEMERIKSAAN PENUNJANG
Nama : .........................................................
Tanggal Lahir/Umur : ................................./.............Tahun
Tanggal Jenis Pemeriksaan
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Ponorogo,..............................
Tanda Tangan Perawat
(.................................................................)
KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018
 PENATALAKSANAAN

Nama : Ny. Boinem No. Rekam Medis : 435545

Tanggal Lahir/Umur : 30-06-1948/70Tahun Tanggal : ........................................................

Injeksi : IV Acran 2x1

Lameson RS 3x1
Rativol 3x1
Ambacim 3x1
Tricadazole 3x500
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Terapi Per-Oral ..............................................................................................
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Terapi Diet Khusus ..............................................................................................
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Tindakan
 Infus.......................................................... RL 20 tpm
 Oksigen.....................................................
 Kateter Urin Sejak tanggal 6 april 2018
 Nasogastric Tube Sejak tanggal 6 april 2018
 Orogastric Tube
 Syringe Pump Valisanbe pump 10 amp dalam NaCl 50 cc/24 jam jalan 2
cc/jam.
 ..................................................................
 ..................................................................

Catatan Lainnya
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Ponorogo,..............................
Tanda Tangan Perawat

(.................................................................)

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

 PEMERIKSAAN NEUROLOGIS

Nama : ......................................................... No. Rekam Medis : ........................................................

Tanggal Lahir/Umur : ................................./.............Tahun Tanggal : ........................................................

Tingkat Kesadaran GCS :  Meningeal Sign

 CM  Delirium √ Sopor E........ V........ M........  Kaku Kuduk
 Apatis  Somnolen  Coma  ......................................

Refleks Fisiologis Refleks Patologis

 Refleks Bisep  Refleks Trisep  Refleks Babinski  ....................................
 Refleks Brakioradialis  Refleks Patela  Refleks Hoffman  ....................................
 Refleks Achilles  Refleks Chaddock  ....................................

Nervus Cranialis
NI Olfaktorius  Normosmia  Parosmia
 Hiposmia  Kakosmia
 Hiperosmia  Halusinasi penciuman
Catatan Lain................................................................................................
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N II Optikus  Lapang pandang ....../......  Visus : ..................................
 Papila N II  Buta warna
Catatan Lain................................................................................................
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N III Okulomotorius  Misosis : ....... mm/....... mm  Isokor
 Midriasis : ....... mm/....... mm  Anisorkor
 Refleks akomodasi negatif  Refleks pupil negatif
 Ptosis  Kelopak mata menutup
Catatan Lain................................................................................................
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N III, Optikus  Exophtalmos  Strabismus
N IV, Troklearis  Nistagmus  Deviasi conjugae : ....../......
N VI Abducens  Diplopia  Ophtalmoplegic........................
Catatan Lain................................................................................................
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NV Trigeminus  Kontraksi otot maseter  Refleks kornea negatif
asimetris ....../......  Sensibilitas pipi negatif
 Sensibilitas dahi negaitif  Sensibilitas dagu negatif
Catatan Lain................................................................................................
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N VII Facialis  Kedudukan alis ....../...... Sensorik khusus 2/3 lidah anterior
 Kekuatan udara pipi ....../......  Sensorik manis negatif
 Deviasi bibir ....../......  Sensorik asam negatif
 Kekuatan kelopak mata  Sensorik asin negatif
....../......  Sensorik pahit negatif
Catatan Lain................................................................................................
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N VIII Vestibulokoklearis (Auditorius)  Test bisik : ....../......  Test Weber : ....../......
 Test Rine : ....../......  Test Swabach : ....../......
Catatan Lain................................................................................................
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KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

N IX Glosofaringeus  Deviasi uvula : ....../......  Refleks batuk negatif
NX Vagus  Refleks muntah negatif
Catatan Lain................................................................................................
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N XI Aksesorius  Kekuatan otot  Kekuatan otot trapezius
sternocleidomastoideus ....../......
asimetris ....../......
Catatan Lain................................................................................................
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N XII Hipoglosus  Deviasi julur lidah ....../......  Dysartria
 Gerak lidah ke lateral ....../......  Tremor lidah
Catatan Lain................................................................................................
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Ponorogo,..............................
Tanda Tangan Perawat

(.................................................................)

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

 LEMBAR OBSERVASI

Nama : ........................................................ Diagnosa : Tanggal : Hari Rawat Ke :

Tanggal Lahir/Umur : ................................./.............Tahun
Alamat : ........................................................
Jenis Kelamin : ........................................................
No. Rekam Medis : ........................................................

Tanda Vital 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 Tanda Vital

TD Suhu Resp. Nadi
260 43 60
240 42 55 220
220 41 50 200
200 40 45 180
180 39 40 160
160 38 35 140
140 37 30 120
120 36 25 100
100 35 20 80
80 34 15 60
60 33 10 40
40 32 5 20
20 31 - 0

Tanda Vital 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 Catatan :

GCS
TD
N
S
R
SpO2

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

 LEMBAR OBSERVASI

Nama : ........................................................ Diagnosa : Tanggal : Hari Rawat Ke :

Tanggal Lahir/Umur : ................................./.............Tahun
Alamat : ........................................................
Jenis Kelamin : ........................................................
No. Rekam Medis : ........................................................

Keterangan 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 Jumlah
Input
Infus
Sonde
Output
Urine
Obat Injeksi

Obat Oral

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

 CATATAN PERKEMBANGAN

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

Tanggal Lahir/Umur : ................................./.............Tahun No. Rekam Medis : ........................................................
Alamat : ......................................................... Diagnosis : ........................................................

Tanggal/Jam SOAP Tanda Tangan

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

 CATATAN TINDAKAN

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

Tanggal Lahir/Umur : ................................./.............Tahun No. Rekam Medis : ........................................................
Alamat : ......................................................... Diagnosis : ........................................................

Tanggal/Jam Dx TINDAKAN RESPON Tanda Tangan

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

 FORMULIR TRANSFER PASIEN ANTAR RUANG

Nama Pasien : ........................................................... No. Rekam Medis : .........................................................

Tanggal Lahir/Umur : ................................../.............Tahun Tanggal Masuk : .........................................................
Alamat : ........................................................... Tanggal Pengkajian : .........................................................
Jenis Kelamin : ........................................................... Diagnosa Masuk : .........................................................
Pekerjaan : ........................................................... ..............................................................................................
Tanggal Transfer : ........................................................... Jam Transfer : .........................................................
KONDISI PASIEN SEBELUM TRANSFER
Keadaan Umum : ................................................................. Alat Bantu Yang Terpasang
..................................................................................................  Oksigen nasal  WSD  ....................
Tanda Vital :  Oksigen masker  ETT  ....................
GCS : E..... V..... M..... Resp : ................ x/mnt  IV line  Infus pump  ....................
TD : ..................... mmHg Suhu : ................ oC  Foley Cateter  Syiringe pump  ....................
Nadi : ..................... x/mnt  Monitor  NGT  ....................
KESIAPAN TRANSFER
Level Kondisi Pasien Untuk Transfer Petugas Transfer Sesuai Level Kondisi Pasien
0  0,5  1  2  3  Dokter  Perawat/Bidan  Non Medis
Telah menghubungi Instalasi/Unit/Ruang ............................................................................................................................
 Nama petugas yang dihubungi .............................................................................................................................................
 Informasi jawaban yang diberikan oleh petugas penerima ..................................................................................................
Kebutuhan Peralatan Untuk Transfer Sesuai Dengan Kondisi Pasien
 Kursi roda  BVM  Defibrilator  Infus pump
 Brancar  Oksimetri  Syringe pump  Selang/masker oksigen
 Oksigen mobile  Jackson rees  Monitor  Box obat emergency
KONDISI PASIEN SAAT SERAH TERIMA
S : ........................................................................................... A : ......................................................................................
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B : ........................................................................................... ......................................................................................
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........................................................................................... R : ......................................................................................
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SERAH TERIMA
Obat Yang Disertakan Lain-Lain Yang Disertakan
...................................................................................................  Hasil pemeriksaan laboratorium
...................................................................................................  Hasil pemeriksaan radiologi
...................................................................................................  Hasil pemeriksaan lainnya (USG, EKG, EEG, dll)
...................................................................................................  ......................................................................................
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Penerima Ponorogo,............................ Pengirim

Jam : ...........................

(..............................................................) (.................................................................)

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

 ANALISA DATA

Nama : Ny. Boinem

Jenis Kelamin : Perempuan
Tanggal Lahir/Umur : 30-06-1948/70Tahun
No. Rekam Medis : 435545
Alamat : Ds. Kemuning Kec. Sambit
Diagnosis : Tetanus.
Ponorogo

No Data Masalah Etiologi

1 DS : keluarga klien mengatakan klien tidak bisa
bicara sejak dibawa MRS, sering kejang Resiko Kejang Berulang Proliferai Clostridium
dengan durasi 15-30 menit, rahang dan perut Tetani ke pembuluh darah
kaku, kedua kaki bengkak.

DO :
- TD: 170/90 mmHg, Tokin dari Clostridium
- N : 86 x/menit, Tetani menyebar ke syaraf
- S : 36,3 °C, di otak melalui pembuluh
- RR: 21 x/menit darah
- Perut dan rahang kaku
- Oedema :
-
- Toksin menimbulkan
reaksi di sistem saraf otak
+
+ dan menyebabkan kejang

2 2

2 2

- GCS : 3-2-2
- Kesadaran Sopor
- Terpasang NGT
- Terpasang kateter urin ±500cc/jam
- Infuse RL 20tpm
- Syringe Pump: Valisanbe pump 10 amp dalam
NaCl 50 cc/24 jam jalan 2 cc/jam.
- Pada jempol kaki kanan terdapat luka, kondisi
luka bersih, tidak ada puss
- Luka pada lidah
- CRT < 3 detik.

2. DS : Keluarga paien mengatakan semenjak MRS Intoleransi Aktifitas Proses Penyakit

pasien tdk dapat beraktivitas, badannya lemes (Kelemahan fisik,
Kekakuan Otot,
DO : Kerusakan Sistem Syaraf
- Pasien bedrest, aktivitas dibantu oleh keluarga Pusat)
dan perawat
- GCS : 3-2-2
- Kesadaran Sopor
- Terpasang NGT
- Terpasang kateter urin ±500cc/jam Intoleransi Aktifitas
- Oedema :
- -
+ +

- Kekuatan Otot
2 2
2 2

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018

 RENCANA KEPERAWATAN

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

Tanggal Lahir/Umur : ................................./.............Tahun No. Rekam Medis : ........................................................
Alamat : ........................................................ Diagnosa : ........................................................

No Diagnosa Keperawatan Tujuan dan Kriteria Hasil Intervensi

KELOMPOK 2 | PROFESI NERS UNMUH PONOROGO 2018