YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN

PROGRAM STUDI S1 KEPERAWATAN
Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536)
3327707

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 : ………….ml…………x/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 :
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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....................................................................................................................
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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
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3. Pola istirahat dan tidur

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Masalah Keperawatan
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4. Kognitif :
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Masalah Keperawatan
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5. Konsep diri (Gambaran diri, ideal diri, identitas diri, harga diri, peran ) :
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Masalah Keperawatan
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 6. Aktivitas Sehari-hari
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Masalah Keperawatan
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7. Koping –Toleransi terhadap Stress

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Masalah Keperawatan
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8. Nilai-Pola Keyakinan
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Masalah Keperawatan
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E. SOSIAL - SPIRITUAL
1. Kemampuan berkomunikasi
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2. Bahasa sehari-hari
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3. Hubungan dengan keluarga :
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4. Hubungan dengan teman/petugas kesehatan/orang lain :
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5. Orang berarti/terdekat :
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6. Kebiasaan menggunakan waktu luang :
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7. Kegiatan beribadah :
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F. DATA PENUNJANG (RADIOLOGIS, LABORATORIUM, PENUNJANG

LAINNYA)

No Pemeriksaan Hasil Normal Kesimpulan

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1 Hb 10, 709 % 11, 7-15, 5 Menurun
2 Eritrosit 3,80 mm3 4, 20-4, 87 Menurun
3 Leukosit 11,86 mm3 4, 5-11, 0 Menurun
4 PLT 292 mm3 150-450 Normal
5 Hematokri 29,80 % 38-44 Menurun
AGDA (analisis gas darah)
6 PH 7, 414 mmHg 7, 35-7, 45 Normal
7 PCO2 51, 7 mmHg 31-50 Meningkat
8 PO2 101, 7 mmHg 75-90 Meningkat
Analisa cairan pleura
9 Warna Merah
10 LDH 433 U/L < 3 g/dl
11 PH 9 7-8 Meningkat

G. PENATALAKSANAAN MEDIS

No. Tanggal 8 Januari 2012

1 1. Infus RL seling Dextrose 5%. 20 tt/menit
2. Tramal 3x1
3. Codein 2x1
4. Amoxcilin 500 mg 3x1
5. 02 : 3x4 L/menit

No. Tanggal 9 Januari 2012

2 1. Infus RL seling Dextrose 5%. 20 tt/menit
2. Tramal 3x1
3. Codein 2x1
4. Amoxcilin 500 mg 3x1
5. 02 : 3x4 L/menit
6. Inj. cedotaxim 1 gr/12 jam
7. Inj. ranitidin 1 amp/8 jam
 Palangka Raya,……………………………
Mahasiswa

( ………………………………)

ANALISIS DATA

DATA SUBYEKTIF DAN

KEMUNGKINAN PENYEBAB MASALAH
DATA OBYEKTIF
 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

 RENCANA KEPERAWATAN

Nama Pasien : ……………………..

Ruang Rawat : ……………………..

Diagnosa Keperawatan Tujuan (Kriteria hasil) Intervensi Rasional

 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Tanda tangan dan

Hari/Tanggal, Jam Implementasi Evaluasi (SOAP)
Nama Perawat
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Tanda tangan dan

Hari/Tanggal, Jam Implementasi Evaluasi (SOAP)
Nama Perawat