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Lampiran 1

FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama pasien : ............................... Tanggal Pengkajian : ...............................


Ruangan : ............................... Jam Pengkajian : ...............................
No. RM : ...............................

A. Pengkajian
1. Identitas
Nama pasien : ............................... Tanggal MRS : ...............................
Umur : ............................... Diagnosa Medis : ...............................
Jenis kelamin : ...............................
Suku/bangsa : ...............................
Agama : ...............................
Pendidikan : ...............................
Pekerjaan : ...............................
Alamat : ...............................
2. Riwayat kesehatan
a. Keluhan
utama : .........................................................................................................
......................................................................................................................
.............
b. Riwayat kesehatan sekarang :
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c. Riwayat kesehatan dahulu :
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d. Riwayat kesehatan keluarga :
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3. Pola aktivitas sehari-hari
a. Pola persepsi kesehatan, pemeliharaan kesehatan
......................................................................................................................
......................................................................................................................

b. Pola nutrisi dan metabolisme


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c. Pola eliminasi
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d. Pola aktivitas-latihan
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e. Pola istirahat tidur
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f. Pola kognitif-persepsi (sensori)
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g. Pola konsep diri
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h. Pola hubungan peran
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i. Pola seksual-reproduksi
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j. Pola penanganan masalah stres
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k. Pola keyakinan, nilai-nilai
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4. Pemeriksaan fisik
a. Keadaan umum :
......................................................................................................................
b. Tanda-tanda vital :
TD : ............................ Nadi : ............................
Suhu : ............................ RR : ............................
c. Pemeriksaan kepala dan leher :
1) Kepala dan rambut
...............................................................................................................
...............................................................................................................
...............................................................................................................

2) Mata
...............................................................................................................
...............................................................................................................
...............................................................................................................
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3) Hidung
...............................................................................................................
...............................................................................................................
...............................................................................................................
4) Telinga
...............................................................................................................
...............................................................................................................
...............................................................................................................
5) Mulut dan faring
...............................................................................................................
...............................................................................................................
...............................................................................................................
d. Pemeriksaan integumen
......................................................................................................................
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e. Pemeriksaan payudara dan ketiak
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f. Pemeriksaan thoraks/dada
......................................................................................................................
......................................................................................................................
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g. Pemeriksaan abdomen
......................................................................................................................
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h. Pemeriksaan genetalia
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i. Pemeriksaan muskuloskeletal
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......................................................................................................................
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j.
Pemeriksaan neurologi
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5. Pemeriksaan penunjang
a. Laboratorium
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b. Rongent
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c. USG
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d. Lain-lain
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6. Terapi
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ANALISA DATA

Nama Pasien : .......................


No. RM : .......................
No. DATA ETIOLOGI MASALAH
..... ............................................................ .................................. .............................
..... ............................................................ .................................. .............................
..... ............................................................ .................................. .............................
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B. Diagnosa Keperawatan
1. ......................................................................................................................
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2. ......................................................................................................................
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INTERVENSI KEPERAWATAN

Nama Pasien : .......................


No. RM : .......................
KRITERIA
No. TGL DX KEPERAWATAN TUJUAN INTERVENSI RASIONAL
HASIL
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CATATAN KEPERAWATAN

Nama Pasien : .........................


No. RM : .........................
No. TGL/JAM NO.DX IMPLEMENTASI TTD
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CATATAN PERKEMBANGAN

Nama Pasien : ...................


No. RM : ...................
No. TANGGAL/JAM EVALUASI
...... ......................... .........................................................................................
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Lampiran 2

LEMBAR PERMOHONAN RESPONDEN

Kepada :
Yth Responden
Di tempat

Dengan hormat,

Saya mahasiswa STIKES Dian Husada Mojokerto, yang akan melakukan

penelitian dengan judul “Asuhan Keperawatan Nyeri Akut Pada Pasien Pasca

Pembedahan ORIF (Open Reduction Internal Fixation) Fraktur Ekstremitas Atas

di RSUD Prof Dr. Soekandar Mojosari”. Sehubungan dengan judul diatas, saya

mohon kesedian Bapak / Ibu bersedia untuk menjadi responden selama penelitian.

Yang bertandatangan dibawah ini :

Nama : Daviq Ayatulloh

NIM : 03. 17. 023

Saya menjamin kerahasiaan dan tidak akan saya gunakan diluar

kepentingan penelitian ini serta hasilnya dapat memberikan sumbangan pemikiran

dan pengembangan ilmu pengetahuan. Atas kesediaannya, saya ucapkan terima

kasih.

Mojokerto, 2018
Hormat Saya

Daviq Ayatulloh
100

Lampiran 3

LEMBAR PERSETUJUAN RESPONDEN

Saya yang bertanda tangan dibawah ini menyatakan bahwa saya bersedia

turut berperan dalam penelitian yang dilakukan oleh mahasiswa Program Studi

Profesi Ners STIKES Dian Husada Mojokerto yang berjudul “Asuhan

Keperawatan Nyeri Akut Pada Pasien Pasca Pembedahan ORIF (Open Reduction

Internal Fixation) Fraktur Ekstremitas Atas di RSUD Prof Dr. Soekandar

Mojosari”.

Tanda tangan saya dibawah ini menunjukkan bahwa saya diberi informasi

dan memutuskan untuk berperan serta, dalam penelitian ini secara sadar dan

sukarela serta tidak ada unsur paksaan dari siapapun.

Mojokerto, 2018

Peneliti Responden

(Daviq Ayatulloh) ( )
101

Lampiran 4
Lembar Implementasi
Intervensi Keperawatan Nyeri Akut dengan Teknik Aromaterapi Lavender
di .............................................. Tanggal ......................................
No. Pasien Intervensi Comparasion Outcame Teori
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102

Lampiran 5

BERITA ACARA
SUPERVISI PEMBIMBING

Pada hari ini ..................... Tanggal .............. Bulan ........................ Tahun.............


Telah dilaksanakan kegiatan supervisi .....................................................................
Di............................................................................ dengan Khasus .........................
...................................................................................................................................

Hal-hal yang telah terjadi selama kegiatan yang berlangsung adalah


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

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

Daviq Ayatulloh

Mengetahui,
Pembimbing I Pembimbing II

Luthfiah Nur Aini, S.Kep., Ns., M.Kep Hj. Iis Suwanti, SST., M.Kes
103

Lampiran 6

BERITA ACARA
PENGUMPULAN DATA

Pada hari ini ..................... Tanggal .......... Bulan ....................... Tahun ..................
Tealah dilaksanakan kegiatan pengumpulan data :
Nama Pasien Khasus Mulai Selesai
.................... ............................................ ........................... ..........................
.................... ............................................ ........................... ..........................
.................... ............................................ ........................... ..........................
.................... ............................................ ........................... ..........................
.................... ............................................ ........................... ..........................
.................... ............................................ ........................... ..........................
.................... ............................................ ........................... ..........................

Hal-hal yang terjadi selama kegiatan yang berlangsung adalah


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

................................................
Pembimbing Ruangan Mahasiswa

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

Mengetahui,
Kepala Ruangan

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