YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN

Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536) 3227707
E-Mail : stikesekaharap110@yahoo.com

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 :
..........................................................................................................................................…
..........................................................................................................................................…
..........................................................................................................................................…
2. Riwayat Penyakit Sekarang :
..........................................................................................................................................……
..........................................................................................................................................……
..........................................................................................................................................……
..........................................................................................................................................……
..........................................................................................................................................……
..........................................................................................................................................……
..........................................................................................................................................……

3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi)

..........................................................................................................................................……
..........................................................................................................................................……
..........................................................................................................................................……
..........................................................................................................................................……
4. Riwayat Penyakit Keluarga
..........................................................................................................................................……
..........................................................................................................................................……
..........................................................................................................................................……
 GENOGRAM KELUARGA :

C. PEMERIKASAAN FISIK
1. Keadaan Umum :
..........................................................................................................................................……
..........................................................................................................................................……
..........................................................................................................................................……
..........................................................................................................................................……
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 :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Masalah Keperawatan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................

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 :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Masalah Keperawatan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
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 : ..................................................................................................
..................................................................................................
Keluhan lainnya :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Masalah Keperawatan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
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 :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
Masalah Keperawatan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
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 :
..........................................................................................................................................

Masalah Keperawatan :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
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 :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
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 :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
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 .................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
Payudara :
 Simetris  Asimetris
 Sear  Lesi
 Pembengkakan  Nyeri tekan
Puting :  Menonjol  Datar  Lecet  Mastitis
Warna areola ...............................................................................................................
ASI  Lancar  Sedikit  Tidak keluar
Keluhan lainnya ...........................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
Masalah Keperawatan :
.....................................................................................................................................
D. POLA FUNGSI KESEHATAN
1. Persepsi Terhadap Kesehatan dan Penyakit :
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
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, LABORATO RIUM, PENUNJANG LAINNYA)

G. PENATALAKSANAAN MEDIS

Palangka Raya, …………………………………

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
Nama Pasien : ……………………..
Ruang Rawat : ……………………..

Tanda tangan
Hari / Tanggal Jam Implementasi Evaluasi (SOAP) dan
Nama Perawat