I.

INFORMASI UMUM Tanggal : 29 Waktu: 0 9: 23

A. Identitas Pasien

Nama : NY ( S ) RM : ____________________
Umur : 71 TAHUN Jenis kelamin :L/P*
Agama : ISLAM Pendidikan : SD /SMP /SMA /S1 /S2 /S3 *
terakhir

Pekerjaan : PNS / Swasta / Pensiun / ibu rumah tangga

Alamat : RUM BALIBUNGA

Diagnosa : _
Medis

B. Identitas Penanggungjawab

Nama : ALDIANA Umur : 41

Pendidikan : SD /SMP /SMA /S1 /S2 /S3 *
terakhir

Pekerjaan : PNS / Swasta / Pensiun / IBU RUMAH TANGGA

Hubungan : Orangtua / Suami / Istri / Anak/ Saudara/ Lainnya ________________________
No Tlp : _

Alamat : RUM BALIBUNGA

C. Riwayat Kesehatan

Keluhan utama : Klien mengatakan sering sakit sakit kepala, pusing, dan
klien sering merasakan sakit atau nyeri pada tangan bagian
kanan dan sering sesak napas saat melakukan aktifitas kerja
Riwayat Kesehatan Sekarang :
Klien mengatakan sering sakit sakit kepala, pusing, dan klien sering merasakan sakit atau
nyeri pada tangan bagian kanan dan sering sesak napas saat melakukan aktifitas kerja

1 Aplikasi Keperawatan Medikal Bedah – FIK UI

 Riwayat Kesehatan Masa Lalu :
Allergy
 Obat : tidak ada
 Makanan : tidak da
 Lainnya : tidak ada
Riwayat operasi
 ___________________________________ tahun _________________
 ___________________________________ tahun _________________
 ___________________________________ tahun _________________

Riwayat penyakit masa lalu :

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Riwayat penyakit keturunan :

 Diabetes  Hipertensi  Asma  Jantung  Kanker Lainnya : tidak ada
Konsumsi obat/ suplemen saat ini
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
II. ADAPTASI (TAHAP I)
A. Fisiologis
1. Oksigenasi
a. Fisik
Batuk : Tidak Ya Produktif Non Produktif
Warna Bersih Putih
Hijau Kuning
Merah
Sesak : Tidak Ya Fatique Tidak Ya

Inspeksi :

2 Aplikasi Keperawatan Medikal Bedah – FIK UI

 Nafas : RR _________ Irama :  Normal  Bradypnea Takypnea
Cheyne-stokes  Kussmaul
Simetris : Tidak Ya
Retraksi dada : Tidak Ya
Palpasi :
Taktil Fermitus : Kanan _____ Kiri ______

Perkusi :
Resonance Letak ____________
Hiperresonance Letak ____________
Flat Letak ____________
Dullnes Letak ____________
Tympany Letak ____________

Auskultasi : Letak Letak

 Bronchial ___________________  Krakles ___________________
 Bronchovesikuler ___________________ Whezze ___________________
 Vesicukuler ___________________ Ronchi ___________________
Friction Rub ___________________
Lainnya:

b. Lab
Nilai Nilai normal H/L
pH ___________________ 7,35 – 7,45
PO2 ___________________ 35,00 – 45,00 mm Hg
PCO2 ___________________ 75,00 – 100,00 mmHg
HCO3 ___________________ 21,00 – 25,00 mEq/liter
Total CO2 ___________________ 21,00 – 27,00 mEq/liter
Sa02 ___________________ 95 – 100%
BE (Base excess / ___________________ - 2 smp 2 mEq/liter
kelebihan basa)

3 Aplikasi Keperawatan Medikal Bedah – FIK UI

 c. Pemeriksaan diagnostik lain (Radiologi Thorax paru dll)
Tidak ada

2. Sirkulasi
a. Fisik
TD : 120/10 mmHg Nadi : 80 x/mnt Irama : Reguler  Irreguler
Konjungtiva : Normal Pucat Kekuatan :Kuat Lemah
 Absent
Membran : Normal Pucat Sianosis : Ya Tidak
mukosa/ bibir Kulit pucat : Ya Tidak
Kapillary refill : __________detik Akral dingin : Ya Tidak
CVP : ______ JVP : ______
Bunyi jantung : S1 – S2 normal  Gallop
 Paradoksial  Murmur

b. Lab
Nilai Nilai normal H/L
Enzim jantung
Creatinin Kinaze total ___________________ ___________________
CK – MB ___________________ ___________________
Serum Lipid
Lipid ___________________ ___________________
Kholesterol ___________________ ___________________
Triglycerida ___________________ ___________________
Plasma High-density ___________________ ___________________
lipoproteins (HDLs)
Plasma Low-density ___________________ ___________________
lipoprotein (LDLs)
Serum markers
Troponins ___________________ ___________________
Myoglobin ___________________ < 90 mcg/l

Hematologi
Red Blood Cell (RBC) ___________________ ___________________

4 Aplikasi Keperawatan Medikal Bedah – FIK UI

 Hemoglobin (Hgb) ___________________ 12 – 18 g/dL
Hematocrit (Hct) ___________________ 40% – 50%
White Blood Cell (WBC) ___________________ ___________________
Prothrombin time (PT) ___________________ ___________________

c. Pemeriksaan diagnostik lain (EKG dll)

Tidak ada

3. Nutrisi
a. Fisik
TB : 147 cm BB : 38 _Kg IMT : ________
Gangguan makan :  Tidak nafsu makan  Mual  Muntah : _________cc/hr
 Sariawan  Gangguan mengunyah  Gangguan menelan
Diet sebelumnya : Porsi makan besar 2 x/hr
Jenis makanan dan minuman
Karbohidrat/ Protein/ Lemak/ Sayur dan buah : nasi, ubi, pisang,
sayur.

Jenis makan ringan/selingan : Tidak ada

Konsumsi suplemen:  Ya  Tidak

Nama :___________________________________________________
________________________________________________________
________________________________________________________

Kebiasaan:
 merokok : _____________________btg/hr/minggu
 alkohol : _____________________gls/hr/minggu
 soda : _____________________gls/hr/minggu
 kopi : _____________________gls/hr/minggu
 teh : 2 kali gls/hr/minggu
 konsumsi gula : _____________________sdk/hr/minggu
 konsumsi garam : _____________________sdk/hr/minggu

5 Aplikasi Keperawatan Medikal Bedah – FIK UI

 Diet saat ini : Porsi makan besar _________x/hr
Cair Jenis makanan dan minuman
Lunak Karbohidrat/ Protein/ Lemak/ Sayur dan buah/pantangan :

Padat ________________________________________________________
________________________________________________________
________________________________________________________

Jenis makan ringan/selingan ________________________________

________________________________________________________
________________________________________________________
________________________________________________________

Abdomen :
Inspeksi :  Normal  Asites _______cm  Stoma  Luka
 Caput medusa  Spider nevi

Auskultasi : Bowel Sound

RUQ :  normal  meningkat  menurun  absent
LUQ :  normal  meningkat  menurun  absent
RLQ :  normal  meningkat  menurun  absent
LLQ :  normal  meningkat  menurun  absent
Perkusi  Normal  Abnormal di Quadran ______________
Palpasi  Lunak  Padat  Tegang

6 Aplikasi Keperawatan Medikal Bedah – FIK UI

 Quadran ____________
Kesimpulan  Pembesaran hati  Pembesaran Spleen

b. Lab
Nilai Nilai normal H/L
Hemoglobin (Hgb) ___________________ 12 – 18 g/dL
Hematocrit (Hct) ___________________ 40% – 50%
Serum Albumin ___________________ 3.5 – 5.5 g/dL
Bilirubin total ___________________ 0.1 – 1.0 mg/dL
Bilirubin direk ___________________ 0.1 – 0.3 mg/dL
Bilirubin inderik ___________________ 0.2 – 0.8 mg/dL
Calcium ___________________ ___________________
Potasium ___________________ ___________________
SGOT ___________________ ___________________
SGPT ___________________ ___________________
Ammonia ___________________ ___________________
Transferin ___________________ 240 -480 mg/dL

c. Pemeriksaan diagnostik lain (USG abdomen dll)

Tidak ada

7 Aplikasi Keperawatan Medikal Bedah – FIK UI

4. Eliminasi
a. Fisik
BAK : Keluhan
 Anuria (< 50 ml/hr)  Dysuria (kesusahan kemih)
 Nocturia  Polyuria  Inkontenensia
 Rasa Panas  Distensi bladder
Frekuensi Sebelum sakit : __________x/hr Saat sakit : ___________x/hr
Jumlah Sebelum sakit : __________cc Saat sakit : ___________cc
Warna  Kuning  Merah
Penggunaan obat _________________________________________________________
dieuretik

BAB : Keluhan
 Belum BAB ___---___hari
 Konstipasi ____----____hari
 Diare ______------______hari
 Hemoroid
Frekuensi Sebelum sakit : ____-----______x/hr Saat sakit : _____-______x/hr
Warna  Kuning  Merah  Hitam
Penggunaan obat _________-________________________________________________
pencahar

b. Lab
Nilai Nilai normal H/L
Kreatinin serum ___________________ ___________________
Blood urea nitrogen (BUN) ___________________ ___________________
pH urine ___________________ ___________________
Ketone ___________________ ___________________
Protein ___________________ ___________________
Crystal ___________________ ___________________
Sodium ___________________ ___________________
Calsium ___________________ ___________________
Chloride ___________________ ___________________

Tidak ada

8 Aplikasi Keperawatan Medikal Bedah – FIK UI

 c. Pemeriksaan diagnostik lain (Kultur urin atau feces )
Tidak ada
5. Aktivitas dan Istirahat
a. Fisik
ADL  Independent  Bantuan sebagian  Dependent
Kemampuan  Sendiri  Membutuhkan alat  Membutuhkan bantuan orang lain
berjalan  Membutuhkan alat dan orang lain
Kemampuan Kepala  Fleksi  Ektensi  Rotasi
rentang gerak Bahu  Elevasi  Depresi
Ekstermitas atas kanan
 Flexi  Ekstensi  Abduksi  Aduksi
 Supinasi  Pronasi  Sirkumduksi
Ekstermitas atas kiri
 Flexi  Ekstensi  Abduksi  Aduksi
 Supinasi  Pronasi  Sirkumduksi
Ekstermitas bawah kanan
 Flexi  Ekstensi  Abduksi  Aduksi
 Supinasi  Pronasi  Sirkumduksi
Ekstermitas bawah kiri
 Flexi  Ekstensi  Abduksi  Aduksi
 Supinasi  Pronasi  Sirkumduksi
Kekuatan otot Segmen Kanan Kiri
 Lengan atas
 Lengan bawah
 Tangan
Keluhan Tidur  Tidak  Ya  Insomnia Lainnya:________________
dan Istirahat Kualitas tidur :  Cukup  Kurang
Kebiasaan tidur Malam : dari jam 07:17 sampai jam_________ total :_______jam
Siang : dari jam _________ sampai jam_________ total :_______jam
Kegiatan  Lampu redup  Lampu terang  Membaca
pengantar tidur  Minum minuman hangat  lainnya : tidak ada

9 Aplikasi Keperawatan Medikal Bedah – FIK UI

 b. Pemeriksaan diagnostik lain (Rongsen tulang dll)
Tidak ada
6. Proteksi dan Perlindungan
a. Fisik
Suhu 31 0C
Luka  Tidak  Ya
 Panjang ________cm  Diameter _________cm
 Merah  Kuning  Hitam Balutan :  Bersih  Berair
Tanda tanda infeksi  Tidak  Ya
Gambar :

Risiko jatuh  Ya  Tidak

Tindakan invasif

b. Lab
Nilai Nilai normal H/L
Hematologi

10 Aplikasi Keperawatan Medikal Bedah – FIK UI

 Eosinofil ___________________ ___________________
Neutrofil ___________________ ___________________
Limfosit ___________________ ___________________
Monosit ___________________ ___________________
LED ___________________ ___________________
c. Pemeriksaan diagnostik lain (dll)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

7. Sensori
a. Fisik
Nyeri :
P : _______________________________________________________
Q: _______________________________________________________
R: _______________________________________________________
S: _______________________________________________________
T: _______________________________________________________

Penglihatan :Ketajaman : klien mengatakan bahwa penglihatan klien cukup baik

11 Aplikasi Keperawatan Medikal Bedah – FIK UI

 Reflek cahaya : + / -
Penciuman :  Sumbatan Kanan/Kiri  Perdarahan Kanan/ Kiri
 Kanan + / -  Kiri + / -
Pengecapan :  Manis  Asin  Asam
Pendengaran : Kanan + /- Kiri + / -

b. Lainnya
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________

8. Cairan dan elektrolit

a. Fisik
Intake cairan sebelumnya : _________cc.
Intake Output
Minum : 2 x sehari ml/hr Urine : _____________ ml/hr
Intravena : _____________ ml/hr Drain : _____________ ml/hr
IWL : _____________ ml/hr
Diare : _____________ ml/hr
Muntah : _____________ ml/hr
Perdarahan : _____________ ml/hr

Total : _____________ ml/hr Total : _____________ ml/hr

Balance :

Tanda Rasa haus Kulit kering Mukosa bibir kering

Dehidrasi Turgor kulit ______dtk
Distensi vena  Tidak  Ya
jugularis

Edema  Tidak  Ya  Sacral  Anasarca

Ektermitas atas
RU +1 +2 +3 +4 LU +1 +2 +3 +4

12 Aplikasi Keperawatan Medikal Bedah – FIK UI

 RL +1 +2 +3 +4 LL +1 +2 +3 +4
Ektermitas bawah
RU +1 +2 +3 +4 LU +1 +2 +3 +4
RL +1 +2 +3 +4 LL +1 +2 +3 +4

Other : _____________

b. Lab
Nilai Nilai normal H/L
Natrium ___________________ ___________________
Kalium ___________________ ___________________
Kalsium ___________________ ___________________
Magnesium ___________________ ___________________
Phostpat ___________________ ___________________

c. Lainnya
____________________________________________________________________________
____________________________________________________________________________
_______________________________________________________

9. Fungsi neurologi
a. Fisik
Status Mental
LOC (Level of Consiousness) : alert  letargi unreponsive
Memory : Panjang Pendek
Perhatian : Dapat mengulang Tidak dapat mengulang
Bahasa : Baik  Tidak
Kognisi : Baik Tidak
Orientasi : Orang Tempat Waktu
Saraf sensori Nyeri tusuk Suhu Sentuhan
Lainnya: ______________

13 Aplikasi Keperawatan Medikal Bedah – FIK UI

 Saraf Cranial 1-12 :
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Saraf koordinasi (cerebral)  Ya  Tidak

Refleks Patella 0 1 2 3 4
Achilles 0 1 2 3 4
Bisep 0 1 2 3 4
Trisep 0 1 2 3 4
Brankioradialis 0 1 2 3 4
Babinski +/-
GCS

14 Aplikasi Keperawatan Medikal Bedah – FIK UI

 b. Lainnya
Tidak ada
10. Endokrin
a. Fisik
Kalenjar tiroid Pembesaran:  Ya  Tidak
Tremor :  Ya  Tidak
Pankreas Trias DM :  Ya  Tidak
Adrenal Tanda Syndrom cushing

b. Lab
Nilai Nilai normal H/L
Serum T3 ___________________ 70 – 205 ng/Dl
Serum T4 ___________________ 4 – 12 mcg/dL
TSH ___________________ 2 – 10 U/mL
Serum paratiroid hormon ___________________ C-terminal 50-330 pg/mL
Gula darah puasa ___________________ < 110 mg/dL
Gula darah sewaktu ___________________ < 140 mg/dL
Glycosylated hemoglobin ___________________ 4% - 6 %
(Hemoglobin A1C
[HbA1c])

c. Lainnya

B. Konsep Diri

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

C. Fungsi Peran

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

15 Aplikasi Keperawatan Medikal Bedah – FIK UI

 _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
D. Interdependen

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

III. Faktor – Faktor Berpengaruh (Tahap II)

A. Fisiologis
1. Oksigenasi
Identifikasi stimulus fokal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. Sirkulasi
Identifikasi stimulus fokal
______________________________________________________________________________
______________________________________________________________________________

16 Aplikasi Keperawatan Medikal Bedah – FIK UI

 ______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Nutrisi
Identifikasi stimulus fokal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Eliminasi
Identifikasi stimulus fokal
______________________________________________________________________________
______________________________________________________________________________

17 Aplikasi Keperawatan Medikal Bedah – FIK UI

 ______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. Aktivitas dan Istirahat
Identifikasi stimulus fokal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

6. Proteksi dan Perlindungan

Identifikasi stimulus fokal

18 Aplikasi Keperawatan Medikal Bedah – FIK UI

 ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

7. Sensori
Identifikasi stimulus fokal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
8. Cairan dan Elektrolit
Identifikasi stimulus fokal

19 Aplikasi Keperawatan Medikal Bedah – FIK UI

 ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

9. Neurologis
Identifikasi stimulus fokal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

10. Endokrin

20 Aplikasi Keperawatan Medikal Bedah – FIK UI

 Identifikasi stimulus fokal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

B. Konsep Diri
1. Identifikasi stimulus fokal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

3. Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

21 Aplikasi Keperawatan Medikal Bedah – FIK UI

C. Fungsi Peran
1. Identifikasi stimulus fokal
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
2. Identifikasi stimulus kontekstual
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

3. Identifikasi stimulus residual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

D. Interdependen
1. Identifikasi stimulus fokal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. Identifikasi stimulus kontekstual

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Identifikasi stimulus residual
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Terapi pengobatan :

22 Aplikasi Keperawatan Medikal Bedah – FIK UI

23 Aplikasi Keperawatan Medikal Bedah – FIK UI