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Profesi Keperawatan Medikal Bedah

Fakultas Keperawatan - UNAND 2019

UJIAN PRAKTEK

Tanggal Pengkajian :................................................................... Nama Mahasiswa : ........................


Tanggal Masuk : .................................................................... NIM : ........................
Waktu Masuk : .................................................................... Sumber informasi : ........................
Nomor MR : ....................................................................
Diagnosa Medis : ....................................................................
Nama pasien : .......................................................................................................................
Tempat/ tanggal lahir : .......................................................................................................................
Jenis kelamin : .......................................................................................................................

A. PENGKAJIAN
a. Riwayat Keperawatan
- Alasan Masuk :
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- Riwayat Penyakit Sekarang :


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- Riwayat Penyakit terdahulu :


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- Riwayat Penyakit Keluaga :


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Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019

b. Pengkajian Fungsional Gordon


POLA PERSEPSI DAN PENANGANAN KESEHATAN
Persepsi terhadap penyakit:
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PENGGUNAAN:
Tembakau : ( ) Ya ( ) Tidak
Berhenti : (Tanggal) ________________ ( ) Pipa ( ) Cerutu
( ) <1bks/hari ( ) 1-2 bks/hari ( ) >2 bks/hari
Riwayat bks/tahun________________
Alkohol : ( ) Ya ( ) Tidak Jenis/Jumlah ____/Hari ____/minggu
_____/bulan
Obat lain : ( ) Ya ( ) Tidak , Jenis ____________ Penggunaan
______________
Alergi : ( ) obat-obatan, ( ) makanan, ( ) plester, ( ) zat warna
Reaksi :
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Obat-obatan warung/tanpa resep dokter :
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POLA NUTRISI/METABOLISME
Diet/Suplemen Khusus : _________________________________________
Instruksi Diet Sebelumnya : ( ) Ya ( ) Tidak
Napsu makan : ( ) Normal ( ) Meningkat ( ) Menurun ( ) Penurunan Sensasi
Kecap ( ) Mual ( ) Muntah ( ) Stomatitis
Perubahan BB 6 Bulan Terakhir : ( ) Ada ( ) Tidak Ada.____kg Peningkatan/Penurunan
Kesulitan Menelan (Disfagia) : ( ) Ya ( ) Tidak ( ) Makanan Padat ( ) Makanan Cair
Gigi :___Atas (___Parsial___Lengkap) ____BawaH(__Parsial
___Lengkap)
Riwayat Masalah Kulit/Penyembuhan ( ) Ada ( ) Tidak Ada
Penyembuhan AbNormal : ( ) Ruam ( ) Kering ( ) Keringat berlebihan
Gambaran diet pasien dalam sehari
Makan Pagi : ________________________________________
Makan Siang : ________________________________________
Makan Malam : ________________________________________
Pantangan/Alergi : ________________________________________

POLA ELIMINASI
Kebiasaan defekasi : ____Defekasi/hari_____ Tgl defekasi
terakhir___DBN____Konstipasi ___Diare __ Inkontinensi
___Ostomi ______Jenis ______Alat _____karakter stoma
Kebiasaan Berkemih : ___DBN ___Frek ___Disuria ___Nokturia __Hematuria
___Retensi
Inkontinensia : ( ) Ya ( ) Tidak
_____Total _____Siang Hari _____Malam Hari___Kadang-
kadang
___ Kesulitan menahan berkemih ___ Kesulitan mencapai toilet
Alat Bantu____ Kateterisasi intermitten_____ Kateter
indwelling_____ Keteter Eksternal ___Jenis implantasi penis
Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019

Lain-
lain_________________________________________________

POLA AKTIVITAS /OLAH RAGA


Kemampuan Perawatan Diri:
0 = Mandiri 2 = Bantuan dari orang lain 4 = tergantung/tdk mampu
1 = Dengan Alat Bantu 3 = Bantuan peralatan dan orang lain
0 1 2 3 4
Makan/Minum
Mandi
Berpakaian/berdandan
Toileting
Mobilisasi di Tempat Tidur
Berpindah
Berjalan
Menaiki Tangga
Berbelanja
Memasak
Pemeliharaan rumah

ALAT BANTU : ___ada ___Tdak ada


____Kruk ___Pispot ditempat tidur ___Walker____Tongkat
____Belat/Mitel_____Kursi roda

Kekuatan Otot :
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Keluhan saat beraktifitas :


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POLA ISTIRAHAT TIDUR


Kebiasaan : ______jam/malam _______ tidur siang ______ Tidur sore
Merasa segar setelah tidur : ( ) Ya ( ) Tidak
Masalah-masalah : __Tidak ada __Terbangun __Terbangun dini __Insomnia __ Mimpi buruk
Lain-lain : ______________________________________________________

POLA KOGNITIF –PERSEPSI


Status mental : _____Sadar _____Afasia reseptif _____Mengingat cerita buruk
_____Terorientasi _____Kelam Pikir _____Kombatif _____Tak responsif
Bicara : _____Normal _____Tak Jelas _____Gagap _____Afasia ekspresif
Bahasa sehari-hari : ______Indonesia ______Daerah ______Lain-lain__________________
Kemampuan membaca bahasa Indonesia : ( ) Ya ( ) Tidak
Kemampuan Berkomunikasi : ( ) Ya ( ) Tidak
Kemampuan Memahami : ( ) Ya ( ) Tidak
Tingkat Ansietas : ( ) Ringan ( ) Sedang ( ) Berat ( ) Panik
Keterampilan Interaksi : ( ) Tepat ( ) Tidak tepat
Lain-lain : ___________________________________________________________
Pendengaran : ( ) DBN ( ) Kerusakan (Kanan_Kiri) ( )Tuli (Kanan_Kiri)
( ) Alat bantu dengar ( ) Tinnitus
Penglihatan : ( ) DBN ( ) Kacamata ( ) Lensa Kontak
( ) Kerusakan (Kanan_Kiri) ( ) Buta (kanan_kiri)
( ) Katarak (Kanan_Kiri) ( )Glaukoma
Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019

( ) Protesis (Kanan_Kiri)
Vertigo : ( ) Ya ( ) Tidak
Ketidaknyamanan/Nyeri : ( ) Ya ( ) Tidak ( )Akut ( ) Kronik
Deskripsi : __________________________________________________________
Penatalaksanaan Nyeri : __________________________________________________________

POLA PERAN HUBUNGAN


Pekerjaan : __________________________________________________
Status Pekerjaan : ______ Bekerja ______ Ketidakmampuan jangka pendek
_____ Ketidakmampuan jangka panjang ______ Tidak Bekerja
Sistem Pendukung : ______ Pasangan ______Tetangga/Teman _____Tidak ada
______ Keluarga serumah ______ Keluarga tinggal berjauhan
Lain-lain : ________________________________________________________
Masalah keluarga berkenaan dengan perawatan dirumah sakit:
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Kegiatan sosial :
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lain-lain :
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POLA SEKSUALITAS/REPRODUKSI
Tanggal Menstruasi Akhir (TMA) : _____________________________
Masalah Menstruasi : ( ) Ya ( ) Tidak
Pap Smear Terakhir : ____________________________________
Pemeriksaan Payudara/Testis Mandiri Bulanan :( ) Ya ( ) Tidak
Masalah Seksual B/D Penyakit : ____________________________________
lain-lain :_____________________________________

POLA KOPING-TOLERANSI STRES


Perhatian utama tentang perawatan di rumah sakit atau penyakit (finansial, perawatan diri):
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Kehilangan/perubahan besar di masa lalu : ( ) Ya ( ) Tidak
Hal yang dilakukan saat ada masalah : ___________________________________
Penggunaan obat untuk menghilangkan stres : ___________________________________
Keadaan emosi dalam sehari har : ( ) santai ( ) tegang
lain-Lain : ___________________________________

POLA KEYAKINAN-NILAI
Agama : ( ) Islam ( ) Katolik Roma ( ) Protestan ( ) Hindu ( ) Budha
Pantangan Keagamaan : ( ) Ada ( ) Tidak Ada (uraikan)____________
Pengaruh agama dalam kehidupan : ____________________________________
Permintaan kunjungan rohaniawan pada saat ini : ( ) Ya ( ) Tidak

PEMERIKSAAN FISIK
Tanda Vital TD : S:

N: P:
Kulit

Kepala

- Mata
Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019

- Hidung

- Telinga

- mulut

Leher
- Trakea

- Karotid Bruit

- Vena

- Kelenjar Tiroid

- Lainnya
Dada
I
A
P
P
Jantung
Auskultasi

Ritme

Abdomen
I
A
P
P
Muskuloskeletal/Sendi

Nodus Limfe

Neurologi
- Status Mental/GCS
E
M
V

- Saraf Kranial
N. I Olfaktorius

N. II Optikus

N. III Okulomotorius

N. IV Troklearis
Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019

N. V Trigeminus

N. VI abdusens

N. VII Fasialis

N. VIII Akustikus

N. IX Glosofaringeus

N. X Vagus

N. XI Aksesorius

N. XII Hipoglosus

- Reflek Patologis :

Sensoris :
Sensibilitas permukaan
Sensibilitas fungsi kortikal

Motorik :
- Bentuk Otot
- Tonus Otot
Ekstremitas
Kekuatan otot
Edema
Vaskuler Perifer

Payudara

Genitalia

Rectal

PEMERIKSAAN PENUNJANG
Diagnostik :
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Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019

TERAPI FARMAKOLOGI
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Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019

WOC
Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019

B. RENCANA KEPERAWATAN

1. Diagnosa Keperawatan :

DO
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DS
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Tujuan :
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Kriteria Hasil :
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Intervensi Keperawatan :
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Implementasi :
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Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019

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Evaluasi :
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2. Diagnosa Keperawatan :

DO
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DS
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Tujuan :
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Kriteria Hasil :
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Intervensi Keperawatan :
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Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019

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Implementasi :
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Evaluasi :
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3. Diagnosa Keperawatan :

DO
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DS
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Tujuan :
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Kriteria Hasil :
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Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019

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Intervensi Keperawatan :
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Implementasi :
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Evaluasi :
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Padang, .............................2019
Mahasiswa Penguji

(........................................) (........................................)
Profesi Keperawatan Medikal Bedah
Fakultas Keperawatan - UNAND 2019