Anda di halaman 1dari 8

1

PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

A. Identitas Klien
Nama : Nn. Z................................ No. RM : 00-38-39-XX
Usia : 21 tahun Tgl. Masuk : 19/10/2019, J.14.21 WIB.
Jenis kelamin : Perempuan....................... Tgl. Pengkajian : 21/10/2019, J.08.00 WIB.
Alamat : Jl. Johar Baru, Jakarta...... Sumber informasi : Keluarga pasien..............
No. telepon : -........................................ Nama klg. dekat yg bisa dihubungi: Ny. S......
Status pernikahan : Belum menikah ................ ..........................................
Agama : Islam................................. Status : Orang tua .......................
Suku : Betawi - Jawa................... Alamat : Jl. Johar Baru, Jakarta....
Pendidikan : S1 (semester 7)................ No. telepon : - ......................................
Pekerjaan : Mahasiswa....................... Pendidikan : S1 ..................................
Lama berkerja : -........................................ Pekerjaan : Ibu Rumah Tangga..........

B. Status kesehatan Saat Ini


1. Keluhan utama : Tidak dapat dikaji, pasien dalam pengaruh miloz.....................................
2. Lama keluhan : - ...............................................................................................................
3. Kualitas keluhan : - ...............................................................................................................
4. Faktor pencetus : Keluarga mengatakan pasien tiba-tiba demam dan diare setelah
malamnya menghadiri acara kampus.......................................................
5. Faktor pemberat : - ...............................................................................................................
6. Upaya yg. telah dilakukan : -
7. Diagnosa medis :

a. DKA + Acidosis Metabolik Berat ......................................... Tanggal 21/10/2019....................

C. Riwayat Kesehatan Saat Ini


Keluarga mengatakan pasien demam selama 2 hari (17-18 Oktober 2019), badan lemas, diare >
3x, mual dan muntah setelah sebelumnya menghadiri acara kegiatan kampus (16 Oktober 2019),
keluarga juga mengatakan jika pasien memiliki penyakit diabetes melitus (DM) sejak ....... dan
injeksi 22 ui setiap harinya, namun sudah 3 bulan pasien tidak injeksi obat tersebut, orang tua juga
tidak tau apa yang menjadi alasan pasien berhenti injeks obat DM.
Keluarga membawa pasien ke klinik pratama RSSC pada tanggal 19 Oktober 2019, hasil
pemeriksaan di Klinik Pratama:
Pasien mengeluh demam + diare, memiliki riwayat

Riwayat Kesehatan Terdahulu


1. Penyakit yg pernah dialami:
Keluarga pasien mengatakan pasien memiliki penyakit DM
2

2. Alergi (obat, makanan, plester, dll):


Keluarga mengatakan pasien tidak memiliki alergi apapun, baik makanan, obat, dan lingkungan

3. Kebiasaan:
Keluarga mengatakan setiap harinya pasien kuliah dan jika sedang libur terkadang pasien
berlibur/rekreasi bersama keluarga atau teman-temannya
4. Obat-obatan yg digunakan:
Pasien menggunakan levemir 20 ui (1x1)

D. Riwayat Keluarga
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
GENOGRAM

Keterangan :
= laki-laki
= Perempuan
= Klien
= Laki2/Perempuan
Meninggal
= Hubungan Keluarga
= Tinggal serumah

E. Pola Aktifitas-Latihan
Rumah Rumah Sakit
 Makan/minum .................................................... ....................................................
 Mandi .................................................... ....................................................
 Berpakaian/berdandan .................................................... ....................................................
 Toileting .................................................... ....................................................
 Mobilitas di tempat tidur .................................................... ....................................................
 Berpindah .................................................... ....................................................
 Berjalan .................................................... ....................................................
 Naik tangga .................................................... ....................................................
Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang lain, 4 = tidak mampu

F. Pola Nutrisi Metabolik


Rumah Rumah Sakit
3
 Jenis diit/makanan .............................................. .................................................
 Frekuensi/pola .............................................. .................................................
 Porsi yg dihabiskan .............................................. .................................................
 Komposisi menu .............................................. .................................................
 Pantangan .............................................. .................................................
 Napsu makan .............................................. .................................................
 Fluktuasi BB 6 bln. terakhir .............................................. .................................................
 Jenis minuman .............................................. .................................................
 Frekuensi/pola minum .............................................. .................................................
 Gelas yg dihabiskan .............................................. .................................................
 Sukar menelan (padat/cair) .............................................. .................................................
 Pemakaian gigi palsu (area) .............................................. .................................................
 Riw. masalah penyembuhan luka .............................................. .................................................

G. Pola Eliminasi
Rumah Rumah Sakit
 BAB:
- Frekuensi/pola .................................................... .................................................
- Konsistensi .................................................... .................................................
- Warna & bau .................................................... .................................................
- Kesulitan .................................................... .................................................
- Upaya mengatasi .................................................... .................................................
 BAK:
- Frekuensi/pola .................................................... .................................................
- Konsistensi .................................................... .................................................
- Warna & bau .................................................... .................................................
- Kesulitan .................................................... .................................................
- Upaya mengatasi .................................................... .................................................

H. Pola Tidur-Istirahat
Rumah Rumah Sakit
 Tidur siang:Lamanya .............................................. ....................................................
- Jam …s/d… ............................................. ..................................................
- Kenyamanan stlh. tidur ............................................. ..................................................
 Tidur malam: Lamanya .............................................. ....................................................
- Jam …s/d… ............................................. ..................................................
- Kenyamanan stlh. tidur ............................................. ..................................................
- Kebiasaan sblm. tidur ............................................. ..................................................
- Kesulitan ............................................. ..................................................
- Upaya mengatasi ............................................. ..................................................
4
I. Pola Kebersihan Diri
Rumah Rumah Sakit
 Mandi:Frekuensi ................................................. .................................................
- Penggunaan sabun ................................................ ................................................
 Keramas: Frekuensi ................................................. .................................................
- Penggunaan shampoo ................................................ ................................................
 Gososok gigi: Frekuensi ................................................. .................................................
- Penggunaan odol ................................................ ................................................
 Ganti baju:Frekuensi ................................................. .................................................
 Memotong kuku: Frekuensi ................................................. .................................................
 Kesulitan ................................................. .................................................
 Upaya yg dilakukan ................................................. .................................................

J. Pola Toleransi-Koping Stres


1. Pengambilan keputusan: ( ) sendiri ( ) dibantu orang lain, sebutkan,.......................................
2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri, dll):...............

3. Yang biasa dilakukan apabila stress/mengalami masalah:.................................................................


4. Harapan setelah menjalani perawatan:..............................................................................................
5. Perubahan yang dirasa setelah sakit:.................................................................................................

K. Konsep Diri
1. Gambaran diri:....................................................................................................................................
2. Ideal diri:.............................................................................................................................................
3. Harga diri:...........................................................................................................................................
4. Peran:.................................................................................................................................................
5. Identitas diri........................................................................................................................................

L. Pola Peran & Hubungan


1. Peran dalam keluarga........................................................................................................................
2. Sistem pendukung:suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain, sebutkan:...............

3. Kesulitan dalam keluarga: ( ) Hub. dengan orang tua ( ) Hub.dengan pasangan


( ) Hub. dengan sanak saudara ( ) Hub.dengan anak
( ) Lain-lain sebutkan,.................................................................
4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS:..................................
......................................................................................................................................................... ..
5. Upaya yg dilakukan untuk mengatasi:................................................................................................
M. Pola Komunikasi
1. Bicara: ( ) Normal ( )Bahasa utama:.....................................
5
( ) Tidak jelas ( ) Bahasa daerah:..................................
( ) Bicara berputar-putar ( ) Rentang perhatian:............................
( ) Mampu mengerti pembicaraan orang lain( ) Afek:..................................................
2. Tempat tinggal: ( ) Sendiri
( ) Kos/asrama
( ) Bersama orang lain, yaitu:.................................................................................
3. Kehidupan keluarga
a. Adat istiadat yg dianut:................................................................................................................
b. Pantangan & agama yg dianut:...................................................................................................
c. Penghasilan keluarga: ( ) < Rp. 250.000 ( ) Rp. 1 juta – 1.5 juta
( ) Rp. 250.000 – 500.000 ( ) Rp. 1.5 juta – 2 juta
( ) Rp. 500.000 – 1 juta ( ) > 2 juta

N. Pola Seksualitas
1. Masalah dalam hubungan seksual selama sakit: ( ) tidak ada ( ) ada
2. Upaya yang dilakukan pasangan:
( ) perhatian ( ) sentuhan ( ) lain-lain, seperti, ............................................................

O. Pola Nilai & Kepercayaan


1. Apakah Tuhan, agama, kepercayaan penting untuk Anda, Ya/Tidak
2. Kegiatan agama/kepercayaan yg dilakukan dirumah (jenis & frekuensi):
3. Kegiatan agama/kepercayaan tidak dapat dilakukan di RS:
4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya:
P. Pemeriksaan Fisik
1. Keadaan Umum: pasien tampak sakit berat
 Kesadaran: kesadaran dalam pengaruh miloz
 Tanda-tanda vital: - Tekanan darah :……… mmHg - Suhu :………oC
- Nadi :……... x/meni - RR :……… x/menit
 Tinggi badan: 165 cm
 Berat Badan : 55 kg
2. Kepala & Leher
a. Kepala: rambut berwarna hitam, tampak kotor, rambur tidak rontok
b. Mata:
c. Hidung:
d. Mulut & tenggorokan:
e. Telinga:
f. Leher:
3. Thorak & Dada:
 Jantung
6
- Inspeksi:
- Palpasi:
- Perkusi:
- Auskultasi:
 Paru
- Inspeksi:
- Palpasi:
- Perkusi:
- Auskultasi:

4. Payudara & Ketiak


..................................................................................................................................................
5. Punggung & Tulang Belakang
..................................................................................................................................................

6. Abdomen
 Inspeksi:........................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
 Palpasi:..........................................................................................................................................
....................................................................................................................................................
 Perkusi:..........................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
 Auskultasi:.....................................................................................................................................
......................................................................................................................................................
7. Genetalia & Anus
 Inspeksi:........................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
 Palpasi:.......................................................................................................................................
8. Ekstermitas
 Atas:............................................................................................................................................
...........................................................................................................................................
7
...........................................................................................................................................
 Bawah:........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
9. Sistem Neorologi
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
10. Kulit & Kuku
 Kulit:
....................................................................................................................................................

....................................................................................................................................................
....................................................................................................................................................
 Kuku:
....................................................................................................................................................

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

Q. Hasil Pemeriksaan Penunjang (terlampir)

R. Terapi
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

S. Persepsi Klien Terhadap Penyakitnya


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

T. Kesimpulan
.............................................................................................................................................................
.............................................................................................................................................................
8
.............................................................................................................................................................
.............................................................................................................................................................

U. Perencanaan Pulang
 Tujuan pulang:....................................................................................................................................
 Transportasi pulang:...........................................................................................................................
 Dukungan keluarga:...........................................................................................................................
 Antisipasi bantuan biaya setelah pulang:...........................................................................................
 Antisipasi masalah perawatan diri setalah pulang:.............................................................................
 Pengobatan:.......................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
 Rawat jalan ke:...................................................................................................................................
....................................................................................................................................................
 Hal-hal yang perlu diperhatikan di rumah:........................................................................................
....................................................................................................................................................
.........................................................................................................................................................
 Keterangan lain:.................................................................................................................................