ASUHAN KEPERAWATAN MEDIKAL BEDAH

STIKES MUHAMMADIYAH KENDAL

Nama mahasiswa : ......................................... No. RM : .................................................

Tgl / Jam Pengkajian : ......................................... Ruangan / Kelas : ................................................
Diagnosa Medis : ......................................... No. Kamar : ..................................................

A. BIODATA
1. Nama :.....................................................................................................................
2. Umur : ............tahun
3. Jenis Kelamin :L/P
4. Status Perkawinan : ...................................................................................................................
5. Agama : ...................................................................................................................
6. Suku / Bangsa : ..................................................................................................................
7. Bahasa : ..................................................................................................................
8. Pendidikan Terakhir : ....................................................................................................................
9. Pekerjaan : .....................................................................................................................
10. Alamat : .....................................................................................................................
11. No. Telp :.......................................................................................................................
12. Penanggung Jawab : ......................................................................................................................
13. Hubungan dengan pasien : ..................................................................................................................

B. RESUME RIWAYAT PENYAKIT SEKARANG

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C. RIWAYAT KESEHATAN
1. Riwayat kesehatan sekarang.
a. Keluhan utama : ........................................................................................................................
b. Kronologis keluhan :
1) Faktor Pencetus : ..........................................................................................................
2) Timbulnya : ..........................................................................................................

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 3) Lamanya : ..........................................................................................................
4) Upaya mengatasi : ..........................................................................................................
2. Riwayat kesehatan masa lalu :
a. Riwayat Alergi (Obat, Makanan, Binatang, Lingkungan) :
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b. Riwayat kecelakaan :
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c. Riwyat dirawat di RS (kapan, alasan, dan berapa lama ) :
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d. Riwayat pemakaian obat :
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3. Riwayat kesehatan keluarga (Genogram dan Keterangan tiga generasi dari klien)

4. Penyakit yang pernah diderita oleh anggota keluarga yang menjadi faktor resiko.
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D. POLA FUNGSI KESEHATAN

1. Pola persepsi dan Management kesehatan :
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2. Pola Nutrisi & Metabolik
a. Pola makan
DI RUMAH DI RUMAH SAKIT
Frekuensi : Frekuensi :
Jenis : Jenis :
Porsi : Porsi :
Pantangan : Pantangan :
Makanan yang disukai : Diit Khusus :

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 Nafsu makan di RS : ( ) Normal ( ) bertambah ( ) Berkurang
( ) mual ( ) Muntah ............ cc ( ) Stomatitis
Kesulitan menelan :( ) tidak ( ) ya
Gigi palsu :( ) tidak ( ) ya
NG tube :( ) tidak ( ) ya
Penggunaan obat – obatan sebelum makan : ( ) tidak ( ) ya
b. Pola minum
DI RUMAH DI RUMAH SAKIT
Frekuensi : Frekuensi :
Jenis : Jenis :
Jumlah : Jumlah :
Pantangan :
Minuman yang disukai :

3. Pola Eliminasi
a. Buang Air Besar
DI RUMAH DI RUMAH SAKIT
Frekuensi : Frekuensi :
Konsistensi : Konsistensi :
Warna : ( ) kuning Warna : ( ) kuning
( ) bercampur darah ( ) bercampur darah
( ) pucat ( ) pucat
( ) lainnya, ......................... ( ) lainnya, .........................
Waktu : (pagi / siang / malam / tak tentu) Waktu : (pagi / siang / malam / tak tentu)
Keluhan : Keluhan :
Penggunaan Laxatif : Penggunaan Laxatif :
Kolostomi : ( ) Ya ( ) tidak

b. Buang Air Kecil

DI RUMAH DI RUMAH SAKIT
Frekuensi : Frekuensi :
Warna : Warna :
Produksi : cc / hari Produksi : cc / hari
Pancaran : kuat / lemah / menetes Pancaran : kuat / lemah / menetes
Perasaan setelah BAK : Perasaan setelah BAK :
Keluhan : Keluhan :
Disuria / Nokturia / Hematuria / Retensi / Disuria / Nokturia / Hematuria / Retensi /
Inkontinen Inkontinen
Penggunaan Kateter : ( ) Ya ( ) tidak Penggunaan Kateter : ( ) Ya ( ) tidak

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4. Pola aktivitas & kebersihan diri
Sebelum sakit Di Rumah Sakit
AKTIVITAS
0 1 2 3 4 0 1 2 3 4
Mandi
Eliminasi / toileting
Mobilisasi di tempat tidur
Berpindah
Berjalan
Berhias
Makan / minum
Skor : 0 = mandiri 3 = dibantu orang lain & alat
1 = alat bantu 4 = tergantung / tidak mampu
2 = dibantu orang lain
 Oral Hygiene :
a. Frekuensi : .............................. x / hari
b. Waktu : Pagi / Siang / malam / setelah makan
 Cuci rambut : ......................................x / hari
Keluhan dalam beraktifitas : ( ) Kesulitan dalam Pergerakan tubuh
( ) Sesak setelah beraktifitas
( ) lainnya ,...........................................
5. Pola istirahat Tidur
KETERANGAN SEBELUM SAKIT SAAT SAKIT
Jumlah jam tidur siang
Jumlah jam tidur malam
Gangguan tidur
Perasaan waktu bangun
Keterangan lain :
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6. Pola persepsi sensori & kognitif

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7. Persepsi diri & konsep diri
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8. Pola Peran dan hubungan dengan orang lain
a. Kemampuan pasien dalam berkomunikasi :
( ) Normal ( ) Gagap ( ) bicara tak jelas
( ) Relevan ( ) Jelas
( ) Mampu mengekspresikan ( ) Mampu mengerti orang lain
b. Orang terdekat & lebih berpengaruh pada pasien :
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c. Kesulitan dalam keluarga :
( ) hubungan dengan orang tua
( ) hubungan dengan saudara
( ) hubungan dengan perkawinan
Keterangan
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d. Kepada siapa pasien meminta bantuan bila mempunyai masalah :
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9. Pola reproduksi & seksual
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10. Pola mekanisme koping
Masalah utama selama di RS (biaya, Penyakit, perawatan diri )
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Upaya klien dalam menghadapi masalahnya sekarang
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11. Pola nilai kepercayaan / keyakinan
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E. PEMERIKSAAN FISIK :
a. Pemeriksaan Fisik Umum :
1) Berat badan : .............................. kg (Sebelum Sakit : .................. Kg)
2) Tinggi Badan : .............................. cm
3) Tekanan Darah : .............................. mmHg
4) Nadi : .............................. X / menit
5) Frekuensi Nafas : .............................. X / menit
6) Suhu Tubuh : .............................. oC
7) Keadaan umum : ( ) Ringan ( ) Sedang ( ) Berat
8) Pembesaran kelenjar getah bening : ( ) Tidak
( ) Ya, Lokasi ............

b. Sistem Penglihatan
1) Sisi mata : ( ) Simetri ( ) Asimetris
2) Klopak mata : ( ) Normal ( ) Ptosis
3) Pergerakan bola mata : ( ) Normal ( ) Abnormal
4) Konjungtiva : ( ) Merah muda ( ) Anemis ( ) Sangat Merah
5) Kornea : ( ) Normal ( ) Keruh/berkabut
( ) Terdapat Perdarahan

6) Sklera : ( ) Ikterik ( ) Anikterik

7) Pupil : ( ) Isokor ( ) Anisokor
( ) Midriasis ( ) Miosis

8) Otot-otot mata : ( ) Tidak ada kelainan ( ) Juling keluar

( ) Juling ke dalam ( ) Berada di atas

9) Fungsi penglihatan : ( ) Baik ( ) Kabur

( ) Dua bentuk/diplopia

10) Tanda-tanda radang : ......................................................................

11) Pemakaian kaca mata : ( ) Tidak ( ) Ya, jenis ....................
12) Pemakaian lensa kontak : ......................................................................
13) Reaksi terhadap cahaya : ......................................................................

c. Sistem Pendengaran :
1) Daun telinga : ( ) Normal ( ) Tidak, Kanan/kiri ............
2) Karakteristik serumen (warna, konsistensi, bau) : .........................................
3) Cairan dari telinga : ( ) Tidak ( ) Ada, .........................
( ) Berdarah, nanah, dll

4) Perasaan penuh di telinga : ( ) Ya ( ) Tidak

5) Tinitus : ( ) Ya ( ) Tidak
6) Fungsi pendengaran : ( ) Normal ( ) Kurang
( ) Tuli, Kanan/kiri .............

7) Gangguan keseimbangan : ( ) Tidak ( ) Ya, ....................

8) Pemakaian alat bantu : ( ) Ya ( ) Tidak

d. Sistem Wicara : ( ) Normal ( ) Tidak : .....................

( ) Aphasia ( ) Aphonia
( ) Dysartria ( ) Dysphasia
( ) Anarthia

e. Sistem Pernafasan :
1) Jalan nafas : ( ) Bersih ( ) Ada sumbatan, ...............
2) Pernafasan : ( ) Tidak sesak ( ) Sesak, ............................
3) Menggunakan otot bantu pernafasan : ( ) Ya ( ) Tidak
4) Pergerakan dinding dada : ( ) simetris ( ) Tidak simetris

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 5) Frekuensi : ....................... x / menit
6) Irama : ( ) Teratur ( ) Tidak teratur
7) Jenis pernafasan : ............... (spontan, Kausmaull, Cheynestoke, Biot, dll)
8) Kedalaman : ( ) Dalam ( ) Dangkal
9) Batuk : ( ) Tidak ( ) Ya, ..........(produktif/tidak)
10) Sputum : ( ) Tidak ( ) Ya, .........(Putih/Kuning/Hijau)
11) Konsistensi : ( ) Kental ( ) Encer
12) Terdapat darah : ( ) Ya ( ) Tidak
13) Palpasi dada : ....................................................................
14) Perkusi dada : ....................................................................
15) Suara nafas : ( ) Vesikuler ( ) Ronkhi
( ) Wheezing ( ) Rales

16) Nyeri saat nafas : ( ) Ya ( ) Tidak

17) Penggunaan alat bantu nafas : ( ) Tidak ( ) Ya, ................................

f. Sistem Kardiovaskuler :
1) Sirkulasi Peripher
a) Nadi ......... x/menit : Irama : ( ) Teratur ( ) Tidak teratur
Denyut : ( ) Lemah ( ) Kuat

b) Tekanan darah : .......................mm/Hg

c) Distensi vena jugularis : Kanan : ( ) Ya ( ) Tidak
Kiri : ( ) Ya ( ) Tidak

d) Temperatur kulit : ( ) Hangat ( ) Dingin

e) Warna kulit : ( ) Pucat ( ) Cyanosis ( ) Kemerahan
f) Pengisian kapiler : .................. detik
g) Edema : ( ) Ya, .................... ( ) Tidak
( ) Tungkai atas ( ) Tungkai bawah
( ) Periorbital ( ) Muka
( ) Skrotalis ( ) Anasarka
2) Sirkulasi Jantung :
a) Kecepatan denyut apical : ............................ x/menit
b) Irama : ( ) Teratur ( ) Tidak teratur
c) Kelainan bunyi jantung : ( ) Murmur ( ) Gallop
d) Sakit dada : ( ) Ya ( ) Tidak
(1) Timbulnya : ( ) Saat aktivitas ( ) Tanpa aktivitas
(2) Katakteristis : ( ) Seperti ditusuk-tusuk ( ) Seperti terbakar
( ) Seperti tertimpa benda berat
(3) Lokasi nyeri : ......................................................................................
(4) Skala nyeri : .................................
(5) Lamanya nyeri : ..................................

g. Sistem Hematologi :
Gangguan Hematologi :

1) Pucat : ( ) Tidak ( ) Ya
2) Perdarahan : ( ) Tidak ( ) Ya, ......................
( ) Ptechie ( ) Purpura ( ) Mimisan
( ) Perdarahan gusi ( ) Echimosis

h. Sistem Syaraf Pusat :

1) Keluhan sakit kepala : ............................ (vertigo/migrain, dll)
2) Tingkat kesadaran : ( ) Compos mentis ( ) Apatis
( ) Somnolent ( ) Soporokoma

3) Glasgow coma scale (GCS) E : ................ M : ............... V : .......................

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 4) Tanda-tanda peningkatan TIK
5) Gangguan sistem persyarafan
: ( ) Tidak ( ) Ya, ......................
( ) Muntah proyektil
( ) Nyeri kepala hebat
( ) Papil edema
: ( ) Kejang ( ) Pelo
( ) Mulut mencong ( ) Disorientasi
( ) Polineuritis / kesemutan
( ) Kelumpuhan ekstremitas (kiri/kanan/atas/bawah)

i. Sistem Pencernaan :
Keadaan mulut :

1) Gigi : ( ) Caries ( ) Tidak

2) Penggunaan gigi palsu : ( ) Ya ( ) Tidak
3) Stomatitis : ( ) Ya ( ) Tidak
4) Lidah kotor : ( ) Ya ( ) Tidak
5) Saliva : ( ) Normal ( ) Abnormal
6) Muntah : ( ) Tidak ( ) Ya, .......................
a) Isi : ( ) Makanan ( ) Cairan ( ) Darah
b) Warna : ( ) Sesuai warna makanan ( ) Kehijauan
( ) Cokelat ( ) Kuning ( ) Hitam

c) Frekuensi : ............................... x/hari

d) Jumlah : ............................... ml
7) Nyeri daerah perut : ( ) Ya, .................... ( ) Tidak
8) Skala nyeri : ...............................
9) Lokasi dan Karakter nyeri :
( ) Seperti ditusuk-tusuk ( ) Melilit-lilit
( ) Cramp ( ) Panas/seperti terbakar
( ) Setempat ( ) Menyebar
( ) Berpindah-pindah ( ) Kanan atas
( ) Kanan bawah ( ) Kiri atas ( ) kiri bawah
10) Peristaltik usus : ............................... x/menit
11) Diare : ( ) Tidak ( ) Ya, .......................
a) Lamanya : ....................... Frekuensi : ................... x/hari
b) Warna faeces : ( ) Kuning ( ) Putih seperti air cucian beras
( ) Cokelat ( ) Hitam ( ) Dempul

c) Konsistensi faeces : ( ) Setengah padat ( ) Cair ( ) Berdarah

( ) Terdapat lendir ( ) Tidak ada kelainan

12) Konstipasi : ( ) Tidak ( ) Ya, .......................

Lamanya : ..................hari

13) Hepar : ( ) Teraba ( ) Tidak teraba

14) Abdomen : ( ) Lembek ( ) Kembung
( ) Acites ( ) Distensi

j. Sistem Endokrin :
Pembesaran kelenjar Tiroid : ( ) Ya ( ) Tidak
( ) Exsoftalmus ( ) Tremor
( ) Diaporesis

Nafas berbau keton : ( ) Ya ( ) Tidak

( ) Poliuri ( ) Palidipsi ( ) Poliphagi
Luka Ganggren : ( ) Tidak ( ) Ya, lokasi.......................

Kondisi luka : .................................................................

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k. Sistem Urogenital :
Balance cairan : Intake ...................ml, Output .................... ml

Perubahan pola kemih : ( ) retensi ( ) Urgency ( ) Disuria

( ) Tidak tuntas ( ) Nocturia
( ) Inkontinensia ( ) Anuria
B.a.k : Warna : ( ) Kuning jernih ( ) Kuning kental/cokelat
( ) Merah ( ) Putih
Distensi/ketegangan kandung kemih : ( ) Ya ( ) Tidak
Keluhan sakit pinggang : ( ) Ya ( ) Tidak
Skala nyeri : .................................................................

l. Sistem Integumen :
Turgor kulit : ( ) Baik ( ) Buruk

Temperatur kulit : .................................................

Warna kulit : ( ) Pucat ( ) Sianosis ( ) Kemerahan

Keadaan kulit : ( ) Baik ( ) Lesi ( ) Ulkus

( ) Luka, Lokasi ....................................................

( ) Insisi operasi, Lokasi .......................................

Kondisi ...................................................................

( ) Gatal-gatal ( ) Memar/lebam

( ) Kelainan pigmen

( ) Luka bakar, Grade ............... Prosentase .........

( ) Dekubitus, Lokasi ............................................

Kelainan kulit : ( ) Tidak ( ) Ya, Jenis .............................

Kondisi kulit daerah pemasangan infus : ......................................................................

Keadaan rambut - Tekstur : ( ) Baik ( ) Tidak ( ) Alopesia

- Kebersihan : ( ) Ya ( ) Tidak

m. Sistem Muskuloskeletal :
Kesulitan dalam pergerakan : ( ) Ya ( ) Tidak

Sakit pada tulang, sendi, kulit : ( ) Ya ( ) Tidak

Fraktur : ( ) Ya ( ) Tidak

Lokasi : ......................................................................

Kondisi : ......................................................................

Kelainan bentuk tulang sendi : ( ) Kontraktur ( ) Bengkak

( ) Lain-lain, sebutkan ..............................

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 Kelainan stuktur tulang belakang : ( ) Skoliasis ( ) Lordosis

( ) Kiposis

Keadaan tonus otot : ( ) Baik ( ) Hipotoni

( ) Hipertoni ( ) Atoni

Keadaan otot :

Data Tambahan :

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5. Data Penunjang ( Pemeriksaan diagnostik yang menunjang masalah : Lab, Radiologi, Endoskopi, dll )

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