FORMAT DOKUMENTASI

ASUHAN KEPERAWATAN MEDIKAL BEDAH I

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Disusun Oleh :
MOH. ADIB MABRURI
P17212195044

PRAKTEK PROFESI KEPERAWATAN MEDIKAL BEDAH I

PROGRAM STUDI PROFESI KEPERAWATAN
JURUSAN KEPERAWATAN POLTEKKES KEMENKES MALANG
TAHUN AKADEMIK 2019/2020
FORMAT LAPORAN PENDAHULUAN

APENDISITIS

Disusun Oleh :
MOH. ADIB MABRURI
P17212195044

PRAKTEK PROFESI KEPERAWATAN MEDIKAL BEDAH I

PROGRAM STUDI PROFESI KEPERAWATAN
JURUSAN KEPERAWATAN POLTEKKES KEMENKES MALANG
TAHUN AKADEMIK 2019/2020
 FORMAT PENGKAJIAN

A. PENGKAJIAN

A1. PENGUMPULAN DATA

I. BIODATA

IDENTITAS ANAK IDENTITAS BAPAK

Nama :..................................... Nama :.....................................
No. Register :..................................... Umur :.....................................
Umur (bln, hr) :..................................... Jenis kelamin :.....................................
Jenis kelamin :..................................... Alamat :.....................................
Alamat :..................................... Pendidikan :.....................................
Suku bangsa :..................................... Pekerjaan :.....................................
Tanggal lahir/Umur :..................................... Suku bangsa :.....................................
Tgl MRS :..................................... No. Tlp/HP
Tanggal pengkajian :..................................... :.....................................
Diagnosa medis :..................................... IDENTITAS IBU :.....................................
Urutan anak :.....................................
Nama :.....................................
Umur :.....................................
Jenis kelamin :.....................................
Alamat :.....................................
Pendidikan :.....................................
Pekerjaan :.....................................
Suku bangsa :.....................................
No. Tlp/HP :.....................................

II. KELUHAN UTAMA/ALASAN KUNJUNGAN

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III. RIWAYAT KESEHATAN
A. RIWAYAT PENYAKIT SEKARANG
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 B. RIWAYAT KESEHATAN YANG LALU
1) Penyakit-penyakit waktu kecil
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2) Pernah dirawat di rumah sakit
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3) Obat-obatan
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4) Tindakan (misalnya : operasi)
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5) Allergi
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6) Kecelakaan
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7) Imunisasi
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C. RIWAYAT TUMBUH KEMBANG

a. Prenatal
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b. Intranatal
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c. Post natal
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IV. Riwayat Keluarga
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V. Riwayat Sosial
a. Yang mengasuh
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b. Hubungan dengan anggota keluarga
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c. Hubungan dengan teman sebaya
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 d. Pembawaan secara umum
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e. Lingkungan rumah
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VI. PEMERIKSAAN FISIK (HEAD TO TOE)

A. Keadaan Umum
Postur:......................................................................................................................
Kesadaran:...............................................................................................................
B. Kepala dan rambut
Kebersihan :.............................................................................................................
Bentuk kepala :.........................................................................................................
Keadaan rambut:......................................................................................................
Keadaan kulit kepala : caput succedanum, cefalohematom: .................................
Fontanela anterior : lunak/menonjol/tegas/cekung/datar: ........................................
Sutura sagitalis : tepat/terpisah/menjauh.................................................................
Distribusi rambut : merata/tidak merata....................................................................
C. Mata Kebersihan : ...................................................................................................
Pandangan :.............................................................................................................
Sclera : ....................................................................................................................
Conjungtiva : ...........................................................................................................
Pupil : ......................................................................................................................
Gerakan bola mata : ................................................................................................
Sekret: .....................................................................................................................
D. Hidung
Pernafasan Cuping hidung : ....................................................................................
Struktur :...................................................................................................................
Kelainan lain : polip/perdarahan/peradangan: ........................................................
Sekresi: ...................................................................................................................
E. Telinga
Kebersihan : ...........................................................................................................
Sekresi : .................................................................................................................
Struktur : .................................................................................................................
Fistulaaurikel: .........................................................................................................
Membran timpani: ..................................................................................................
F. Mulut dan Tengorokan
Jamur (stomatitis, moniliasis): ................................................................................
 Kelaianan bibir dan rongga mulut (gnato/labio/palato skizis): ...............................
Problem menelan : ................................................................................................
G. Leher
Vena jugularis : .......................................................................................................
Arteri karotis : .........................................................................................................
Pembesaran tiroid dan limfe : .................................................................................
Torticoliis: ...............................................................................................................
H. Dada/Thorak (jantung dan Paru)
Bentuk dada: ...........................................................................................................
Pergerakan kedua dinding dada: .............................................................................
Tarikan dinding dada ke atas/bawah: ......................................................................
Suara pernafasan: ...................................................................................................
Frekwensi nafas: .....................................................................................................
Abnormalitas suara nafas: .......................................................................................
Suara jantung: .........................................................................................................
I. Ekstremitas atas
Tonus otot: ..............................................................................................................
CRT: ........................................................................................................................
Trauma, deformitas: ................................................................................................
Kelainan struktur: ....................................................................................................
J. Perut
Bentuk perut: ...........................................................................................................
Bising usus: .............................................................................................................
Ascites:.....................................................................................................................
Massa: .....................................................................................................................
Turgor kulit: ..............................................................................................................
Vena: .......................................................................................................................
Hepar: ......................................................................................................................
Lien: .........................................................................................................................
Distensi: ...................................................................................................................
K. Punggung
Spina bifida: .............................................................................................................
Deformitas: ..............................................................................................................
Kelainan struktur: .....................................................................................................
L. Kelamin dan anus
Keadaan kelamin luar (kebersihan, lesi, kelainan):..................................................
Anus :.......................................................................................................................
 Kelainan: ..................................................................................................................
M. Ekstremitas bawah
Tonus otot: ...............................................................................................................
Trauma, deformitas: ................................................................................................
Kelainan struktur: .....................................................................................................
N. Integumen
Warna kulit: ..............................................................................................................
Kelembaban: ...........................................................................................................
Lesi: .........................................................................................................................
Warna kuku : ...........................................................................................................
Kelainan: .................................................................................................................

VII. PENGUKURAN ANTROPOMETRI

Berat badan: ..................................................................................................................
Panjang/Tinggi badan: ..................................................................................................
Lingkar kepala: .............................................................................................................
Lingkar dada: ................................................................................................................
Lingkar lengan Atas: .....................................................................................................
Kesimpulan Status gizi: Baik, kurus, Sangat kurus, Gemuk, Sangat gemuk (lingkari
salah satu)

VIII. RIWAYAT IMUNISASI

Sebutkan imunisasi yang sudah diberikan beserta umur saat diimunisasi
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IX. PEMENUHAN KEBUTUHAN DASAR

A. OKSIGEN
Kebutuhan oksigen: ................................................................................................
Dosis oksigen: ........................................................................................................
Cara pemberian: ....................................................................................................
B. CAIRAN:
Kebutuhan cairan dalam 24 jam: ............................................................................
Jenis cairan yang diberikan: ...................................................................................
Cara/rute pemberian: ..............................................................................................
 Balance cairan dalam 24 jam:
Intake: .....................................................................................................................
Output : ...................................................................................................................
IWL: ........................................................................................................................
Kesimpulan: ............................................................................................................
C. Nutrisi:
Kebutuhan kalori: ....................................................................................................
Bentuk/jenis nutrisi yang diberikan: ........................................................................
Cara pemberian: .....................................................................................................
Frekwensi pemberian: ............................................................................................
Alergi/Pantangan: ...................................................................................................
Nafsu makan: .........................................................................................................
D. ELIMINASI URINE
Volume
urine:........................................................................................................................
Warna:.....................................................................................................................
Frekwensi:...............................................................................................................
Cara BAK (spontan/kateter):.................................................................................
Kelaianan pemenuhan BAK:..................................................................................

E. ELIMINASI ALVI
Volume feses:..........................................................................................................
Warna feses:...........................................................................................................
Konsistensi: ............................................................................................................
Frekwensi:...............................................................................................................
Darah, lendir dalam feses:.......................................................................................
F. TIDUR
Jumlah jam tidur dalam 24 jam: ..............................................................................
Kualitas tidur (sering terbangun, rewel, tidak bisa tidur): ........................................
G. PSIKOSOSIAL
Hubungan orangtua dengan anak: .........................................................................
Yang mengasuh: ....................................................................................................

X. TANDA-TANDA VITAL
a. Tekanan Darah: ......................................................................................................
b. Denyut Nadi:............................................................................................................
c. Pernafasan:.............................................................................................................
 d. Suhu Tubuh:............................................................................................................

XI. PEMERIKSAAN TINGKAT PERKEMBANGAN (KPSP/Denver)

Interpretasi perkembangan :
KPSP
Sesuai
Meragukan
Penyimpangan
(Lampirkan KPSP)

Denver
Normal
Suspect
Untestable
(Lampirkan formulir Denver)
XII. DATA PENUNJANG
A. Radiologi
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

B. Laboratorium
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan
C. Pemeriksaan lainnya
Tanggal Jenis Pemeriksaan Hasil Pemeriksaan

...............................,.......................................

Mengetahui,

Pembimbing klinik Mahasiswa

(.......................................................) (............................................................)
NIM.
A2. ANALISIS DATA

HARI/TGL : .........................................................................................................................

NO KEMUNGKINAN
DATA MASALAH
PENYEBAB
B. DIAGNOSA KEPERAWATAN

NAMA & TANDA

NO TANGGAL DIAGNOSA KEPERAWATAN
TANGAN
C. RENCANA TINDAKAN KEPERAWATAN

NAMA &
DIAGNOSA TUJUAN DAN KRITERIA
NO INTERVENSI RASIONAL TANDA
KEPERAWATAN HASIL
TANGAN
 NAMA &
DIAGNOSA TUJUAN DAN
NO INTERVENSI RASIONAL TANDA
KEPERAWATAN KRITERIA HASIL
TANGAN
D. IMPLEMENTASI RENCANA TINDAKAN KEPERAWATAN

NAMA & TANDA

NO TANGGAL JAM TINDAKAN KEPERAWATAN
TANGAN
E. EVALUASI
DIAGNOSA
NO
KEPERAWATAN
S:
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TANGGAL
S:
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A:
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P:
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S:
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O:
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A:
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P:
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 .............................,.......................................

Mengetahui,

Pembimbing Klinik Mahasiswa

(............................................................) (.......................................................)
NIM.