ASUHAN KEPERAWATAN MEDIKAL BEDAH

PRODI D III KEPERAWATAN

STIKES MUHAMMADIYAH KENDAL

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

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

I. PENGKAJIAN

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 : ..........................................................................................................
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. Riwayat 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
 Antropometri :

 Biochemical (px diagnostik) :

 Clinical (penampilan klinis) :

 Diit :

a. Keterangan Tambahan
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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 :

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 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 ( ) Penggunaan Kateter : ( ) Ya ( )
tidak tidak
a. Keterangan Tambahan
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4. Pola aktivit as & kebersihan diri

Pengkajian Aktivitas dengan Indeks Barthel
No Item Yang Dinilai
1 Makan (Feeding)
2 Mandi (bathing)
3 Perawatan diri (grooming)
4 Berpakaian (dressing)
5 Buang air kecil (bladder)
6 Buang air besar (bowel)
7 Penggunaan toilet
8 Bergerak
9 Berpindah
10 Naik turun tangga
Skor Nilai
0 = Tidak mampu
1 = Butuh Bantuan
2 = Mandiri
0 = Tergantung orang lain
1 = Mandiri
0 = Membutuhkan bantuan orang lain
1 = Mandiri dalam perawatan muka, rambut, gigi,
dan bercukur
0 = Tergantung orang lain
1 = Sebagian dibantu
2 = Mandiri
0 = Inkontinensia atau pakai kateter & tidak
terkontrol
1 = Kadang inkontinensia (maks 1x24 jam)
2 = Kontinensia (teratur utk lebih dari 7 hari)
0 = Inkontinensia (tidak teratur atau perlu enema)
1 = kadang inkontinensia (sekali seminggu)
2 = Kontinensia (teratur)
0 = Tergantung bantuan orang lain
1 = membutuhkan bantuan, tapi dapat melakukan
beberapa hal sendiri
2 = Mandiri
0 = tidak mampu
1 = butuh bantuan untuk bisa duduk (2 orang)
2 = bantuan kecil (1 orang)
3 = Mandiri
0 = Immobile (tidak mampu)
1 = menggunakan kursi roda
2 = berjalan dengan bantuan 1 orang
3 = mandiri (meskipun menggunakan alat bantu
seperti tongkat)
0 = tidak mampu
1 = membutuhkan bantuan (alat bantu)
2 = mandiri
Total

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 Interpretasi hasil :
20 = mandiri; 12-19 = ketergantungan ringan; 9 – 11 = Ketergantungan sedang
5-8 = ketergantungan berat; 0-4 = ketergantungan total
 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 ,...........................................

Keterangan Tambahan
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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
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c. Sistem Pendengaran :
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d. Sistem Wicara :
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e. Sistem Pernafasan :
1) Inspeksi dada : ....................................................................
2) Palpasi dada : ....................................................................
3) Perkusi dada : ....................................................................
4) Auskultasi / Suara nafas : ( ) Vesikuler ( ) Ronkhi
( ) Wheezing ( ) Rales
Keterangan:
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5) Jalan nafas : ( ) Bersih ( ) Ada sumbatan, ...............
6) Pernafasan : ( ) Tidak sesak ( ) Sesak, ............................
7) Menggunakan otot bantu pernafasan : ( ) Ya ( ) Tidak
8) Pergerakan dinding dada : ( ) simetris ( ) Tidak simetris
9) Frekuensi : ....................... x / menit
10) Irama : ( ) Teratur ( ) Tidak teratur
11) Kedalaman : ( ) Dalam ( ) Dangkal
12) Batuk : ( ) Tidak ( ) Ya, ..........(produktif/tidak)
13) Sputum : ( ) Tidak ( ) Ya, .........(Putih/Kuning/Hijau)
14) Konsistensi : ( ) Kental ( ) Encer
15) Terdapat darah : ( ) Ya ( ) Tidak
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 Jantung : ............................ x/menit
b) Irama : ( ) Teratur ( ) Tidak teratur
c) 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 : .................................
Lamanya nyeri : ..................................
3) Pemeriksaan Jantung
a) Inspeksi : ..............................................................................................
b) Palpasi : ...............................................................................................
c) Perkusi : ...............................................................................................
d) Auskultasi : ...............................................................................................

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g. Sistem Pencernaan :
1) Inspeksi Perut : ( ) datar ( ) Buncit
2) Auskultasi perut : .................................................................................
3) Perkusi : .................................................................................
4) Palpasi : .................................................................................
5) Gigi : ( ) Caries ( ) Tidak
6) Penggunaan gigi palsu : ( ) Ya ( ) Tidak
7) Stomatitis : ( ) Ya ( ) Tidak
8) Lidah kotor : ( ) Ya ( ) Tidak
9) Saliva : ( ) Normal ( ) Abnormal
10) Muntah : ( ) Tidak ( ) Ya, .......................
a) Isi : ( ) Makanan ( ) Cairan ( ) Darah
b) Warna : ( ) Sesuai warna makanan ( ) Kehijauan
( ) Cokelat ( ) Kuning ( ) Hitam
c) Frekuensi : ............................... x/hari
d) Jumlah : ............................... ml
11) Nyeri daerah perut : ( ) Ya, .................... ( ) Tidak
12) Skala nyeri : ...............................
13) 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

14) 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
15) Konstipasi : ( ) Tidak ( ) Ya, .......................
Lamanya : ..................hari
16) Hepar : ( ) Teraba ( ) Tidak teraba
17) Abdomen : ( ) Lembek ( ) Kembung
( ) Acites ( ) Distensi
h. Sistem Endokrin :
Luka Ganggren : ( ) Tidak ( ) Ya, lokasi.......................
Kondisi luka : .................................................................
Pemeriksaan Gula Darah : .............................................

i. 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 : .................................................................

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 j. 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

k. 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 ..............................
Kelainan stuktur tulang belakang : ( ) Skoliasis ( ) Lordosis
( ) Kiposis
Keadaan tonus otot : ( ) Baik ( ) Hipotoni
( ) Hipertoni ( ) Atoni

Kekuatan otot :

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

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6. Terapi (obat, tindakan, dll)
NO TANGGAL TERAPI TUJUAN KOMPLIKASI

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II. ANALISA DATA & DIAGNOSA KEPERAWATAN
Tgl/No DATA FOKUS ETIOLOGI PROBLEM

DIAGNOSA KEPERAWATAN
1.
2.
3.
4.

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III. PRIORITAS DIAGNOSA KEPERAWATAN

NO DIAGNOSA PRIORITAS RASIONAL

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IV. PERENCANAAN KEPERAWATAN

Diagnosa Keperawatan :

Tanggal Tujuan & Kriteria Hasil Intervensi Rasional Ttd

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V. IMPLEMENTASI
Diagnosa
Tanggal Jam Tindakan Respon Pasien Ttd
Kep.

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VI. EVALUASI
Evaluasi
Tanggal Jam Diagnosa Kep. Ttd

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