YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN

PROGRAM STUDI S1 KEPERAWATAN
Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536) 3327707

ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :
NIM :
Ruang Praktek :
Tanggal Praktek :
Tanggal & Jam Pengkajian :

I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama :
Umur :
Jenis Kelamin :
Suku/Bangsa :
Agama :
Pekerjaan :
Pendidikan :
Status Perkawinan :
Alamat :
Tgl MRS :
Diagnosa Medis : ……………………………………………………………..

B. RIWAYAT KESEHATAN /PERAWATAN

1. Keluhan Utama :
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2. Riwayat Penyakit Sekarang:

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3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi)

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4. Riwayat Penyakit Keluarga

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 GENOGRAM KELUARGA:

C. PEMERIKASAAN FISIK
1. Keadaan Umum:
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2. Status Mental :
a. Tingkat Kesadaran : ………………….
b. Ekspresi wajah : ………………….
c. Bentuk badan : ………………….
d. Cara berbaring/bergerak : ………………….
e. Berbicara : ………………….
f. Suasana hati : ………………….
g. Penampilan : ………………….
h. Fungsi kognitif :
 Orientasi waktu : ………………….
 Orientasi Orang : ………………….
 Orientasi Tempat : ………………….
i. Halusinasi :  Dengar/Akustic  Lihat/Visual  Lainnya .......
j. Proses berpikir :  Blocking  Circumstansial  Flight oh ideas
 Lainnya ......................................................................
k. Insight :  Baik  Mengingkari  Menyalahkan orang lain
m. Mekanisme pertahanan diri :  Adaptif  Maladaptif
n. Keluhan lainnya : ………………….

3. Tanda-tanda Vital :
a. Suhu/T : ……………….0C  Axilla  Rektal  Oral
b. Nadi/HR : ………………x/mt
c. Pernapasan/RR : …..…………..x/tm
d. Tekanan Darah/BP : ……...………..mm Hg

4. PERNAPASAN (BREATHING)
Bentuk Dada : .........................................................................
Kebiasaan merokok : …………………………………...Batang/hari
 Batuk, sejak ………………………………………
 Batuk darah, sejak ………………………………………
 Sputum, warna ………………………………………
 Sianosis
 Nyeri dada
 Dyspnoe nyeri dada  Orthopnoe  Lainnya …….………..
 Sesak nafas  saat inspirasi  Saat aktivitas  Saat istirahat
Type Pernafasan  Dada  Perut  Dada dan perut
 Kusmaul  Cheyne-stokes  Biot
 Lainnya
Irama Pernafasan  Teratur  Tidak teratur
Suara Nafas  Vesukuler  Bronchovesikuler
 Bronchial  Trakeal
Suara Nafas tambahan  Wheezing  Ronchi kering
 Ronchi basah (rales)  Lainnya……………
 Keluhan lainnya :
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Masalah Keperawatan :
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5. CARDIOVASCULER (BLEEDING)
 Nyeri dada  Kram kaki  Pucat
 Pusing/sinkop  Clubing finger  Sianosis
 Sakit Kepala  Palpitasi  Pingsan
 Capillary refill  > 2 detik  < 2 detik
 Oedema :  Wajah  Ekstrimitas atas
 Anasarka  Ekstrimitas bawah
 Asites, lingkar perut ……………………. cm
 Ictus Cordis  Terlihat  Tidak melihat
Vena jugularis  Tidak meningkat  Meningkat
Suara jantung  Normal,………………….
 Ada kelainan
Keluhan lainnya :
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Masalah Keperawatan :
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6. PERSYARAFAN (BRAIN)
Nilai GCS : E : ………………….
V : ………………….
M : ………………….
Total Nilai GCS : ……………………
Kesadaran :  Compos Menthis  Somnolent  Delirium
 Apatis  Soporus  Coma
Pupil :  Isokor  Anisokor
 Midriasis  Meiosis
Refleks Cahaya :  Kanan  Positif  Negatif
 Kiri  Positif  Negatif
 Nyeri, lokasi ………………………………..
 Vertigo  Gelisah  Aphasia  Kesemutan
 Bingung  Disarthria  Kejang  Trernor
 Pelo
Uji Syaraf Kranial :
Nervus Kranial I : .........................................................................................
Nervus Kranial II : .........................................................................................
Nervus Kranial III : .........................................................................................
Nervus Kranial IV : .........................................................................................
Nervus Kranial V : .........................................................................................
Nervus Kranial VI : .........................................................................................
Nervus Kranial VII : .........................................................................................
Nervus Kranial VIII : .........................................................................................
Nervus Kranial IX : .........................................................................................
Nervus Kranial X : .........................................................................................
Nervus Kranial XI : .........................................................................................
Nervus Kranial XII : .........................................................................................
 Uji Koordinasi :
Ekstrimitas Atas : Jari ke jari  Positif  Negatif
Jari ke hidung  Positif  Negatif
Ekstrimitas Bawah : Tumit ke jempul kaki  Positif  Negatif
Uji Kestabilan Tubuh :  Positif  Negatif
Refleks :
Bisep :  Kanan +/-  Kiri +/- Skala…………. Trisep
:  Kanan +/-  Kiri +/- Skala………….
Brakioradialis: :  Kanan +/-  Kiri +/- Skala………….
Patella :  Kanan +/-  Kiri +/- Skala………….
Akhiles :  Kanan +/-  Kiri +/- Skala………….
Refleks Babinski :  Kanan +/-  Kiri +/-
Refleks lainnya : .........................................................................................
Uji sensasi : .........................................................................................
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Keluhan lainnya :
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Masalah Keperawatan :
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7. ELIMINASI URI (BLADDER) :

Produksi Urine : ………….ml…………x/hr
Warna :
Bau :
 Tidak ada masalah/lancer  Menetes  Inkotinen
 Oliguri  Nyeri  Retensi
 Poliuri  Panas  Hematuri
 Dysuri  Nocturi
 Kateter  Cystostomi
Keluhan Lainnya :
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Masalah Keperawatan :
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8. ELIMINASI ALVI (BOWEL) :

Mulut dan Faring
Bibir : ..................................................................................................
Gigi : ..................................................................................................
Gusi : ..................................................................................................
Lidah : ..................................................................................................
Mukosa : ..................................................................................................
Tonsil : ..................................................................................................
Rectum :
Haemoroid :
BAB : ……….x/hr Warna :..……… . Konsistensi : …………….
 Tidak ada masalah  Diare  Konstipasi  Kembung
 Feaces berdarah  Melena  Obat pencahar  Lavement
Bising usus : .........................................................................................
Nyeri tekan, lokasi : .........................................................................................
Benjolan, lokasi : .........................................................................................
 Keluhan lainnya :
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Masalah Keperawatan :
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9. TULANG - OTOT – INTEGUMEN (BONE) :

 Kemampuan pergerakan sendi  Bebas  Terbatas
 Parese, lokasi .................................................................................................
 Paralise, lokasi ...............................................................................................
 Hemiparese, lokasi ........................................................................................
 Krepitasi, lokasi .............................................................................................
 Nyeri, lokasi
 Bengkak, lokasi .............................................................................................
 Kekakuan, lokasi ...........................................................................................
 Flasiditas, lokasi ............................................................................................
 Spastisitas, lokasi ...........................................................................................
 Ukuran otot  Simetris
 Atropi
 Hipertropi
 Kontraktur
 Malposisi
Uji kekuatan otot :  Ekstrimitas atas………..  Ekstrimitas bawah……..
 Deformitas tulang, lokasi................................................................................
 Peradangan, lokasi ..........................................................................................
 Perlukaan, lokasi.............................................................................................
 Patah tulang, lokasi .........................................................................................
Tulang belakang  Normal  Skoliosis
 Kifosis  Lordosis

10. KULIT-KULIT RAMBUT

Riwayat alergi  Obat ........................................................................
 Makanan .................................................................
 Kosametik ..............................................................
 Lainnya ..................................................................
Suhu kulit  Hangat  Panas  Dingin
Warna kulit  Normal  Sianosis/ biru  Ikterik/kuning
 Putih/ pucat  Coklat tua/hyperpigmentasi
Turgor  Baik  Cukup  Kurang
Tekstur  Halus  Kasar
Lesi :  Macula, lokasi
 Pustula, lokasi ........................................................
 Nodula, lokasi ........................................................
 Vesikula, lokasi ......................................................
 Papula, lokasi .........................................................
 Ulcus, lokasi ...........................................................
Jaringan parut lokasi .............................................................................................
Tekstur rambut ..................................................................................................
Distribusi rambut ..................................................................................................
Bentuk kuku  Simetris  Irreguler
 Clubbing Finger  Lainnya .................
Masalah Keperawatan :
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11. SISTEM PENGINDERAAN :
a. Mata/Penglihatan
Fungsi penglihatan :  Berkurang  Kabur
 Ganda  Buta/gelap
Gerakan bola mata :  Bergerak normal  Diam
 Bergerak spontan/nistagmus
Visus : Mata Kanan (VOD) : ...........................................................
Mata kiri (VOS) : ............................................................
Selera  Normal/putih  Kuning/ikterus  Merah/hifema
Konjunctiva  Merah muda  Pucat/anemic
Kornea  Bening  Keruh
Alat bantu  Kacamata  Lensa kontak  Lainnya…….
Nyeri : ................................................................................................
Keluhan lain : .................................................................................................
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b. Telinga / Pendengaran :
Fungsi pendengaran :  Berkurang  Berdengung  Tuli
c. Hidung / Penciuman:
Bentuk :  Simetris  Asimetris
 Lesi
 Patensi
 Obstruksi
 Nyeri tekan sinus
 Transluminasi
Cavum Nasal Warna………………….. Integritas……………..
Septum nasal  Deviasi  Perforasi  Peradarahan
 Sekresi, warna ………………………
 Polip  Kanan  Kiri  Kanan dan Kiri
Masalah Keperawatan :
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12. LEHER DAN KELENJAR LIMFE

Massa  Ya  Tidak
Jaringan Parut  Ya  Tidak
Kelenjar Limfe  Teraba  Tidak teraba
Kelenjar Tyroid  Teraba  Tidak teraba
Mobilitas leher  Bebas  Terbatas
13. SISTEM REPRODUKSI
a. Reproduksi Pria
Kemerahan, Lokasi ......................................................
Gatal-gatal, Lokasi ......................................................
Gland Penis .................................................................
Maetus Uretra .............................................................
Discharge, warna .......................................................
Srotum ....................................................................
Hernia ....................................................................
Kelainan ……………………………………………
Keluhan lain ………………………………………….
a. Reproduksi Wanita
Kemerahan, Lokasi ......................................................
Gatal-gatal, Lokasi ......................................................
Perdarahan .................................................................
Flour Albus .............................................................
Clitoris .......................................................................
Labis ....................................................................
Uretra ....................................................................
 Kebersihan :  Baik  Cukup  Kurang
Kehamilan : ……………………………………
Tafsiran partus : ……………………………………
Keluhan lain .....................................................................................................
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Payudara :
 Simetris  Asimetris
 Sear  Lesi
 Pembengkakan  Nyeri tekan
Puting :  Menonjol  Datar  Lecet  Mastitis
Warna areola ....................................................................................................
ASI  Lancar  Sedikit  Tidak keluar

Keluhan lainnya ................................................................................................

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Masalah Keperawatan :
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D. POLA FUNGSI KESEHATAN

1. Persepsi Terhadap Kesehatan dan Penyakit :
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2. Nutrisida Metabolisme
TB : Cm
BB sekarang : Kg
BB Sebelum sakit : Kg
Diet :
 Biasa  Cair  Saring  Lunak
Diet Khusus :
 Rendah garam  Rendah kalori  TKTP
 Rendah Lemak  Rendah Purin  Lainnya……….
 Mual
 Muntah…………….kali/hari
Kesukaran menelan  Ya  Tidak
Rasa haus
Keluhan lainnya ....................................................................................................
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Pola Makan Sehari-hari Sesudah Sakit Sebelum Sakit
Frekuensi/hari
Porsi
Nafsu makan
Jenis Makanan
Jenis Minuman
Jumlah minuman/cc/24
jam
Kebiasaan makan
Keluhan/masalah
Masalah Keperawatan
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 3. Pola istirahat dan tidur
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Masalah Keperawatan
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4. Kognitif :
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Masalah Keperawatan
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5. Konsep diri (Gambaran diri, ideal diri, identitas diri, harga diri, peran ) :
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Masalah Keperawatan
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6. Aktivitas Sehari-hari
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Masalah Keperawatan
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7. Koping –Toleransi terhadap Stress

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Masalah Keperawatan
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8. Nilai-Pola Keyakinan
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Masalah Keperawatan
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E. SOSIAL - SPIRITUAL
1. Kemampuan berkomunikasi
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2. Bahasa sehari-hari
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3. Hubungan dengan keluarga :
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4. Hubungan dengan teman/petugas kesehatan/orang lain :
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5. Orang berarti/terdekat :
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6. Kebiasaan menggunakan waktu luang :
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7. Kegiatan beribadah :
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F. DATA PENUNJANG (RADIOLOGIS, LABORATO RIUM, PENUNJANG
LAINNYA)

G. PENATALAKSANAAN MEDIS

Palangka Raya,…………………
Mahasiswa

( ………………………………)
 ANALISIS DATA

DATA SUBYEKTIF DAN KEMUNGKINAN

MASALAH
DATA OBYEKTIF PENYEBAB
PRIORITAS MASALAH
 RENCANA KEPERAWATAN

Nama Pasien : ……………………..

Ruang Rawat: ……………………..

Diagnosa Keperawatan Tujuan (Kriteria hasil) Intervensi Rasional

 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Tanda Tangan
Hari/Tanggal, Jam Implementasi Evaluasi (SOAP) dan
Nama Perawat