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Ruang :Melati

No. Medical Record :18-11-41


Tgl Pengkajian :15-05-2019
Pukul :19:45
I. DATA DASAR
A. Identitas Pasien
1. Nama : Tn.R
2. Usia : 50 Tahun
3. Status Perkawinan :Kawin
4. Pekerjaan :Petani
5. Agama :Islam
6. Pendidikan :SD
7. Suku :Jawa
8. Bahasa yang digunakan :Jawa dan Indonesia
9. Alamat Rumah :Tanjung Rejo
10. Sumber Biaya : Asuransi BPJS
11. Tanggal Masuk : 14-05-19
12. Diagnosa Medis Saat Pengkajian :

B. Sumber Informasi (Penanggung Jawab)


Nama : Ny.J
Umur : 49 Tahun
Hubungan Dengan Pasien :Istri
Pendidikan : SD
Pekerjaan : Petani
Alamat : Tanjung Rejo

II. RIWAYAT KESEHATAN

A. Riwayat kesehatan masuk RS (UGD/POLIKLONIK)


3tahun lalu pasien datang ke UGD di antar oleh keluarga setelah mengalami kecelakaan lalu
lintas,dan dioperasi pasang pen dipaha kanan,dan saat ini sudah tidak ada keluhan lagi,dan
disarankan untuk lepas pen.

B. Riwayat kesehatan saat pengkajian/riwayat penyakit sekarang

(1) Keluhan utama

P (Penyebab) :Pemasangan pen/KLL/Fraktur Femur Dextra

Hal yang memperberat :Melakukan aktivitas bagian tubuh bawah

Hal yang memperingan :Beristirahat

Q ( quantity/quality )
R ( region/radiasi )

Lokasi dan penyebaran :Femur dextra

S ( saverity/scale )

Lamanya :Selama 15 menit

Frekuensi :

Intensitas :

T ( time )

Kapan terjadinya :Ketika melakukan aktivitas

(2) Keluhan penyerta :Tidak ada

C. Riwayat kesehatan lalu:

Riwayat alergi :Tidak ada

Riwayat kecelakaan :3 tahun lalu

Riwayat perawatan di RS :3 tahun lalu di RS Abdoel Moeloek

Riwayat penyakit berat/kronis :Tidak ada

Riwayat pengobatan :PO pemasangan pen femur dextra

Riwayat operasi :PO pemasangan pen femur dextra

D. Riwayat kesehatan keluarga : (genogram, penyakit yang pernah diderita oleh anggota
keluarga yang menjadi faktor resiko, 3 generasi) dan analisa dari genogram.

E. Riwayat Psikososial-spiritual
 Konsep diri :Tenang
 Support System :Keluarga,istri dan anak
 Komunikasi :Normal
 System nilai kepercayaan :Islam

F. Pendidikan/ pengajaran klien dan keluarga:


 Kaji persepsi pasien dan keluarga tentang penyakit, prognosis, program pengobatan,
diet, dan perawatan.
G. Lingkungan
1. Rumah
 kebersihan :Bersih
 polusi :Tidak ada
 bahaya :Tidak ada
2. pekerjaan
 kebersihan :Cukup
 polusi :Tidak ada
 bahaya :Racun pestisida

H. Pola kebiasaan sehari-hari sebelum dan sesudah sakit:


1. Pola Nutrisi dan Cairan (sebelum dan saat sakit):
a. Pola nutrisi:
 Asupan :Oral
 Frekwensi :3x/Hari
 Nafsu makan : Baik

 Diit :Tidak ada


 Makanan tambahan :Tidak ada
 Makanan yang tidak disukai/alergi/pantangan :Tidak ada
 Kebiasaan makan (sebelum dan sesudah makan) :Tidak ada
 Jumlah kalori :
 Perubahan berat badan 3 bulan terakhir : Tetap tidak berubah
2. Pola Cairan:
 Asupan cairan : ( ) Oral, jenis, volume total

2. Pola eliminasi (sbelum daan saat sakit):


a.BAK
 Keluhan yang berhubungan dengan BAK :Tidak ada keluhan
 Frekwensi :
 Waktu :
 Jumlah :
 Bau :

b. BAB
 Frekwensi :
 Waktu :
 Warna :Kuning
 Bau :
 Konsistensi :
 Keluhan :Tidak ada keluhan
 Penggunaan laxatif/pencaha :Tidak ada
c. IWL (Insensible Water Lose) : cc/hari
d.Blance cairan : Intake-output
3.Pola Personal Hygiene (sebelum dan saat sakit):
a.Mandi
 Frekwensi : 2 x/hari
b.Oral hygiene
 Frekwensi : 2 x/hari
 Waktu :Pagi dan sore
c.Cuci Rambut
 Frekwensi : 3 x/Miunggu

4.Pola istirahat dan tidur (sebelum dan saat sakit):


 Lama tidur : 8 jam/hari
 Waktu
-Siang : 1 jam
-Malam : 7 jam
 Kebiasaan sebelum tidur/pengantar tidur :Tidak ada
Kesulitan dalam hal tidur :Tidak ada

5. Pola aktivitas dan latihan (seblum dan saat sakit):


 Jenis pekerjaan :Petani
 Waktu bekerja :6 jam
 Kegiatan waktu luang :Pekerja bangunan
 Keluhan dalam beraktivitas :Mudah lelah
 Olahraga :Jalan pagi
Jenis :Jalan
Frekwensi :30 menit/hari
 Keterbatasan dalam hal :Tidak ada

6. Pola kebiasaan yang mempengaruhi kesehtan


a. Merokok : Ya
-Frekwensi :1/2 bungkus/hari
-Jumlah :8 batang
-Lama pemakaian :30 tahun yang lalu
b. Minuman keras : Tidak

c. Ketergantungan obat : Tidak

I. Pengkajian fisik
Pemeriksaan umum
-Kesadaran :
-Tekanan Darah :130/80 mmhg
-Nadi :78x/menit
-Pernafsan :18x/menit
-Suhu :36,30C
-TB/BB :160 cm / 45 kg
1. Pemeriksaan Fisik Head To Toe
1) Kepala dan Rambut :
a. Bentuk kepala :Normal
b. Keadaan rambut :Berminyak
c. Kulit kepala :Kotor

2) Mata :
a.Posis mata :Simetris
b.Kelopal mata :Normal
c.Pergerakan bola mata :Normal
d.Konjungtiva :Normal/merah muda
e.Sklera :Ikterik
f.Pupil :Isokor
g.Otot-otot mata :Tidak ada kelainan
h.Fungsi penglihatan :Normal
i.Tanda-tanda radang :Tidak ada
j.Pemakaian kaca mata :Tidak
k.Pemakaian lensa kontak :Tidak
l.Reaksi terhadap cahaya :
3) Hidung
a.Septum hidung :Di tengah
b.Sekret hidung :Tidak
c.Bila terdapat sekret :Tidak
d.Perdarahan hidung :Tidak
e.Polip hidung :Tidak
f.Peradangan mukosa hidung :Tidak
4) Telinga
a.Daun telinga :Tidak sakit saat digerakkan
b.Kondisi telinga :Normal
c. Cairan dari telinga :Tidak ada
d. Rasa penuh dalam telinga :Tidak
e. Titinus :Tidak
f. Fungsi pendengaran :Normal
h. Fungsi Keseimbang :Tidak ada gangguan
i. Hasil pemeriksaan fungsi pendengaran
 Tes Rinne :Tidak
 Tes Weber :Tidak
 Tes Swabach :Tidak
5) Mulut
a. Rongga mulut :
Bau mulut :Ya
Radang Mukosa :Tidak
(Stomatis)
Labio/plato schisis :Tidak

b. Gigi geligi
Karang/ karies gigi :Tidak
Gigi yang tanggal :Ya
Gigi palsu :Tidak
GInggivitis :Tidak

c. Lidah
Keadaan lidah : Bersih
Tepi lidah : Merah muda

d. Tonsil
Peradangan faring : Tidak

6). Leher
a. Pembengkakan kelenjar Tiroit : TIdak
b. Pembengkakan kelenjar limfe :Tidak
c. Massa/benjolan tumor : Tidak
d. Jaringan parut : Tidak
7). Pernapasan
a. Jalan napas : Bersih

b. Pernapasan :Dengan aktivitas

c.Menggunakan otot-otot bantu :Tidak

d. Frekuensi pernapasan :18x/mnt


e. Irama pernapasan :Teratur
f. Kedalaman : Dalam
g. Batuk : Tidak
h. Sputum ( ) Putih ( ) Kuning
( ) Hijau
i. Konsistensi sputum ( ) Kental ( ) Encer
j. Suara napas : Normal
8). Jantung
a. Sirkulasi Perifer
Nadi :78x/mnt
Irama : Teratur
Denyut : Kuat
Tekanan darah :130/80mmHg
Distensi Vena Jugularis:
Kanan : Ya
Kiri : Ya
Temperatur kulit :Hangat
Warna kulit : Normal (sawo mateng)

b. Sirkulasi Jantung
Frekuensi denyut apical :80x/mnt
Irama :Teratur
Kelainan bunyi jantung ( ) Murmur ( ) Gallop
Nyeri dada : Tidak

9). Pencernaan
a. Riwayat muntah:
Isi ( ) Makanan ( ) Cairan
( ) Darah
Warna ( ) Sesuai warna makanan ( ) Kehijauran
( ) Hitam
Mual ( ) Ya ( ) Tidak
Nafsu makan ( ) Baik ( ) Kurang
Rasa penuh perut ( ) Ya ( ) Tidak
Nyeri pada perut ( ) Ya` ( ) Tidak
Bila nyeri, ( ) Seperti ditusuk-tusuk
karakteristik ( ) Melilit
( ) Cramp
( ) Panas seperti terbakar
( ) Menyebar
( ) Setempat
( ) Berpindah-pindah
( ) Kanan atas
( ) Kanan bawah
( ) Kiri bawah
( ) Epigastrum
b. Abdomen
Inspeksi
Perkusi
Palpasi
Auskultasi
Bising usus
c.Hepar ( ) Teraba ( ) Tidak teraba
d. Lien/Spleen ( ) Teraba ( ) Tidak teraba
e. Kebiasaan BAB x/Hari0
f. Diare ( ) Ya ( ) Tidak
Bila diare Lamanya........ Frekwensi x/hari
g. Warna feces ( ) Kuning ( ) Cokelat
( ) Hitam ( ) Dempul
( ) Putih seperti cucian beras
h. Konsistensi feces ( ) Setengah padat ( ) Cair
( ) Berdarah ( ) Terdapat lendir
( ) Tidak ada kelainan

10. Perkeimihan (Urogenital)


BAK:
Pola rutih 3 x/hari : Terkontrol
Jumlah urine cc/hari
Warna : Kuning
Distensi kndung kemih ( ) Ya ( ) Tidak
Perubahan pola ( ) Retensi ( ) Tidak lampias
Berkemih
Keluhan sakit pinggang : Tidak

11. Integumen
Turgor kulit : Elastik baik
Warna kulit : Kemerahan
Kondisi kulit : Baik/utuh

Kelainan pada kulit :Tidak ada


12. Muskuloskeletal
Tonus otot ( ) Kelemahan (flasiditas)
( ) Spastisitas
Struktur tulang : Normal
Kelaian columna vertebralis :Tidak ada
Kesulitan gerak : Ya
Kemampuan melakukan ROM :- Lemah
- Hanya satu sisi
Nyeri sendi : Ya
Nilai kekuatan otot :Lemah

III. Pemeriksaan Penunjang


1) Data laboratorium yang berhubungan

2) Pemeriksaan penunjang diagnostic

IV. Penatalaksanaan
 Penatalaksanaan Medis (Terapi obat ,Operatif dan lain lain)
 Penatalaksanaan Keperawataan (Saat Pengkajian

V.Data Fokus:
 Data Subjektif:
 Data Objektif:

VI.ANALISA DATA
No. DATA (S) MASALAH (P) ETIOLOGI (E)
1 DS :
DO :

VII.DIAGNOSA KEPERAWATAN SESUAI DENGAN PRIORITAS


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2. Status Kesehatan
a. Status Kesehatan Saat Ini
1) Keluhan Utama (Saat MRS dan saat ini)
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2) Alasan masuk rumah sakit dan perjalanan penyakit saat ini


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3) Upaya yang dilakukan untuk mengatasinya


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b. Satus Kesehatan Masa Lalu


1) Penyakit yang pernah dialami
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2) Pernah dirawat
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3) Alergi
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4) Kebiasaan (merokok/kopi/alkohol dll)


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c. Riwayat Penyakit Keluarga


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d. Diagnosa Medis dan therapy


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3. Pola Kebutuhan Dasar ( Data Bio-psiko-sosio-kultural-spiritual)


a. Pola Persepsi dan Manajemen Kesehatan
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b. Pola Nutrisi-Metabolik
 Sebelum sakit :
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 Saat sakit :
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c. Pola Eliminasi
1) BAB
 Sebelum sakit :
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 Saat sakit :
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2) BAK
 Sebelum sakit :
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 Saat sakit :
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d. Pola aktivitas dan latihan


1) Aktivitas
Kemampuan 0 1 2 3 4
Perawatan Diri
Makan dan minum
Mandi
Toileting
Berpakaian
Berpindah
0: mandiri, 1: Alat bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung
total

2) Latihan
 Sebelum sakit
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 Saat sakit
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e. Pola kognitif dan Persepsi


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f. Pola Persepsi-Konsep diri


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g. Pola Tidur dan Istirahat


 Sebelum sakit :
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 Saat sakit :
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h. Pola Peran-Hubungan
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i. Pola Seksual-Reproduksi
 Sebelum sakit :
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 Saat sakit :
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j. Pola Toleransi Stress-Koping


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k. Pola Nilai-Kepercayaan
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4. Pengkajian Fisik
a. Keadaan umum : ……………………………………….
Tingkat kesadaran : komposmetis / apatis / somnolen / sopor/koma
GCS : verbal:……….Psikomotor:……….Mata :……………..
b. Tanda-tanda Vital : Nadi = ……… , Suhu =…………. , TD =…………, RR
=………
c. Keadaan fisik
a. Kepala dan leher :
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b. Dada :
 Paru
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 Jantung
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c. Payudara dan ketiak :


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d. abdomen :
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e. Genetalia :
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f. Integumen :
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g. Ekstremitas :
 Atas
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 Bawah
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h. Neurologis :
 Status mental da emosi :
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 Pengkajian saraf kranial :
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 Pemeriksaan refleks :
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b. Pemeriksaan Penunjang
1. Data laboratorium yang berhubungan
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2. Pemeriksaan radiologi
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3. Hasil konsultasi
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4. Pemeriksaan penunjang diagnostic lain


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5. ANALISA DATA
A. Tabel Analisa Data
DATA Etiologi MASALAH