FORMAT LAPORAN ASUHAN KEPERAWATAN KEPERAWATAN MEDICAL BEDAH LPENGKAJIAN A. IDENTITAS PASIEN Nama (inisial) Te. OY Usia/tanggal lahir 1G Aahun / 2-02-1976 Jenis kelamin 1 Lowi ~lare Alamat 'Dl Pasar arum Noe.772 et oe (006 .%0 Nir Paler Sukwbangsa # Andomesia Status perkawinan Betum menioh Agama/keyakinan Aslam Pekerjaan/sumber penghasilan: Wiraswaste Diagosa medis rom, No. medical record 204 008% Tanggal masuk 2/09/2019 Tanggal pengkajian 114 fog /2019 B, IDENTITAS PENANGGUNG JAWAB. Nama [ramen Usia Jenis kelamin Lote -Vare! Pekeriaan/sumber penghasiian: w traswasto Hubungan dengan kien: Kerabot C. KELUHAN UTAMA Pasien mengeluh vadannye 4eraso temas dan dingin , 3 i eganggren (4), pus (4) Terdaper \uko diverge aie 9m aren (4), pus2. Riwayat kesehtan lalu 3, Riwayat kesehatan keluarga : Tidak ade rwoyet OM pode anggete Kelvorge D. RIWAYAT KESEHATAN E, RIWAYAT PSIKOSOISAL Posien mengarakan jpron F. RIWAYAT SPRITUAL fasten, eecengasatnn ‘jireoiy) Wertctabe G.POLA AKTIVITAS SEHARI-HARI TPasien mengatakan menderite BM tejake thn Yong 1. Riwayat keschatan sckarang :Pasien menderite OM dan ade Wea clisemper tte tole fo Pertesiaticori dengan lingkungon seitar . NO] AKTIVITAS” SEBELUM SAKIT ‘SELAMA SAKIT 1. _| Pola Nutrisi a. Makan b. Minum @. Selera maken gotten waite 1b. Grex minum pasion boi t & getas Sheri fa. Cetera mokan CY fe. Grek minum wai TP 9 aeles Mori 2, | Pola Eliminasi a BAK b. BAB a Pasien mengarakon bering BAK lp Pasien rengarakan BAB Nancar + tide ado konseipasi GSe\ama AN eS Gren AE OD be. AB lancar tidek ade. Konttipos 3, _| Istirahat /Tidur a: Fasten mengatakon Jerong ttdur sang, Jb. Rosien mengotatcon Eider mojom F-8 Jam ja paeeeee cca Stang, teok Si FE 1b Ratien etdoke wnengalom Keruviton ardor Pasten melokukan cnerivitarnya Secores mondics Paasien menga tatean akeivites- nye dikomte kelssrge Mareno adonnye Xerase, Nemas: a. Siang b. Malam (4. | Aktifitas/ Mobilisasi Fisik 3. | Komunikasi Bicare lancar, jawaban Sesuci Yereangaon Bleara pasion lantor , mamun Relion , Jowaban pasien Serwai Pertanyoar ¢. | Polo Hygiene &.Monai b. Games baju Ja. Fasten mengarakan mardi 2* hor + aitotca- kan mandate 1. Games baju dilekukon «. Ses mandir? 6. Gosek gigh Tekin SeNaR agi dan. ma\am a. Posten mergatakan bongs maondi 1X age core Aap | Wetwargs lo Selama di #S Okmvitos pasien dibanty c. bosok 9193 dveante wewareeF. PEMERIKSAAN FISIK 1, Keadaan umum Kesadaran : (M-E4.vs-Me NADI : 80 */m 1D 10/10 mmitg, RR: 20°/m 1B 2160em BB: 68 *9 SUHU 2 Bote 2. Kepala :Bentuk \eepola normal 3. Rambut ——: Ramiour ike! Witom rkelersinan boik 4, Mata jak ado Yenurunan pengiihoten 5. Muka Benue Muka oval, Hdak ada edema palpeora 6. Telinga 2 Rungsi pendengaron baie, kebersihon telinga boik 7. Hidung “ungsi Penciuman woik. Kebersihan baik 8. Mulut 2 Kebersinan mutuk baik, bilir lembale 9. Gigi Kerersihon boil, 10. Lidah 1 Uda bertin bide ade foriawan 11. Tenggorokan : TWdow ado ketuliton mencion 12. Leher Tidak ada gemetioron Kelenjar thyretd 13. Dada i Benak dada stmevris 14, Abdomen? Kuadran 12/3 dan 4 normol 15. Genetalia Xidaw diteasi 16, Integumen : Warne teutit fase mateng , leutit \embale 17 Ekstremitas :“Terdayot Woke pada Mati gempot WH 18, Persyarafan ‘a Gangguan syaraf kranial: LILILIV.V.VLVI,VULIXXXLXT b. Refleks patologis + babinski( ~), keming( - ).eseque( —),brudzinski(~) c. Kekuatan otot a. G. PEMERIKSAAN PENUNJANG Labortorium(hasil dan normalnya) Bea g fat ante Ro foto Hematoxnt 33% 40-48 CT Scan F Lewwosi# 17. 2 MRI,USG,EEG,ECG.All aes woe Gloxesa 594 ee H. PENATALAKSAAN/ THERAPY SAAT INI “AVEO gL get Got/m cole + Cepirioxone 2x1 = Aaj. ranitidine 20 - Inj deazepom 5 mg = lnguin 36 NCS grem)AeRaa OMY t omnnGred gy * gy SASOAMIE! 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