ASUHAN KEPERAWATAN KEPERAWATAN MEDIKAL BEDAH

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NERS FIK UNIVERSITAS PAHLAWAN TUANKU TAMBUSAI

Nama mahasiswa : .........................................................

Tempat praktek : ……………………………………

Tanggal : ……………………………………

I. Identitas diri klien

Nama : .......................................... Suku : …………………………………............

Umur : .......................................... Pendidikan :..........................................................
Jemis kelamin :........................................... Pekerjaan :..........................................................
Alamat :........................................... Lama bekerja :..........................................................
………………………………………………..........................
…………………………………………………....................... Tanggal masuk RS :........................................
Status perkawinan........................................................... Tanggal Pengkajian :
……………………........... Agama: ................................................................................ Sumber Informasi
: ……………………….......

II. Riwayat penyakit

1. Keluhan utama saat masuk RS:
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2. Riwayat penyakit sekarang:
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3. Riwayat Penyakit Dahulu
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Genogram:
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4. Diagnosa medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah
dilakukan:
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III. Pengkajian saat ini (mulai hari pertama saudara merawat klien)
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1. Persepsi dan pemeliharaan kesehatan
Pengetahuan tentang penyakit/perawatan
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2. Pola nutrisi/metabolic
Program diit RS:
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Intake makanan:

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Intake cairan:

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3. Pola eliminasi
a. Buang air besar
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b. Buang air kecil

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4. Pola aktifitas dan latihan:
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Kemampuan perawatan diri 0 1 2 3 4

Makan/minum

Mandi

Toileting

Berpakaian

Mobilitas di tempat tidur

Berpindah

Ambulasi/ROM
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total
Oksigenasi:
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5. Pola tidur dan istirahat

(lama tidur, gangguan tidur, perawasan saat bangun tidur)

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6. Pola persepsual
(penglihatan, pendengaran, pengecap, sensasi):
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7. Pola persepsi diri
(pandangan klien tentang sakitnya, kecemasan, konsep diri)
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 8. Pola seksualitas dan reproduksi
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(fertilitas, libido, menstuasi, kontrasepsi, dll.)
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9. Pola peran hubungan
(komunikasi, hubungan dengan orang lain, kemampuan keuangan):
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10. Pola managemen koping-stess
(perubahan terbesar dalam hidup pada akhir-akhir ini):
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11. Sistem nilai dan keyakinan
(pandangan klien tentang agama, kegiatan keagamaan, dll)
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IV. Pemeriksaan fisik

(cephalocaudal) yang meliputi : Inspeksi, Palpasi, Perkusi dan Auskultasi
keluhan yang dirasakan saat ini

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o
TD: mm/H P: x/m N: x/m S: C

BB/TB…………………………………………
Kepala:
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Mata dan Telinga (Penglihatan dan pendengaran)

a. Penglihatan

 Berkurang  Ganda  Kabur  Buta/ gelap

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 Visus: dioptri
 Sklera ikterik : (ya/tidak)
 Konjungtiva : (anemis/ tidak anemis)
 Nyeri : (ya/tidak), intensitas :
 Kornea : jernih/keruh/berbintik
 Alat bantu : tidak ada/lensa kontak/kaca mata

b. Pendengaran

 Normal  Berdengung  Berkurang  Alat bantu  Tuli

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Keluhan lain:

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Hidung:

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Mulut/Gigi/Lidah:

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Leher :

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Respiratori
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a. Dada :
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b. Batuk : ya/tidak; produktif/tidak produktif

Karakteristik Sputum .......................................................................................................................................

c. Napas bunyi : vesikuler/lainnya, jelaskan

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 Sesak napas saat :

 Ekspirasi  Inspirasi  Istirahat  Aktivitas

Tipe pernapasan :
 Perut  Dada  Biot
 Kussmaul  Cynestokes  Lainnya
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Frekuensi nafas : x/mnt

Penggunaan otot-otot asesori: (ya/tidak), Napas Cuping Hidung:

..................................... Fremitus:
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Sianosis : (ya/ tidak)

 Keluhan Lain:
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Kardiovaskular

Riwayat Hipertensi: .............................................................. Masalah jantung……………..

Demam Rematik: ..................................................................

Bunyi Jantung: Frekuensi:................................................. Irama………………….

Kualitas……………………………….. …………………
Murmur ……..
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 Nyeri dada, Intensitas :
Palpitasi
 Pusing  Cianosis
 Capillary
refill :

 Riwayat Keluhan lainnya

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 Edema, lokasi : grade :
 Hematoma, lokasi :
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................ Neurologis

Rasa ingin pingsan/ pusing:

...................................................................................................................... Sakit Kepla: Lokasi

nyeri ...................................................................... Frekuensi ...................................

 GCS : Eye = Verbal = Motorik =

 Pupil : isokor/unisokor
 Reflek cahaya :
 Sinistra : +/- cepat/lambat
 Dextra : +/- cepat/lambat

 Bicara :

 Komunikatif  Aphasia  Pelo


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 Keluhan lain :

 Kesemutan  Bingung  Tremor  Gelisah  Kejang

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 Koordinasi ekastemitas

 Normal  Paralisis, Lokasi :  Plegia, Lokasi :

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 Keluhan lain:
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Integumen

 Warna kulit

 Kemerahan  Pucat  Sianosis  Jaundice  Normal

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 Kelembaban :

 Lembab  Kering
 Turgor : elastis / tidak elastic

 > 2 detik  < 2 detik

Keluhan lain :
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Abdomen

Nyeri Tekan: .......................................................................................................................................................

Lunak/keras: .......................................................................................................................................................

Massa:……………………………..ukuran/ Lingkar Perut:................................................................................

Bising usus: .........................................................................................................................................................
Asites : ..................................................................................................................................................................

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Keluhan lain: .......................................................................................................................................................

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 Muskuloskeletal
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 Nyeri otot/tulang, lokasi : intensitas :
 Kaku sendi, lokasi :
 Bengkak sendi, lokasi :
 Fraktur (terbuka/tertutup), lokasi :
 Alat bantu, jelaskan :
 Pergerakan terbatas, jelaskan :
 Keluhan lain, jelaskan :

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Seksualitas
Aktif melakukan hubungan seksual: ................................................................................................................
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Penggunaan alat kontrasepsi: ............................................................................................................................

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Masalah/kesulitan seksual: ..................................................................................................................................

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Perubahan terakhir dalam frekuensi:...............................................................................................................

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Wanita:

Usia Menarche :…………… lamanya siklus:……………..durasi:………………..

Periode menstruasi terakhir:……………………..Menopouse:……………………
Melakukan pemeriksaan payudara sendiri:
................................................................................................... PAP smear terakhir:

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Pria
Rabas penis :……………………….Gangguan prostat:……………………………
Sirkumsisi :…………………………Vasektomi:…………………………………..

Impoten :…………………………….Ejakulasi dini:………………………………

 V. Program terapi:
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Hasil Pemeriksaan Penunjang dan Laboratorium

(dimulai saat anda mengambil sebagai kasus kelolaan, cantumkan tanggal pemeriksaan,

dan kesimpulan hasilnya)

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Pekanbaru, ................... 20
Perawat

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VI. Analisa Data
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No Data Penunjang Kemungkinan Penyebab Masalah

1. Data Subjektif :
dst

Data Objektif :

VII. Diagnosa Keperawatan

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4. …………………………………………………………………………………………………………………………………………………………
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 RENCANA KEPERAWATAN
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DIAGNOSA KEPERAWATAN
NO TUJUAN (NOC) INTERVENSI (NIC) RASIONAL
/MASALAH KOLABORASI

Dst

Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah
 Catatan Perkembangan
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Nama Klien : Umur :

No RM : Ruang :

Hari/Tgl No. Dx Implementasi Evaluasi (SOAP) Paraf

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Buku Panduan Praktik Klinik Program Pendidikan Profesi Ners Stase Keperawatan Medikal Bedah