FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :

NIM :

Ruang Praktek :

Tanggal Praktek :

Tanggal & Jam Pengkajian :

I. PENGKAJIAN
A. IDENTITAS PASIEN
Nama : Tn M

Umur : 48 tahun

Jenis Kelamin : laki - laki

Suku/Bangsa : Indonesia Dayak

Agama. : Hindu

Pekerjaan : Swasta

Pendidikan : SMP

Status Perkawinan :

Alamat : Ds Timpah

Tgl MRS :
 Diagnosa Medis :

B. RIWAYAT KESEHATAN /PERAWATAN

1. Keluhan Utama :

Px mengatakan mual dan muntah < 10×

........................................................................................................................................……………

........................................................................................................................................……………

2. Riwayat Penyakit Sekarang :

........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

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

........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

4. Riwayat Penyakit Keluarga

 ........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

GENOGRAM KELUARGA :

C. PEMERIKASAAN FISIK
1. Keadaan Umum :

Compos mentis,px tampak berbaring dibed,wajah pucat, badan lemas terpasang

Inpus Nacl 0,9% 20 tmp

........................................................................................................................................……………

........................................................................................................................................……………

........................................................................................................................................……………

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 :

........................................................................................................................................

........................................................................................................................................

Masalah Keperawatan :

........................................................................................................................................

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 :

........................................................................................................................................

........................................................................................................................................

Masalah Keperawatan :

........................................................................................................................................

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 : ................................................................................................

................................................................................................

Keluhan lainnya :

........................................................................................................................................

........................................................................................................................................

Masalah Keperawatan :

........................................................................................................................................

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 :

........................................................................................................................................

........................................................................................................................................

Masalah Keperawatan :

........................................................................................................................................

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 :

........................................................................................................................................

........................................................................................................................................

Masalah Keperawatan :

........................................................................................................................................

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 :

........................................................................................................................................

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 :

…………………………………………………………………

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 :

........................................................................................................................................

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................................................................................................................

....................................................................................................................................

Payudara :

 Simetris  Asimetris

 Sear  Lesi

 Pembengkakan  Nyeri tekan

Puting :  Menonjol  Datar  Lecet  Mastitis

Warna areola .............................................................................................................

ASI  Lancar  Sedikit  Tidak keluar

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

....................................................................................................................................

Masalah Keperawatan :

....................................................................................................................................

D. POLA FUNGSI KESEHATAN

1. Persepsi Terhadap Kesehatan dan Penyakit :

Px mengatakan kesehatan itu sangat penting dan px berharap ingin cepat pulang

........................................................................................................................................

........................................................................................................................................

........................................................................................................................................

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...............................................................................................................

Pola Makan Sehari-hari Sesudah Sakit Sebelum Sakit

Frekuensi/hari 3×/ hari 3×/ hari

Porsi

Nafsu makan Kurang Baik

Jenis Makanan Bervariasi Bervariasi

Jenis Minuman Air putih Teh,air putih

Jumlah minuman/cc/24 jam

Kebiasaan makan Saat lapar Saat lapar

Keluhan/masalah

Masalah Keperawatan

…………………………………………………………………………………………………

3. Pola istirahat dan tidur

…………………………………………………………………………………………………

…………………………………………………………………………………………………
 …………………………………………………………………………………………………

Masalah Keperawatan

…………………………………………………………………………………………………

4. Kognitif :
…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

Masalah Keperawatan

…………………………………………………………………………………………………

5. Konsep diri (Gambaran diri, ideal diri, identitas diri, harga diri, peran ) :
…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………Masalah Keperawatan

…………………………………………………………………………………………………

6. Aktivitas Sehari-hari
…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………Masalah Keperawatan

…………………………………………………………………………………………………

7. Koping –Toleransi terhadap Stress

 …………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………Masalah Keperawatan

…………………………………………………………………………………………………

8. Nilai-Pola Keyakinan
…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

Masalah Keperawatan

…………………………………………………………………………………………………

E. SOSIAL - SPIRITUAL
1. Kemampuan berkomunikasi

…………………………………………………………………………………………………

…………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………
………………………………………

2. Bahasa sehari-hari

…………………………………………………………………………………………………

…………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………
………………………………………
 3. Hubungan dengan keluarga :

…………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………
………………………………………

…………………………………………………………………………………………………

4. Hubungan dengan teman/petugas kesehatan/orang lain :

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

5. Orang berarti/terdekat :
…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

6. Kebiasaan menggunakan waktu luang :

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

7. Kegiatan beribadah :
…………………………………………………………………………………………………

…………………………………………………………………………………………………

F. DATA PENUNJANG (RADIOLOGIS, LABORATO RIUM, PENUNJANG LAINNYA)

G. PENATALAKSANAAN MEDIS

…. …………..……………..

Mahasiswa
 ( ………………………………)

ANALISIS DATA

DATA SUBYEKTIF DAN DATA

KEMUNGKINAN PENYEBAB MASALAH
OBYEKTIF
DATA SUBYEKTIF DAN DATA KEMUNGKINAN PENYEBAB MASALAH
OBYEKTIF
PRIORITAS MASALAH
 RENCANA KEPERAWATAN

Nama Pasien : ……………………..

Ruang Rawat : ……………………..

Diagnosa Keperawatan Tujuan (Kriteria hasil) Intervensi Rasional

Diagnosa Keperawatan Tujuan (Kriteria hasil) Intervensi Rasional
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/Tanggal Tanda tangan dan

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