APLIKASI PENGKAJIAN TEORI MODEL ADAPTASI ROY

PADA KLIEN DENGAN .......................................

Kasus Kelolaan Pasien dengan Gangguan Sistem ............................................ :

I. INFORMASI UMUM Tanggal : .................... Waktu: ............ WIB

A. Identitas Pasien

Nama : RM :
Umur : Jenis kelamin :
Agama : Pendidikan :
terakhir
Pekerjaan :

Alamat :

Diagnosa :
Medis

B. Identitas Penanggungjawab

Nama : Umur :
Pendidikan :
terakhir

Pekerjaan :
Hubungan :
No Tlp :
Alamat :

C. Riwayat Kesehatan

Keluhan utama :

Riwayat Kesehatan Sekarang :

Riwayat Kesehatan Masa Lalu :

Allergy
 Obat : Tidak / Ada : sebutkan............
 Makanan : Tidak / Ada : sebutkan............
 Lainnya : Tidak / Ada : sebutkan............
Riwayat operasi
 Tidak ada tahun _________________
  __________________________________ tahun _________________
 ___________________________________ tahun _________________

Riwayat penyakit masa lalu :

Riwayat penyakit keturunan :

Tidak ada / Ada : sebutkan............
 Diabetes  Hipertensi  Asma  Jantung  Kanker Lainnya : Tidak / ada

Konsumsi obat/ suplemen saat ini : tanggal ...................................

II. ADAPTASI (TAHAP I)

A. FISIOLOGIS
1. OKSIGENASI
a. Fisik
Batuk  Tidak  Ya  Produktif  Non Produktif
Warna  Bersih  Putih
 Hijau  Kuning
 Merah
Sesak :  Tidak  Ya Fatique  Tidak  Ya

Inspeksi :
Nafas : RR: ..... x/mnt Irama:  Normal  Bradypnea
 Takypnea  Kussmaul
 Cheyne-stokes
Simetris :  Tidak  Ya
Retraksi dada :  Tidak  Ya
Palpasi :
Taktil Fermitus : Kanan + / - Kiri + / -

Perkusi :
 Resonance Letak : __________.
 Letak ____________
hiperresonance
 Flat Letak ____________
 Dullnes Letak ____________
 Tympany Letak ____________
 Auskultasi : Letak Letak
 Bronchial ___________________  Krakles Tidak / Ada
 Ronchovesikuler ___________________  Whezzing Tidak / Ada
 Vesicukuler ___________________.  Ronchi Tidak / Ada
 Friction Rub Tidak / Ada
Lainnya:

b. Lab :
Tanggal ................................... 2015
Variabel Nilai Nilai normal Kesan
pH 7,35 – 7,45
PO2 75,00 – 100,00 mmHg
PCO2 35,00 – 45,00 mm Hg
HCO3 22,00 – 24,00
mEq/liter
Total CO2 21,00 – 27,00
mEq/liter
Sa02 95 – 100%
BE (Base excess - 2 smp 2 mEq/liter
/ kelebihan basa)
c. Pemeriksaan diagnostik lain (Radiologi Thorax paru dll)
Radiologi Paru:
Kesan : ...............................................................................................
USG :
Kesan : ...............................................................................................

2. SIRKULASI
a. Fisik
TD : ........ mmHg Nadi : ..... x/mnt Irama :  Reguler  Irreguler
Konjungtiva :  Normal  Pucat Kekuatan :  Kuat  Lemah
 Absent
Membran :  Normal  Pucat Sianosis :  Ya  Tidak
mukosa/ bibir Kulit pucat :  Ya  Tidak
Kapillary refill : < / > 2 detik Akral :  Ya  Tidak
dingin
CVP : - JVP : .......... cmH2O
Bunyi jantung :  S1 – S2 normal  Gallop
 Paradoksial  Murmur
 b. Lab : tidak dilakukan pemeriksaan
Nilai Nilai normal Kesan
Hematologi : Tanggal ............................. 2015
Hemoglobin 12.0-15.0
Hematokrit 36.0-46.0
Trombosit 150-400 x103/mm3
PT 9.8 – 12.6
APTT 31.0 – 47.0

c. Pemeriksaan diagnostik lain (EKG tanggal ...........................................)

Kesan : .........................................................................

Pemeriksaan Morfologi Darah Tepi:

Eritrosit
Leukosit
Trombosit
Kesan

3. NUTRISI
a. Fisik
TB : ... cm BB : ... Kg IMT : .... kg/cm2 (status gizi kurang)
Klien mengatakan ada/tidak penurunan berat badan .... Kg dalam waktu 1 bulan.
Gangguan :  Tidak nafsu makan  Mual  Muntah : _____-____cc/hr
makan  Sariawan  Gangguan mengunyah  Gangguan menelan
Diet : ..................... Kalori
sebelumnya Jenis makanan dan minuman
Karbohidrat/ Protein/ Lemak/ Sayur dan buah :
Nasi, tahu/ tempe, lauk (ikan, telor) sayur dan buah.
Klien mengeluhkan ................................................................
Jenis makan ringan/selingan : ..............................................
Konsumsi suplemen:  Ya  Tidak
Nama Supllemen :
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_
 Kebiasaan:
 merokok : ___________________btg/hr/minggu
 alkohol : _____________________gls/hr/minggu
 soda : _____________________gls/hr/minggu
 kopi : ___________________gls/hr/minggu
 teh : _____________________gls/hr/minggu
 konsumsi gula : _________________sdk/hr/minggu
 konsumsi garam : _____________________sdk/hr/minggu

Diet saat ini : ......................... Kalori

 Cair Jenis makanan dan minuman
 Lunak Karbohidrat/ Protein/ Lemak/ Sayur dan buah/pantangan :

 Padat Diet makanan dari rumah sakit

Jenis makan ringan/selingan

Klien mengeluhkan ........................................................
Abdomen :
Inspeksi :  Normal  Asites ___-____cm  Stoma  Luka
 Caput medusa  Spider nevi

Auskultasi : Bowel Sound

RUQ :  normal  meningkat  menurun  absent
LUQ :  normal  meningkat  menurun  absent
RLQ :  normal  meningkat  menurun  absent
LLQ :  normal  meningkat  menurun  absent
Perkusi  Normal  Abnormal di Quadran ______________
Palpasi  Lunak  Padat  Tegang
 Quadran ____________
Kesimpulan  Pembesaran hati  Pembesaran Spleen
Pembesaran Hepar 3 jari di bawah coste.

b. Lab : pada tanggal .......................... 2015

Jenis Pemeriksaan Hasil Satuan Nilai Rujukan Kesan

HEMATOLOGI

Darah Lengkap Perifer

Haemoglobin g/dl 13.0 - 17.0

Hematokrit % 40.0 - 50.0

MCHC g/dl 32.0 – 36.0

Trombosit 10^3/µL 150 – 400

Leukosit 10^3/µL 5.00 – 10.00

KIMIA KLINIK

SGOT (AST) U/L < 33

SGPT (ALT) U/L < 50

Kreatinin Darah mg/dL 0.60 – 1.30

Ureum darah mg/dL < 50

Glukosa Sewaktu mg/dL <140

ELEKTROLIT

Natrium (Na) Darah mEq/L 132 – 147

Kalium (K) darah mEq/L 3.30 – 5.40

Klorida (Cl) Darah mEq/L 94.0 – 111.0

HEMOSTASIS

Masa Protrombin (PT)

Pasien Detik 9.8 – 12.6

Kontrol Detik

APTT

Pasien Detik 31.0 – 47.0

 Kontrol Detik

Kadar fibrinogen mg/dL 136.0 – 384.0

d-Dimer Kuantitatif µg/dL 0.0 – 0.3

c. Pemeriksaan diagnostik lain (USG abdomen dan Bone Marrow Puncture (BMP))
Belum dilakukan

4. ELIMINASI
a. Fisik
BAK : Keluhan : Ada / Tidak ada keluhan
 Anuria (< 50 ml/hr)  Dysuria (kesusahan kemih)
 Nocturia  Polyuria  Inkontenensia
 Rasa Panas  Distensi bladder
Frekuensi Sebelum sakit : Saat sakit : ... – ... x/hr
Jumlah Sebelum sakit : ............. cc Saat sakit : ....... cc
Warna  Kuning  Merah
Penggunaan : Tidak ada
obat dieuretik

BAB : Keluhan : tidak ada

 Belum BAB ___-___hari
 Konstipasi ____-___hari
 Diare ________-___hari
 Hemoroid
Frekuensi Sebelum sakit : .... x/hr Saat sakit : .... x/hr
Warna  Kuning  Merah  Hitam
Penggunaan ___tidak ada _________________
obat pencahar

b. Lab : Tanggal ............................. 2015

Nilai Nilai normal Kesan
Warna Kuning Muda-Tua
Kejernihan Jernih
Berat Jenis 1.005 – 1.030
pH 4.5 – 8.0
Protein Negatif
Glukosa Negatif
Keton Negatif
 Darah Negatif
Bilirubin Negatif
Urobilinogen 3.2 – 16.0
Nitrit Negatif
Esterase Leukosit Negatif
Sel Epitel 1+
Leukosit 1– 5
Kristal Negatif
Bakteri Negatif

c. Pemeriksaan diagnostik lain (Kultur feces )

Tidak dilakukan

5. AKTIVITAS DAN ISTIRAHAT

a. Fisik
ADL  Independent  Bantuan sebagian  Dependent
Kemampuan  Sendiri  Membutuhkan alat  Membutuhkan bantuan orang
berjalan lain
 Membutuhkan alat dan orang lain
Kemampuan Kepala  Fleksi  Ektensi  Rotasi
rentang gerak Bahu  Elevasi  Depresi
Ekstermitas atas kanan
 Flexi  Ekstensi  Abduksi  Aduksi
 Supinasi  Pronasi  Sirkumduksi
Ekstermitas atas kiri
 Flexi  Ekstensi  Abduksi  Aduksi
 Supinasi  Pronasi  Sirkumduksi
Ekstermitas bawah kanan
 Flexi  Ekstensi  Abduksi  Aduksi
 Supinasi  Pronasi  Sirkumduksi
Ekstermitas bawah kiri
 Flexi  Ekstensi  Abduksi  Aduksi
 Supinasi  Pronasi  Sirkumduksi

Kekuatan otot Segmen Kanan Kiri

 Tangan 5555 5555
 Kaki 5555 5555
 Keluhan Tidur  Tidak  Ya  Insomnia
dan Istirahat Lainnya: ..................................................
Kualitas tidur :  Cukup  Kurang
Kebiasaan tidur Malam : dari jam .. sampai jam .... total : .. jam
Siang : dari jam .... sampai jam .... total : .. jam
Kegiatan  Lampu redup  Lampu terang  Membaca
pengantar tidur  Minum minuman hangat  lainnya : Tidak Ada

b. Pemeriksaan diagnostik lain (Rongsen tulang dll)

Tidak Ada

6. PROTEKSI DAN PERLINDUNGAN

a. Fisik
Suhu .... 0C
Luka  Tidak  Ya
 Panjang _________cm  Diameter _________cm
 Merah  Kuning  Hitam Balutan :  Bersih  Berair
Tanda tanda infeksi  Tidak  Ya
Gambar :

Risiko jatuh  Ya  Tidak

Tindakan
 invasif

b. Pemeriksaan diagnostik lain (dll)

tidak ada

7. SENSORI
a. Fisik
Nyeri :
P : ..................................................................
Q: ..................................................................
R: ..................................................................
S: ..................................................................
T: ..................................................................

Penglihatan : Ketajaman : Visus normal/Tidak, konjungtiva anemis/Tidak,

sklera ikterik/Tidak.
Reflek cahaya : + / +
Penciuman :  Sumbatan Kanan/Kiri  Perdarahan Kanan/ Kiri
 Kanan + / +  Kiri + / + tidak ada gangguan
Pengecapan :  Manis  Asin  Asam
Pendengaran : Kanan + /+ Kiri + / + tidak ada gangguan

b. Lainnya
 _____________________________________________________________________
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_____________________________________________________

8. CAIRAN DAN ELEKTROLIT

a. Fisik
Intake cairan sebelumnya :............. cc.
Intake Output
Minum : ......... ml/24 jam Urine : .......... ml/24 jam
Intravena : ....... ml/24 jam Drain : ____________ ml/24 jam
IWL : ....... ml/hr
Diare : ____________ml/24 jam
Muntah : ____________ ml/24 jam
Perdarahan : ..... ml/24 jam

Total : ........ ml/24 jam Total : ...... ml/24 jam

Balance : ..... cc

Tanda  Rasa haus  Kulit kering  Mukosa bibir kering

Dehidrasi  Turgor kulit < 3 dtk
Distensi  Tidak  Ya
vena
jugularis
Edema  Tidak  Ya  Sacral  Anasarca
Ektermitas atas
RU +1 +2 +3 +4 LU +1 +2 +3 +4
RL +1 +2 +3 +4 LL +1 +2 +3 +4
Ektermitas bawah
RU +1 +2 +3 +4 LU +1 +2 +3 +4
RL +1 +2 +3 +4 LL +1 +2 +3 +4

Other : _____________

b. Lab : Tanggal ...................................... 2015

Nilai Nilai normal KESAN
Natrium (Na) Darah . mEq/L 132 – 147
Kalium (K) darah . mEq/L 3.30 – 5.40
Klorida (Cl) Darah . mEq/L 94.0 – 111.0
 Tanggal .................... 2015
Nilai Nilai normal KESAN
Natrium (Na) Darah . mEq/L 132 – 147
Kalium (K) darah . mEq/L 3.30 – 5.40
Klorida (Cl) Darah . mEq/L 94.0 – 111.0
c. Lainnya
Ada / Tidak ada, Sebutkan; ............
9. FUNGSI NEUROLOGI
a. Fisik
Status Mental
LOC (Level of :  alert  letargi  unreponsive
Consiousness)
Memory :  Panjang  Pendek
Perhatian :  Dapat mengulang  Tidak dapat mengulang
Bahasa :  Baik  Tidak
Kognisi :  Baik  Tidak
Orientasi :  Orang  Tempat  Waktu
Saraf sensori  Nyeri tusuk  Suhu  Sentuhan
Lainnya: ______________

Saraf koordinasi (cerebral)  Ya  Tidak

Refleks Patella 0 1 2 3 4
Achilles 0 1 2 3 4
Bisep 0 1 2 3 4
Trisep 0 1 2 3 4
Brankioradialis 0 1 2 3 4
Babinski +/-
GCS : E4M6V5 : Composmentis
 b. Lainnya

10. ENDOKRIN
a. Fisik
Kalenjar tiroid Pembesaran:  Ya  Tidak
Tremor :  Ya  Tidak
Pankreas Trias DM :  Ya  Tidak
Adrenal Tanda Syndrom cushing

b. Lab tanggal ....................................... 2015

Nilai Nilai normal KESAN
Gula darah sewaktu < 140 mg/dL

c. Lainnya
III. Faktor – Faktor Berpengaruh (Tahap II)
Penerapan Teori Keperawatan Adaptasi Roy Pada Pasien dengan ................................................................

1. Adaptasi Fisiologis
Pengkajian Stimulus
Pola Pengkajian Perilaku
Stimulus Fokal Stimulus Kontekstual Stimulus Residual
1. Oksigenasi .........................................................................
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2. Nutrisi .........................................................................
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3. Eliminasi .........................................................................
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4. Aktivitas dan .........................................................................

Istirahat .........................................................................
 Pengkajian Stimulus
Pola Pengkajian Perilaku
Stimulus Fokal Stimulus Kontekstual Stimulus Residual
a. Aktivitas .........................................................................
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5. Proteksi .........................................................................
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6. Pengindera-an .........................................................................
 Pengkajian Stimulus
Pola Pengkajian Perilaku
Stimulus Fokal Stimulus Kontekstual Stimulus Residual
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7. Cairan .........................................................................
elektrolit dan .........................................................................
asam basa .........................................................................
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8. Neurologis .........................................................................
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a. Kognitif .........................................................................
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b. Kesadaran .........................................................................
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 Pengkajian Stimulus
Pola Pengkajian Perilaku
Stimulus Fokal Stimulus Kontekstual Stimulus Residual
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9. Endokrin .........................................................................
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2. Adaptasi Konsep Diri

Pola Pengkajian Perilaku
Stimulus Fokal
Perkembangan .......................................................
diri .......................................................
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Focus diri .......................................................
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Pengkajian Stimulus
Stimulus Kontekstual Stimulus Residual
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Pola Pengkajian Perilaku
Stimulus Fokal
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Identitas diri .......................................................
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3. Adaptasi Fungsi Peran
Pola Pengkajian Perilaku
Stimulus Fokal
Pengembangan ................................................
peran ................................................
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Pengambilan ................................................
peran ................................................
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Integrasi peran ................................................
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Pengkajian Stimulus
Stimulus Kontekstual Stimulus Residual
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Pengkajian Stimulus
Stimulus Kontekstual Stimulus Residual
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 4. Adaptasi Interdependensi
Pola Pengkajian Perilaku
Stimulus Fokal
Affectional ................................................
adequacy ................................................
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Sumber daya ................................................
yang adekuat ................................................
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Pengkajian Stimulus
Stimulus Kontekstual Stimulus Residual
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4. Diagnosa Keperawatan

Berdasarkan hasil pengkajian diatas, diagnosa yang muncul pada Tn. B berdasarkan
NANDA 2015 – 2017, antara lain:
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7. ..............................................................................................................................................
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5. Intervensi Keperawatan (Kroteria NOC & NIC)
N Diagnosa Keperawatan
o
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Tujuan Dan Kriteria Hasil
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6. IMPLEMENTASI
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Tanda
No Waktu Evaluasi
tangan
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 Tanda
No Waktu Evaluasi
tangan
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No Waktu Evaluasi
tangan
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 Tanda
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 Tanda
No Waktu Evaluasi
tangan
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