ASUHAN KEPERAWATAN MEDIKAL BEDAH

Pada Tn.As dengan DM hyiperglikemia dan

dyspepsia

Di susun oleh :
Sohibul makki H

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS ILMU KESEHATAN
UNIVERSITAS ISLAM AS-SYAFI’IYAH
JAKARTA
2020
 FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH
Tanggal MRS :4 agustus 2020 Jam Masuk :12:00
Tanggal Pengkajian :5 agustus 2020 No. RM :
Jam Pengkajian :10:00 Diagnosa Masuk :
Hari rawat ke :kedua

IDENTITAS
1. Nama Pasien :Tn.As
2. Umur :48 tahun
3. Suku/ Bangsa :sasak
4. Agama :islam
5. Pendidikan :
6. Pekerjaan :
7. Alamat :lombok timur
8. Sumber Biaya : peribadi

KELUHAN UTAMA
1. Keluhan utama:
Klien mengatakan nafsu makan menurun ,lemas saat beraktifitas ,BAK sering lebih dari 10 kali selama 12 jam
dengan volume banyak (tidak di ukur)

RIWAYAT PENYAKIT SEKARANG

1. Riwayat Penyakit Sekarang:
Klien mengalami riwayat penyakit DM hyperglikemia dan dyspepsia

RIWAYAT PENYAKIT DAHULU

 Pernah dirawat : ya √ tidak √kapan :…… diagnosa :…………
1. Riwayat penyakit kronik dan menular ya tidak √ jenis……………………
Riwayat kontrol : .............................
Riwayat penggunaan obat :..............
2. Riwayat alergi:
Obat ya √ tidak jenis……………………
Makanan ya tidak jenis……………………
Lain-lain ya tidak jenis……………………

3. Riwayat operasi: ya
tidak
- Kapan : ……………………
- Jenis operasi : ……………………

RIWAYAT KESEHATAN KELUARGA

Ya √ tidak
- Jenis
:…………………..............................................................................................................................
- Genogram :
 PERILAKU YANG MEMPENGARUHI KESEHATAN
Perilaku sebelum sakit yang mempengaruhi kesehatan:
Alkohol ya tidak keterangan……….....................
Merokok ya tidak
keterangan…………………….........................................................
Obat ya tidak
keterangan…..............................................................………………
Olah raga ya tidak
keterangan…..........................................................…………………

OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda tanda vital
S :36c N :92xmenit T :100/70 RR :24x menit
Kesadaran kualitatif: Compos Mentis Apatis Somnolen Sopor Koma

Kesadaran kualitatif : jumlah GCS: E :4 V :4√√ M :5

2. Sistem Pernafasan (B1)

a. RR:................................
b. Keluhan: sesak √ nyeri waktu nafas orthopnea
Batuk produktif tidak produktif
Sekret:…….. Konsistensi :......................
Warna:.......... Bau :..................................
c. Penggunaan otot bantu nafas:
......................................................................................................................................................
......................................................................................................................................................
.
d. PCH ya tidak
e. Irama nafas teratur tidak teratur
f. Pleural Friction rub:................................ ............................ ................................... ......................
g. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot
h. Suara nafas Cracles Ronkhi Wheezing
 i. Alat bantu napas ya tidak

Jenis................................................ Flow.............l/pm

j. Penggunaan WSD:
- Jenis :
................................................................................................................................................
- Jumlah cairan :
................................................................................................................................................
- Undulasi
:.............................................................................................................................................
- Tekanan :
................................................................................................................................................

k. Tracheostomy: ya tidak
......................................................................................................................................................
......................................................................................................................................................
l. Lain-lain:
......................................................................................................................................................
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3. Sistem Kardio vaskuler (B2)

a. TD :100/70 mmhg
b. N :92x menit
c. Keluhan nyeri dada: ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
d. Irama jantung: reguler ireguler
e. Suara jantung: normal (S1/S2 tunggal) murmur
gallop lain-lain.....
f. Ictus Cordis:
......................................................................................................................................................
g. CRT :.............detik
h. Akral: hangat kering merah basah
pucat
panas dingin
i. Sikulasi perifer: normal menurun
j. JVP :.................................
k. CVP :.................................
l. CTR :.................................
m. ECG & Interpretasinya:
......................................................................................................................................................
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n. Lain-lain :
......................................................................................................................................................
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......................................................................................................................................................
…………………………………………………………………………………………………
4. Sistem Persyarafan (B3)
a. GCS : ..................................................
Dikaji PRS (Pupil reactivity Score) , terutama untuk pasien dengan disfungsi neurologi
b. Refleks fisiologis patella triceps biceps
c. Refleks patologis babinsky brudzinsky kernig
Lain-lain
d. Keluhan pusing ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................

e. Pemeriksaan saraf kranial:

N1 : normal tidak Ket.:
……..............................................................
N2 : normal tidak Ket.:
……..............................................................
N3 : normal tidak Ket.:
……..............................................................
N4 : normal tidak Ket.:
……..............................................................
N5 : normal tidak Ket.:
……..............................................................
N6 : normal tidak Ket.:
……..............................................................
N7 : normal tidak Ket.:
……..............................................................
N8 : normal tidak Ket.:
……..............................................................
N9 : normal tidak Ket.:
……..............................................................
N10 : normal tidak Ket.:
……..............................................................
N11 : normal tidak Ket.:
……..............................................................
N12 : normal tidak Ket.:
……..............................................................

f. Pupil
anisokor isokor Diameter: ……/......
g. Sclera
anikterus ikterus
h. Konjunctiva ananemis anemis
i. Isitrahat/Tidur :................. Jam/Hari Gangguan tidur :
..............................................................
j. Lain-lain:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
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..................................................................................................................................
5. Sistem perkemihan (B4)
a. Kebersihan genetalia: Bersih Kotor
b. Sekret: Ada Tidak
c. Ulkus: Ada Tidak
d. Kebersihan meatus uretra: Bersih Kotor
e. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
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f. Kemampuan berkemih:
Spontan Alat bantu, sebutkan: .....................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
g. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
h. Kandung kemih : Membesar ya tidak
i. Nyeri tekan ya tidak
j. Intake cairan oral : ……… cc/hari parenteral...............cc/hari
k. Balance cairan:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
k. Lain-lain:
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6. Sistem pencernaan (B5)
a. TB :............... BB :................................
b. IMT :............... Interpretasi :................................

c. Mulut:
bersih kotor berbau
d. Membran mukosa:
lembab kering stomatitis
e. Tenggorokan:
sakit menelan
kesulitan menelan
pembesaran tonsil
nyeri tekan
f. Abdomen: tegang kembung ascites
g. Nyeri tekan: ya tidak
h. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
i. Peristaltik...............x/menit
j. BAB: ......................x/hari Terakhir tanggal :
............................................................................
k. Konsistensi: keras lunak cair lendir/darah
l. Diet: padat lunak cair
m. Diet Khusus:
......................................................................................................................................................
......................................................................................................................................................
n. Nafsu makan: baik menurun Frekuensi.......x/hari
o. Porsi makan: habis tidak Keterangan:.......................

p. Lain-lain:
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7. Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior

OD OS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO

b. Keluhan nyeri ya tidak

P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................

c. Luka operasi:
ada tidak
Tanggal operasi
:................
Jenis operasi
:................
Lokasi
:................
Keadaan
:................
d. Pemeriksaan penunjang lain : .........................
e. Lain-lain :
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior

OD OS
Aurcicula
MAE
Membran
Tymphani
Rinne
Weber
Swabach

b. Tes Audiometri
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c. Keluhan nyeri ya tidak

P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
d. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
e. Alat bantu dengar: .........................
f. Lain-lain :
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
9. Sistem muskuloskeletal (B6)
a. Pergerakan sendi: bebas terbatas
b. Kekuatan otot:

c. Kelainan ekstremitas: ya tidak

d. Kelainan tulang belakang: tidak
ya
................................................................................
e. Fraktur: ya tidak
Jenis :...................
f. Traksi: ya tidak
- Jenis :...................
- Beban :...................
- Lama pemasangan :...................

g. Penggunaan spalk/gips: ya tidak

h. Keluhan nyeri: ya tidak

P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
i. Sirkulasi perifer: ..............................................
j. Kompartemen syndrome ya tidak

k. Kulit: ikterik
sianosis kemerahan hiperpigmentasi
 l. Turgor baik kurang jelek

m. Luka operasi: ada tidak

Tanggal :................
operasi Jenis :................
operasi Lokasi :................
Keadaan :................

Drain : ada tidak

- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................

n. ROM : .................................................

o. Cardinal Sign : ................................................

p. Lain-lain:
......................................................................................................................................................
......................................................................................................................................................
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10. Sistem Integumen
a. Penilaian resiko decubitus
Aspek Yang Kriteria Penilaian Nilai
Dinilai 1 2 3 4
Persepsi Terbatas Sangat Keterbatasan Tidak Ada
Sensori Sepenuhnya Terbatas Ringan Gangguan
Kelembaban Terus Sangat Kadang2 Jarang
Menerus Lembab Basah Basah
Basah
Aktifitas Bedfast Chairfast Kadang2 Lebih Sering
Jalan jalan
Mobilisasi Immobile Sangat Keterbatasan Tidak Ada
Sepenuhnya Terbatas Ringan Keterbatasan
Nutrisi Sangat Kemungkinan Adekuat Sangat Baik
Buruk Tidak
Adekuat
Gesekan & Bermasalah Tidak Potensial
Pergeseran Bermasalah
Menimbulkan
Masalah
NOTE: Pasien dengan nilai total < 16 maka dapat dikatakan Total Nilai
bahwa pasien beresiko mengalami dekubisus (pressure
ulcers)
(15 or 16 = low risk, 13 or 14 = moderate risk, 12 or less =
high risk)

b. Warna
c. Pitting edema: +/- grade:................
d. Ekskoriasis : ya Tidak
e. Psoriasis: ya Tidak
f. Pruritus: ya tidak
g. Urtikaria: ya tidak
h. Lain-lain:
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 11. Sistem Endokrin
a. Pembesaran tyroid: ya tidak
b. Pembesaran kelenjar getah bening: ya tidak
c. Hipoglikemia: ya tidak
d. Hiperglikemia: √ ya tidak
e. Kondisi kaki DM
- Luka gangren ya √ tidak
Jenis ................................................................................................................
- Lama luka ...............................................................................................
- Warna ...............................................................................................
- Luas luka ...............................................................................................
- Kedalaman ...............................................................................................
- Kulit kaki ...............................................................................................
- Kuku kaki ...............................................................................................
- Telapak kaki ...............................................................................................
- Jari kaki ...............................................................................................
- Infeksi ya tidak
- Riwayat luka sebelumya ya tidak
Jika ya:
- Tahun :
- Jenis Luka :
- Lokasi :
- Riwayat amputasi sebelumya ya tidak
Jika ya:
- Tahun :
- Lokasi :
f. ABI : ....................................................
g. Lain-lain:
......................................................................................................................................................
......................................................................................................................................................
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PENGKAJIAN PSIKOSOSIAL
a. Persepsi klien terhadap penyakitnya:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

b. Ekspresi klien terhadap penyakitnya

Murung/diam gelisah tegang marah/menangis
c. Reaksi saat interaksi kooperatif tidak kooperatif curiga
d. Gangguan konsep diri:
..............................................................................................................................................................
..............................................................................................................................................................
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e. Lain-lain:
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PERSONAL HYGIENE & KEBIASAAN
Jelaskan :
...............................................................................................................................
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PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah

b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:

...............................................................................................................................
..............................................................................................................................................................
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PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)

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TERAPI
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DATA TAMBAHAN LAIN :

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 ANALISA DATA

Hari/
DATA ETIOLOGI MASALAH
Tgl/ Jam
DS :
-Klien mengatakan sering BAK lebih Resiko
dari 10 kali ketidakseimbangan cairan Manajemen cairan
-Klien mengatakan tennggorokan terasa
kerimg

DO:
-mukosa mulut kering
-terpasang kateter urine
-terpasang Infus Nacl

DS:
_klien mengatakan sering merasa lelah
saat beraktifitas
Ketidakstabilan kadar
Manajamen Hiperglikemia
glukosa darah
-GDS:530

TTV:
TD:100/70
N :92x /menit
RR:24x/ menit
S :36 c

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

TANGGAL:
1.Resiko ketidakseimbangan Cairan berhungan dengan intake dan output cairan
2.Ketidakstabilan Kadar glukosa Darah berhubungan dengam ristensi insulin
 RENCANA INTERVENSI

Hari/ Tgl/ DIAGNOSA

No. INTERVENSI RASIONAL
Jam KEPERAWATAN
1 Resiko ketidakseimbangan 1.monitor status hidrasi 1.Untuk menentukan
cairan berhungan dengan 2.monitor berat badan harian intervensi selanjutnya
intake dan output cairan 2.untuk menentukan
3.monitor berat badan sebelum peninkataan dan
dan sesudah dialisis penurunan berat badan
4.monitor hasil pemeriksaan lab 3.
5.catat intake output dan hitung 4. untuk mengetahui
balance cairan 24 jam jumlah asupan cairan
6.berikan asupan cairan sesuai yang masuk dan keluar
5.Untuk mengantikan
kebutuhan
asupan kehilangan
7.berikan cairan intravena jika cairan dan
perlu memperbaiki
Kolaburasi: keseimbangan cairan
-kolaburasi pemberian 7.untuk menggatikan
diuretik,jika perlu kehilangan cairan dan
memeprbaiki
keseimbangan cairan

2. Ketidakstabilan kadar gula 1.identifikasi penyebab

1.untuk mengetahui
darah berhungan dengan hiperglikemia penyebab hiperglikemia
ristensi insulin 2.monitor kadar glukosa darah 2.untuk mengetahui
3.monitor tanda dan gejala 3.untuk mengetahui
hiperglikemia penyebab terjadinya
4.monitor intake dan output cairan hiperglikemia dan
5.identifikasi situasi yang menentukan intervensi
menyebabkan kebetuhan insulin yang sesuai dan efektif
meninkat 4.untuk mengetahui
Kolaburasi: jumlah asupan cairan
Pemberian insulin jika perlu yang masuk dan keluar
 IMPLEMENTASI KEPERAWATAN

Hari/
No.
Tgl/ Jam Implementasi Evaluasi Paraf
Shift Dx
dx.1 1.monitor berat badan harian
Hasil:berat badan klien 53 kg

2.mengajurkan kepada klien untuk

meninkatkan pemasukan cairan

Hasil:klien mengangguk mengatakan

mengerti dan akan mulai banyak
menkonsumsi air putih

dx. 1.Monitor kadar gulukosa darah

2
Hasil:
GDS:360 mmhg

2.monitor intake dan output cairan

Hasil:klien minum sehari 2000 ml dan

BAK sehari 10 kali
 CATATAN PERKEMBANGAN

Tanggal
Jam No. Dx EVALUASI/ SOAP
DX 1 S :klien mengatakan mulai menkonsumsi air putih

0:klien terlihat bingung

A:masalah belum teratasi

P:intervensi di lanjutkan

Dx 2 S:klien mengatakan makan nasi,ikan dan sayur

0:GDS 360

A:maslah belum teratasi

P:intervensi di lanjutkan