FORMAT PENGKAJIAN

DATA KEPERAWATAN

BIODATA
Nama : Tn Z
Jenis kelamin : Laki - laki
Umur : 32 Tahun
Status perkawinan : Belum Menikah
Pekerjaan : Pegawai Swasta
Agama : Islam
Pendidikan terakhir : SMA
Alamat : Kelapa dua tugu ciamis depok.
No. Register 0140568
Tanggal MRS : 30 Juli 2017
Tanggal pengkajian : 31 Juli 2017

RIWAYAT KESEHATAN KLIEN

1. Keluhan Utama/Alasan Masuk Rumah Sakit:

Nyeri didaerah perut kuadran kanan atas dan dibelakang tengah

2. Riwayat Penyakit Sekarang

P : Pasien mengatakan nyeri daerah perut kuadran kanan dan nyeri timbul saat berjalan
dan berkurang saat posisi semi fowler.
Q : Karakteristik nyeri panas
R : Nyeri di daerah perut kuadran kanan
S:8
T : Nyeri timbul saat berjalan , muncul selama 30 menit secara mendadak

Setelah diberikan obat paracetamol 2 x 500mg via oral, nyeri berkurang, klien merasa
mual, tidak selera makan, perut terasa begah, BB turun 2kg, makanan habis ½ porsi, kilen
mengatakan minum dalam sehari kurang lebih 1 ½ liter

3. Riwayat Kesehatan Yang Lalu

Pasien tidak mempunyai riwayat penyakit sebelumnya

4. Riwayat Kesehatan Keluarga

A. POLA TIDUR/ITIRAHAT

1. Waktu Tidur : ..................................................................................

..................................................................................
2. Waktu Bangun : ..................................................................................
..................................................................................
3. Masalah Tidur : ..................................................................................
..................................................................................
4. Hal-hal yang mempermudah tidur : Nyeri akan hilang jika tidur menggunakan
semi fowler
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
5. Hal-hal yang mempermudah pasien terbangun : .................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
B. POLA ELIMINASI

1. BAB : ..................................................................................
..................................................................................
2. BAK : ..................................................................................
..................................................................................
3. Kesulitan BAB/BAK : ..................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

4. Upaya/cara mengatasi masalah tersebut : ...........................................................

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

C. POLA MAKAN DAN MINUM

1. Jumlah dan jenis makanan : Habis ½ porsi

.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
2. Waktu pemberian makan :
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
3. Jumlah dan jenis cairan : Minum sehari kurang lebih 1 ½ Liter

4. Waktu pemberian cairan :

.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
5. Pantangan :
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................

6. Masalah makan dan minum

a. Kesulitan mengunyah : ......................................................................
b. Kesulitan menelan : ......................................................................
c. Mual dan muntah : Klien merasa mual dan perut terasa begah
d. Tidak dapat makan sendiri : ......................................................................
7. Upaya mengatasi masalah : ......................................................................
......................................................................

D. KEBERSIHAN DIRI/PERSONAL HYGIENE

1. Pemeliharaan badan : ......................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
2. Pemeliharaan gigi dan mulut :
......................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
3. Pemeliharaan kuku :
......................................................................
.............................................................................................................................
.............................................................................................................................
 .............................................................................................................................

E. POLA KEGIATAN/AKTIVITAS LAIN:

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

DATA PSIKOSOSIAL
A. Pola Komunikasi : .............................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................

B. Orang yang paling dekat dengan klien :.....................................................................

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

C. Rekreasi
Hobby : ......................................................................................................................
Penggunaan waktu senggang : ..................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................

D. Dampak dirawat di RS : ............................................................................................

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

E. Hubungan dengan orang lain/interaksi sosial : .........................................................

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

F. Keluarga yang dihubungi bila diperlukan : ...............................................................

....................................................................................................................................
...................................................................................................................................
DATA SPIRITUAL

A. Ketaataan beribadah : ................................................................................................

....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
. B. Keyakinan terhadap sehat/sakit :
...............................................................................
....................................................................................................................................
....................................................................................................................................
...................................................................................................................................
. C. Keyakinan terhadap penyembuhan :
.........................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

PEMERIKSAAN FISIK
A. Kesan Umum/Keadaan Umum: Keadaan Umum sedang, kesadaran
compos mentis, GCS 15 (E: 4, M: 6, V: 5),

B. Tanda-tanda vital
 Suhu tubuh : 36.3◦C Nadi : 128 x/mnt
Tekanan darah : 100/70 mmHg Respirasi : 22x/mnt
Tinggi badan : 164cm Berat badan : SMRS : 59kg , MRS : 57kg

C. Pemeriksaan kepala dan leher:

1. Kepala dan rambut
a. Bentuk kepala : ..............................................................................................
Ubun-ubun : ..............................................................................................
Kulit kepala : ..............................................................................................

b. Rambut : ..............................................................................................
Penyebaran dan keadaan rambut : ...................................................................
Bau : ..............................................................................................
Warna : ..............................................................................................

c. Wajah : ..............................................................................................
Warna kulit : Pucat
Struktur wajah : ..............................................................................................

2. Mata
a. Kelengkapan dan kesimetrisan : ......................................................................
..........................................................................................................................
b. Kelopak mata (palpebra) :
......................................................................
..........................................................................................................................
c. Konjumgtiva : Ikterik
d. sclera : Anemis
e. Pupil : ......................................................................
..........................................................................................................................
f. Korneadan iris :
......................................................................
..........................................................................................................................
g. Ketajaman penglihatan/visus :
......................................................................
..........................................................................................................................
h. Tekanan bola mata :
......................................................................
..........................................................................................................................

3. Hidung
a. Tulang hidung dan posisi septum nasi : ..........................................................
..........................................................................................................................
..........................................................................................................................
b. Lubang hidung : ..............................................................................................
..........................................................................................................................
..........................................................................................................................

c. Cuping hidung : ..............................................................................................

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

4. Telinga
a. Bentuk telinga : ..............................................................................................
b. Ukuran telinga : ..............................................................................................
c. Ketegangan telinga : ..................................................................................
d. Lubang telinga : ..............................................................................................
..........................................................................................................................
..........................................................................................................................
e. Ketajaman pendengaran : ................................................................................
..........................................................................................................................
..........................................................................................................................
 5. Mulut dan faring
a. Keadaan bibir : ..............................................................................................
..........................................................................................................................
..........................................................................................................................
b. Keadaan gusi dan gigi : ....................................................................................
..........................................................................................................................
..........................................................................................................................

c. Keadaan lidah : ..............................................................................................

..........................................................................................................................
..........................................................................................................................
d. Orofarings : ..............................................................................................
..........................................................................................................................
..........................................................................................................................

6. Leher
a. Posisi trachea : ..................................................................................
b. Tiroid : ..................................................................................
c. Suara : ..................................................................................
d. Kelenjar limfe : ..................................................................................
e. Vena jugularis : ..................................................................................
f. Denyutnadi carotis : ..................................................................................

D. Pemeriksaan Integumen (kulit)

a. Kebersihan : ..................................................................................
b. Kehangatan : Dingin
c. Warna : ..................................................................................
d. Tekstur : ..................................................................................
e. Kelembaban : ..................................................................................
f. Kelainanpada kulit : CRT 4 detik

E. Pemeriksaan Payudara dan Ketiak

a. Ukuran dan bentuk payudara : ......................................................................
..........................................................................................................................
..........................................................................................................................

b. Warna payudara dan areola : ......................................................................

..........................................................................................................................
..........................................................................................................................
c. Kelainan-kelainan payudara dan puting : ........................................................
..........................................................................................................................
..........................................................................................................................
d. Axilla dan clavicula :
......................................................................
..........................................................................................................................
..........................................................................................................................

F. Pemeriksaan Thorax/Dada
a. Inspeksi Thorax
a. Bentuk thorax : ..............................................................................................
........................................................................................................................
........................................................................................................................
b. Pernafasan
Frkewensi : ..............................................................................................
Irama : ..............................................................................................

c. Tanda-tanda kesulitan bernafas : ...................................................................

........................................................................................................................
........................................................................................................................
 2. Pemeriksan Paru
a. Palpasi getaran suara (vokal fremitus) : ........................................................
........................................................................................................................
........................................................................................................................
b. Perkusi : ..............................................................................................
........................................................................................................................
........................................................................................................................
c. Asukultasi :
Suara nafas : ..................................................................................
........................................................................................................................
........................................................................................................................
Suara ucapan :
..................................................................................
........................................................................................................................
........................................................................................................................
Suara tambahan :
..................................................................................
........................................................................................................................
........................................................................................................................

3. Pemeriksaan Jantung
a. Inspkesi dan palpasi
Pulsasi : ..............................................................................................
Ictus cordis : ..............................................................................................
b. Perkusi
Batas-batas jantung : .....................................................................................
........................................................................................................................
........................................................................................................................
c. Auskultasi
d. Bunyi jantung I : ......................................................................
.......................................................................
Bunyi jantung II : ......................................................................
.......................................................................
Bunyi jantung tambahan : ......................................................................
.......................................................................
Bising/murmur : ......................................................................
.......................................................................
Frekwensi denyut jantung : ......................................................................

G. Pemeriksaan Abdomen:
a. Inspeksi
Bentuk abdomen : Asites
Benjolan/massa : ..............................................................................................
..............................................................................................
Bayangan pembuluh darah abdomen : .................................................................
...............................................................................................................................
...............................................................................................................................
b. Auskultasi
Peristaltik usus : Peristitik ( + )
Bunyi jantung anak/BJA : 8x / mnit
c. Palpasi
Tanda nyeri tekan : ..................................................................................
..................................................................................
Benjolan/massa : ..................................................................................
..................................................................................
Tanda-tanda ascites : ..................................................................................
..................................................................................
Hepar : ..................................................................................
..................................................................................
Lien : ..................................................................................
..................................................................................
 Titik McBurney : ..................................................................................
..................................................................................

d. Perkusi
Suara abodmen : ..................................................................................
..................................................................................
Pemeriksaan ascites : ..................................................................................
..................................................................................

H. Pemeriksaan Kelamin dan Daerah Sekitarnya

a. Genetalia
Rambut pubis : ..............................................................................................
Meathus urethra : ..............................................................................................
Kelainan-kelainan pada genelatia eksterna dan daerah inguinal : .......................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
b. Anus dan perineum
Lubang anus : ..............................................................................................
Kelainan pada anus: ..............................................................................................
...............................................................................................................................
...............................................................................................................................
Perineum : ..............................................................................................
...............................................................................................................................
...............................................................................................................................

I. Pemeriksaan Muskuloskeletal (Ekstremitas)

a. Kesimetrisan otot : ..............................................................................................
..............................................................................................
b. Pemeriksaan oedem: .............................................................................................
..............................................................................................
c. Kekuatan otot : ..............................................................................................
..............................................................................................
d. Kelainan-kelainan pada ekstremitas dan kuku : ...................................................
................................................................................................................................

J. Pemeriksaan Neurologi
a. Tingkat kesadaran (secara kwantitatif)/GCS
...............................................................................................................................
...............................................................................................................................
b. Tanda-tanda rangsangan otak (meningeal sign)
..............................................................................................................................
...............................................................................................................................
c. Syaraf otak (nervus cranialis)
...............................................................................................................................
...............................................................................................................................
d. Fungsi motorik
...............................................................................................................................
...............................................................................................................................
e. Fungsi sensorik
...............................................................................................................................
...............................................................................................................................
f. Refleks
Refleks fisiologis : ................................................................................................
...............................................................................................................................
...............................................................................................................................
Refleks patologis : ..............................................................................................
...............................................................................................................................
...............................................................................................................................
 K. Pemeriksaan Status Mental:
a. Kondisi emosi/perasaan : ..................................................................................
.............................................................................................................................
............................................................................................................................
. b. Orientasi :
..................................................................................
.............................................................................................................................
.............................................................................................................................
c. Proses berfikir (ingatan, atensi, keputusan, perhitungan) : ................................
.............................................................................................................................
.............................................................................................................................
d. Motivasi (kemampuan) :
..................................................................................
.............................................................................................................................
............................................................................................................................
. e. Persepsi :
..................................................................................
.............................................................................................................................
............................................................................................................................
. f. Bahasa :
..................................................................................
.............................................................................................................................
.............................................................................................................................

PEMERIKSAAN PENUNJANG
A. Diagnosa Medis: …………………………………………………………………...

B. Pemeriksaan Diagnostik/Penunjang medis:

1. Laboratorium :
Pemeriksaan penunjang tanggal 30 Juli 2017 :
 Hemoglobin ↓ 7.8 g/dL (13.2 -17.3 g/dL),
 Hematokrit ↓ 27 % (33 - 45 %),
 Leukosit ↓ 2.7 ribu/ul (5.0 - 10.0 ribu/uL),
 Trombosit 155 ribu/ul (150 - 440 ribu/uL),
 Eritrosit ↓ 3.40 juta/uL (4.40 - 5.90 juta/uL

2. Rotgen : Pemeriksaan rotgen thorax tanggal 30 Juli 2017,

kesan : cord an pulmo dalam batas normal
3. ECG : ..........................................................................................................
..............................................................................................................................
.............................................................................................................................
4. USG : Pemeriksaan ulrasongrafi tanggal 29 Juli hasil :
 Sirosis hepatis
 Splenomegaly
 Asites
5. Lain-lain : ..........................................................................................................
..............................................................................................................................
.............................................................................................................................

PENATALAKSANAAN DAN TERAPI

………………………………………………………………………………………
.

Perawat

……………………………
… Rizky Fironika
NIM: 202303102101
 ANALISIS DATA

NAMA PASIEN : Tn Z
UMUR : 32thn
NO. REGISTER 0140568

DATA PENUNJANG INTERPRETASI DATA MASALAH

DS | Nyeri akut
P : Pasien mengatakan nyeri Inflamasi akut pada hati
daerah perut kuadran kanan |
dan nyeri timbul saat Pembesaran hepar
berjalan dan berkurang saat |
posisi semi fowler. Respon nyeri pada perut
Q : Karakteristik nyeri panas kanan atas
R : Nyeri di daerah perut |
kuadran kanan Nyeri akut
T : Nyeri timbul saat berjalan ,
muncul selama 30 menit
secara mendadak
Klien mengatakan tidak nafsu
makan

DO : -
- Skala nyeri 8
- TAMPAK MERINGIS
- nadi: 128 / menit
- klien sulit tidur dan gelisah

Tidak selera makan

DS : Mual dan perut terasa

- Pasien merasa mual, begah
- Pasien tidak selera makan,
- Pasien mengatakan perut terasa BB turun Resiko Defisit
begah, nutrisi
- Pasien mengatakan dalam sehari Resiko Defisit Nutrisi
minum kurang lebih 1 ½ liter
DO :
- Berat badan turun 2kg
- Makanan habis ½ porsi dan
minuman sehari ± 1 ½ liter
- Bising usus hiperaktif
- perut kembung
- TTV :
S : 36,3 C
N : 128x/ menit
TD : 100/70 mmHg
RR ; 22x / menit
DS : Sirosis hepatitis Hipervolomia
- Pasien mengeluh sesak nafas, |
muncul setiap malam hari. Sumbatan aliran darah ke
- Pasien tidur dengan 2 bantal vena kava inferior
untuk mengurangi sesak. |
- Klien mengatakan minum 1 Resistensi pembuluh darah
½ liter/hari meningkat
DO : |
- Permukaan perut asites Tekanan simsoid
- JVP (+) meningkat
- Refleks hepatojugular (+) |
- Kadar Hb : 7,8 gr/dl Hipertensi portal
- Pembesaran hepar dan teraba |
- Hasil USG : Sirosis hepar Tekanan hidrostatik naik
Splenomegaly Asites |
Ekstravasasi
|
Hipervolemia
DS : - Perubahan ikatan O2 Perfusi perifer tidak efektif
DO: dengan Hb
- Akral dingin
- Warna kulit pucat Penurunan konsentrasi Hb
- CRT : 4 detik dalam darah

Perfusi perifer tidak efektif

DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN : Tn Z
UMUR : 32Thn
NO. REGISTER 0140568

TGL
NO TGL MUNCUL DIAGNOSA KEPERAWATAN TT
TERATASI

1. 31 Juli 2017 Nyeri akut B.D agen pencedera fisik 3 Agustus 2017
2. 31 Juli 2017 Defisit nutrisi b.d factor psikologis 2 Agustus 2017

Hipevolemia b.d gangguan aliran

3. 31 Juli 2017 2 Agustus 2017
balik vena
Perfusi perifer tidak efektif b.d
4. 31 Juli 2017 2 Agustus 2017
hEMOGLOBIN
 RENCANA ASUHAN KEPERAWATAN
NAMA PASIEN : Tn Z
UMUR : 32Thn
NO. REGISTER 0140568
TGL NO. DIAGNOSA KEPERAWATAN SLKI
Nyeri akut berhubungan dengan Setelah dilakukan intervensi selama
1. agen pencedera fisik 4 x 24 jam, maka diharapkan nyeri
akut b.d agen pencedera fisik
menurun, dengan kriteria hasil :
1. keluhan nyeri menurun
31 Juli
2. merigis menurun
2017
3. kesulitan tidur menurun
4. frekuensi nadi m3mbaik
Defisit nutrisi b.d factor psikologi Setelah dilakukan intervensi selama
2. 3 x 24 jam, maka diharapkan deficit
nutrisi b.d factor psikologi
membaik, dengan kriteria hasil :
1. Porsi makanan yang
31 Juli diberikan dihabiskan
2017 2. Berat badan membaik
3. Imt membaik
4. Diare membaik
5. Nafsu makan membaik
SIKI TTD
- Identifikasi lokasi, karakteristik, durasi, frekuensi,
kualitas, intensitas nyeri
- Identifikasi skala nyeri
- Identifikasi factor yang memperberat dan memperingan nyeri
- Berikan teknik nonformakologis untuk mengurangi rasa nyeri
- Fasilitasi istirahat dan tidur
- Anjurkan menggunakan analgesik secara tepat
- Ajarkan teknik nonformakologis untuk mengurangi rasa nyeri
- Kolaborasi Memberikan analgesic, jika perlu
- Identifikasi alergi dan intoleransi makanan
- Identifikasi makanan yang disukai
- Monitor asupan makanan
- Monitor berat badan
- Berikan makanan tinggi kalori dan tinggi protein
- Berikan suplemen makanan, jika perlu
- Anjurkan posisi duduk, jika perlu Kolaborasi pemberian medikasi
sebelum makan (mis. Pereda nyeri, antlemetik), jika perlu
 3. Hipevolemia b.d gangguan aliran Setelah dilakukan intervensi selama
balik vena 3 x 24 jam, maka diharapkan
Hipevolemia b.d gangguan aliran
balik vena meningkat, dengan
kriteria hasil :
31 Juli 1. Asupan cairan meningkat
2017 2. Haluaran urin meningkat
3. Kelembaban membrane
mukosa meningkat
4. Perfusi perifer tidak efektif b.d Setelah dilakukan intervensi selama
hEMOGLOBIN 3 x 24 jam, maka diharapkan Perfusi
perifer tidak efektif b.d
hEMOGLOBIN meningkat, dengan
kriteria hasil :
31 Juli 1. Denyut nadi prefer
2017 meningkat
2. Warna kulit pucat meningkat
3. Tugor kulit meningkat
-periksa tanda dan gejala hypervolemia
- tinggikan kepala tempat tidur dengan 30 – 40 derajat
- anjurkan melapor jika BB bertambah >1g dalam sehari
- kaloborasi pemberian diuretik
- Identifikasi faktor resiko gangguan sirkulasi
- Periksa sirkulasi perifer
-Hindari pemasangan infus atau pengambilan darah diarea
keterbatasan perfusi
-Anjurkan minum obat pengontrol tekanan darah secara
teratur
-Informasi tanda dan gejala darurat yang harus dilaporkan
 CATATAN KEPERAWATAN

NAMA PASIEN : Tn Z
UMUR : 32Thn
NO. REGISTER 0140548

TGL/JAM NO. DX. TINDAKAN TT

KEP
1 Mengidentifikasi lokasi, karakteristik, durasi,
Pada tanggal 31– 07-2020 frekuensi, kualitas, intensitas nyeri
pada jam 8.00 WIB ▪Lokasi nyeri diperut kanan atas dan belakang
tengah frekuensi 8, intensitas 30 menit
Respon Klien :

4 - memeriksa sirkulasi perifer

JAM 8.15 WIB ▪ Akral dingin, Warna kulit pucat, CRT : 4 detik

1 - Mengidentifikasi skala nyeri : 8

Jam 8.30 WIB
Respon Klien :

3 -memeriksa tanda dan gejala hypervolemia

Jam 8.40 WIB
▪ JVP (+), Refleks hepatojugular (+), Kadar Hb : 7,8
gr/dl, Pembesaran hepar dan teraba,Hasil USG :
Sirosis hepar Splenomegaly Asites

- Mengidentifikasi factor yang memperberat dan

1 memperingan nyeri
Jam 8.50 WIB
▪mengajarkan posisi semy fowler untuk mengurangi
rasa nyeri
Respon Klien :

Jam 10.10 WIB -Mengidentifikasi faktor resiko gangguan sirkulasi

4 karna terjadi Penurunan konsentrasi Hb dalam darah
yaitu hippertensi

- Mengidentifikasi alergi dan intoleransi makanan,

2 yaitu pasien alergi mie dan telor
Jam 10.40 WIB
Respon klien :
3 - meninggikan kepala tempat tidur dengan cara 30 –
Pada tanggal 1 – 08 2020
Jam 7.50 WIB 40 derajat
2 - Mengidentifikasi makanan yang disukai, yaitu
Jam 8.29 WIB
makanan yang disukai ikan mujaer dan sayur sop
Respon klien :

Jam 8.40 WIB - Memberikan teknik nonformakologis untuk

1 mengurangi rasa nyeri
Respon Klien : klien sudah memahami cara teknik
nonformakologis

-menghindari pemasangan infus atau pengambilan

4 darah diarea keterbatasan perfusi yaitu didaerah
Jam 9.20 WIB
vena kava inferior

Pada tanggal 2 – 08 2020 -Memonitor asupan makanan

2 ▪ SMRS : 2x / hari ( Porsi sedang, jenis makanan
Jam 7.50 WIB
nasi, ikan, sayur )
 ▪MRS : 3x / Hari habis ½ porsi
Respon Klien :

-menganjurkan melaporkan jika BB bertambah >1kg

dalam sehari
Jam 8.10 WIB
4 -mengkaloborasi pemberian diuretic yang digunakan
untuk membuang kelebihan garam dan air dari tubuh
melalui urine
Jam 9.20 WIB 3
-menganjurkan minum obat pengontrol tekanan
darah secara teratur
Jam 10.20 WIB
4 - Memonitor berat badan 47Kg
Respon Klien :

Jam 11.20 WIB 2 -Menginformasikan kepada tenaga kesehatan jika

ada gejala darurat hang harus dilaporkan seperti
rasa sakit yang tidak hilang saat istirahat, luka
Jam 14.20 WIB 3 tidak sembuh, dll

- Menganjurkan menggunakan analgesik secara

tepat, analgesic yaitu berpa paracetamol 2 x 500
Jam 16.20 WIB 2 mmhg via oral
Respon Klien :

- Memberikan makanan tinggi kalori dan tinggi

protein berupa sayur dan ikan
Respon Klien :
Pada tanggal 3 – 08 – 2020 1
Jam 7.40 WIB - Memberikan suplemen makanan, jika perlu
Respon Klien :

Jam 8.20 WIB 1 - Mengkolaborasi Memberikan analgesic berupa

paracetamol 2 x 200 mg dengan cara oral.
Respon klien :
Jam 9.30 WIB 2
-Menganjurkan posisi duduk, jika perlu Kolaborasi
pemberian medikasi sebelum makan (mis. Pereda
nyeri, antlemetik), jika perlu
Jam 10.10 WIB 2 Respon Klien :

- Menfasilitasi istirahat dan tidur untuk

mengurangi rasa nyeri pada pada abdomen
Respon klien :
Jam 11.10 WIB 1
 EVALUASI

NAMA PASIEN : Tn Z
UMUR : 32Thn
NO. REGISTER 0140548

NO. DX TANGGAL TANGGAL TANGGAL TANGGAL

KEP.
31 Juli 2017
DX 1
S:
P : Klien mangatakan masih nyeri di
daerah perut kuadran kanan
Q : Karakteristik nyeri panas
R : Nyeri di daerah perut kuadran kanan
S:8
T : Nyeri timbul saat berjalan , muncul
selama 30 menit secara mendadak
O:
 TD 100/70 mmHg
 Klien tampak memegang perut
 Skala nyeri 8
A: Masalah belum teratasi
P: lanjutkan intevensi ( D.0077 )
1 Agustus 2017 2 Agustus 2017 3 Agustus 2017
S: S: S:
 P : Klain mengatakan nyeri semakin berat bila
P : Keluarga klien mengatakan, klien P : Keluarga klien mengatakan, klien
pasien beraktivitas sedang berjalan dan nyeri
Sudah mengetahui cara teknik Sudah mengetahui cara teknik
berkurang saat pasien tiduran dengan posisi
nonformakologis nonformakologis
setengah duduk sudah tidak timbul lag
Q : Karakteristik nyeri panas berkurang Q : Karakteristik nyeri panas
 Q : Pasien mengatakan nyeri berkurang.
R : Klien mengatakan nyeri di perut berkurang
berkurang R : Klien mengatakan nyeri di perut  R : Nyeri didaerah perut kanan atas dan belakang
tengah sudah tidak timbul
S : Skala nyeri berkurang
7 S : Skala nyeri 7  T : Intensitas nyeri 30 menit, dan nyeri tidak
timbul secara mendadak.
T : Nyeri timbul saat berjalan , muncul T : Nyeri timbul saat berjalan , muncul
selama 30 menit secara mendadak selama 30 menit secara mendadak
O:
● Pasien tidak mengeluh nyeri perut kanan atas,
O: O: ● Skala nyeri 8 menjadi 5
● TD 110/90 mmHg ● TD 120/80 mmHg ● TTV : Tekanan Darah : 120/80
● Klien sedikit tidak memegang perut ● Klien sudah tidak memegang perut
A : Masalah teratasi
A: Masalah teratasi sebagian A: Masalah teratasi sebagian
P : Intervensi di hentikan
P: lanjutkan intervensi ( D.0077 ) P: intervensi dipertahankan ( D.0077 )
 31 Juli 2017
DX 2
S:
- Pasien merasa mual,
- Pasien tidak selera makan,
- Pasien mengatakan perut terasa
begah,
- Pasien mengatakan dalam sehari
minum kurang lebih 1 ½ liter
O:
- Berat badan turun 2kg
- Makanan habis ½ porsi
A : Masalah belum teratasi
P : Intervensi dilanjutkan ( D.0019 )
DX 3 31 Juli 2017
DS :
- Pasien mengeluh sesak nafas,
muncul setiap malam hari.
- Pasien tidur dengan 2 bantal
untuk mengurangi sesak.
- Klien mengatakan minum 1 ½
liter/hari
DO :
- Permukaan perut asites
1 Agustus 2017
S:
- Pasien mengatakan rasa mual menurun - Pasien mengatakan rasa mual sudah
- Keluarga klien mengatakan klien sudah
tidak makan makanan yang
mengandung protein tinggi
- Pasien mengatakan perut masih terasa
begah,
- Pasien mengatakan dalam sehari
minum kurang lebih 2 liter
O:
- Berat badan turun 2kg
- Makanan habis 1 porsi makanan
-Klien terlihat suka makanan ikan
A : Masalah teratasi sebagian
P : Intervensi dilanjutkan ( D.0019 )
1 Agustus 2017
DS :
- Pasien mengeluh sesak nafas,
muncul 1 x dalam sehari yaitu
pada bangun tidur
- Pasien tidur dengan 1 bantal
- Klien mengatakan minum 3
liter/hari
DO :
- Permukaan perut asites
2 Agustus 2017
S:
tidak timbul lagi
- Keluarga klien mengatakan klien
sudah tidak makan makanan yang
mengandung protein tinggi
- Pasien mengatakan perut sudah tidak
terasa begah lagi
- Pasien mengatakan dalam sehari
minum kurang lebih 2 liter
O:
- Berat badan normal sebelum masuk
RS 59Kg
- Makanan habis 1 porsi makanan
-Klien terlihat suka makanan ikan
A : Masalah teratasi
P : Intervensi dihentikan
2 Agustus 2017
DS :
- Pasien mengeluh sesak nafas,
muncul 1 x dalam sehari yaitu
pada bangun tidur
- Pasien tidur dengan 1 bantal
- Klien mengatakan minum 3
liter/hari
DO :
- Permukaan perut normal
 - JVP (+) - JVP (+) - JVP mulai normal
- Refleks hepatojugular (+) - Refleks hepatojugular (+) - Kadar Hb : 15 gr/dl
- Kadar Hb : 7,8 gr/dl - Kadar Hb : 7,8 gr/dl - Pembesaran hepar dan tidak
- Pembesaran hepar dan teraba - Pembesaran hepar dan tidak teraba
Hasil USG : Sirosis hepar teraba
Splenomegaly Asites A : Masalah teratasi
A : Masalah teratasi sebagian
A : Masalah belum teratasi P : Intervensi dihentikan
P : Intervensi dipertahankan
P : Intervensi dilanjutkan ( D.0023 )
DX 4 31 Juli 2017 1 Agustus 2017 2 Agustus 2017
DS : - DS : - DS : -
DO: DO: DO:
- Akral dingin - Akral dingin - Akral dingin
- Warna kulit pucat - Warna kulit tidak terlihat pucat - Warna kulit tidak terlihat pucat
CRT : 4 detik CRT : 4 detik CRT : 3 detik
A : Masalah belum teratasi A : Masalah teratasi sebagian A : Masalah teratasi

P : Intervensi dilanjutkan ( D.0009 ) P : Intervensi dilanjutkan ( D.0009 ) P : Intervensi dipertahankan