STIKES ABDI NUSANTARA JAKARTA

PROGRAM PENDIDIKAN PROFESI NERS

ALAMAT : JL.Swadaya Kubah Putih No. 9 kel. Jatibening Kec. Pondok Gede

Nama Mahasiswa : Margaretha Magdalena Chresia

NIM : 200512032

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Tanggal MRS : 09/08/2021 Jam Masuk : 03.00
Tanggal Pengkajian : 09/08/2021 No. RM : 000257
Jam Pengkajian : 16.00
Diagnosa Masuk : ACS, NSTEMI, PNEUMONIA, DM tipe 2. EC EDEMA PARU
Hari rawat ke :1

IDENTITAS
1. Nama Pasien : Tn. H
2. Umur: 67 Tahun (11 Oktober 1953)
3. Suku/ Bangsa : Batak/ Indonesia
4. Agama : Kristen
5. Pendidikan : SMP
6. Pekerjaan : Karyawan swasta
7. Alamat : Binong permai, blok B8, no.8
8. Sumber Biaya : BPJS

KELUHAN UTAMA
Keluhan utamaPasien masuk IGD tgl 09/8/21 pukul21.00 dengan GCS E4M6V5. pasien mengeluh sesak
nafas sejak lama dan memberat sejak siang hari. Nyeri dada tidak ada, tapi dada terasa tertimpa beban
berat, keringat dingin tidak ada, merokok sejak masih muda. Suara nafas ronchi. Ketika dilakukan
perekaman EKG, ditemukan NSTEMI. Pasien juga dilakukan CT thorax, ditemukan Sugestif, gambaran
edema paru disertai efusi pleura ringan bilateral, fibrosis di lobus superior paru kanan. Dan thorax
tampak bercak opasitas pada kedua lapang paru, dd/pneumonia, TB CTR 51% dengan aorta kalsifikasi.
Awalnya pasien diberikan oksigen menggunakan NRM 15 lpm namun SPO2 hanya 92%, pH : 7.1,
PO2:92, PCO2 :81,
HCO3: 23,3 Hemodinamik Bp: 138/89 mmHg, HR: 135x/ menit ,RR: 24 , S: 36,3ᵒC, sehingga pada
pukul 03.00 dilakukan intubasi dengan batas bibir ETT
22 cm, ventilator mode PC 20, PEEP 8, FIO2 100% RR 20. AGD Post intubasi, PH:7,34 PCO2:31,3
PO2:188 HCO3: 15,8

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1. Riwayat Penyakit Sekarang:
Pasien masuk ke ruang ICU sejak tgl 09/08/21 on ventilator mode PC 20, RR 12, PEEP 5, FiO2 50%, GCS
E2-3,M4-5Vt, batas bibir ETT 22 cm, no ETT

7,5. Reaksi cahaya+/+ pupil size 2/2 Terpasang iv line di vena metacarpal sinistra dan iv line vena brachialis
dextra, sudah terpasang NGT no.16 di nares dextra, kateter urin no .16 dengan produksi 30-80 urin ml/jam.
Hemodinamik Bp: 138/89 mmHg, HR: 105x/ menit, RR: 25 x/menit, S: 36,2ᵒC. pada tgl 09/8/2021 pasien
mengalami hematuria dengan produksi urin 30-70 ml/jam dengan lasix 5 mg/jam. Drip. Terdapat slem, kental
putih, banyak, batuk adekuat. Kulit tampak pucat, kering dan kasar, ada bekas luka dikaki sebelah kanan, pasien
tidak dapat melakukan mobilitas secara mandiri.

RIWAYAT PENYAKIT DAHULU

1. Pernah dirawat : ya tidak kapan : tahun 2019 diagnosa : TB
2. Riwayat penyakit kronik dan menular ya tidak jenis : droplet, air bone
Riwayat kontrol : Pengobatan tuntas
Riwayat penggunaan obat :
3. Riwayat alergi:
Obat ya tidak jenis……………………
Makanan ya tidak jenis……………………
Lain-lain ya tidak jenis……………………

4. Riwayat operasi: ya tidak

- Kapan : ……………………
- Jenis operasi : ……………………
5. Lain-lain:
..........................................................................................................................................................................................
..........................................................................................................................................................................................

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

2
 Obat ya tidak
keterangan…..............................................................………………
Olah raga ya tidak
keterangan…..........................................................…………………

OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda tanda vital
S : 36.5°C N : 76X/menit TD : 117/60mmhg RR :12X/mnt (ETT tdk ada napas spontan)
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma

2. Sistem Pernafasan (B1)

a. RR: 12X/mnt (ETT tdk ada napas spontan)
b. Keluhan: sesak nyeri waktu nafas orthopnea
Batuk produktif tidak produktif
Sekret: Banyak Konsistensi : Kental
Warna: Putih Bau :.................................. Masalah Keperawatan :
c. Penggunaan otot bantu nafas: 1.Gangguan pertukaran gas
2.Bersihan jalan nafas tidak
.................................................................................................................................................................................
.................................................................................................................................................................................
efektif
..
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 Ronki Wheezing
i. Alat bantu napas ya tidak

Jenis ETT no 7.5 Flow : PC 20, RR 12, PEEP 5, FiO2 50%,

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

k. Tracheostomy: ya tidak
.................................................................................................................................................................................
...............................................................................................................................................................................
l. Lain-lain:
.................................................................................................................................................................................
...............................................................................................................................................................................
................................................................................................................................................................................

3. Sistem Kardio vaskuler (B2)

a. TD : 117/60 mmHg Masalah Keperawatan :
b. N : 76X/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 : <3 detik
h. Akral: hangat kering merah basah pucat

3
 panas dingin
i. Sikulasi perifer: normal menurun
j. JVP :-
k. CVP :-
l. CTR :-
m. ECG & Interpretasinya:
Hasil Elektrocardiogram (10-08-2021) Temuan:
Dimensi ruang jantung dalam batas normal. LVH-
Fungsi sistol LV cukup. LVEF 50%, normal kinetik saat istirahat, disfungsi diastolik grade 1, katub-
katub baik. Kontraktilitas right ventrikal baik tidak tampak efusi pericard. Tidak tampak SEC atau
trombus.
Kesan: fungsi sistolik LV cukup, LVEF 50%
n. Lain-lain :
.-

4. Sistem Persyarafan (B3)

a. GCS : . E3,M5,Vt, Masalah Keperawatan :
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: 2/2

g. Sclera anikterus ikterus
h. Konjunctiva ananemis anemis
i. Isitrahat/Tidur : 8 Jam/Hari Gangguan tidur : tidak ada
j. Lain-lain:
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.....

5. Sistem perkemihan (B4)

Masalah Keperawatan
a. Kebersihan genetalia: Bersih Kotor
E
b. Sekret: Ada Tidak

4
 c. Ulkus: Ada Tidak
d. Kebersihan meatus uretra: Bersih Kotor
e. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
............................................................................................................................................................................
f. Kemampuan berkemih:
Spontan Alat bantu,
sebutkan: .................................................................................................
Jenis :2 way folley cath
Ukuran : 16
Hari ke :1
g. Produksi urine : 30-70 ml/jam
Warna : kuning jernih
Bau :-
h. Kandung kemih : Membesar ya tidak
i. Nyeri tekan ya tidak
j. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
k. Balance cairan:
09-08-2021 : Balance cairan/24 jam = (+) 377 ml/24 jam
10-08-2021 : Balance cairan/24 jam = (+) 65 ml/24 jam
11-05-2021 : Balance cairan 24 jam= (-) 166 ml/24 jam
k. Lain-lain:
.................................................................................................................................................................................
.................................................................................................................................................................................
..............................................................................................................................................................................

6. Sistem pencernaan (B5) Masalah Keperawatan :

a. TB : 160 BB : 62
b. IMT : 24.2 Interpretasi : normal

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 15x/menit
j. BAB: 1x/hari Terakhir tanggal : 8/08/2021
k. Konsistensi: keras lunak cair lendir/darah
l. Diet: padat lunak cair

5
 m. Diet Khusus:
Susu
n. Nafsu makan: baik menurun Frekuensi 3x/hari
o. Porsi makan: habis tidak Keterangan:.......................
p. Lain-lain:
Terpasang NGT no 16. Pasien dengan pengaruh sedatif
7. Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
Tidak Ada
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
Masalah Keperawatan :
Tidak ada
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 :
.................................................................................................................................................................................
.................................................................................................................................................................................
..............................................................................................................................................................................
8. Sistem muskuloskeletal (B6)
a. Pergerakan sendi: bebas terbatas
b. Kekuatan otot: Masalah Keperawatan :

c. Kelainan ekstremitas: ya tidak

d. Kelainan tulang belakang: ya tidak
Frankel: ................................................................................
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 :................

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 Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
n. ROM : .................................................

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

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

b. Warna Masalah Keperawatan :

c. Pitting edema: +/- grade:................
d. Ekskoriasis: ya tidak
e. Psoriasis: ya tidak
f. Pruritus: ya tidak
g. Urtikaria: ya tidak
h. Lain-lain:
.................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................

11. Sistem Endokrin

a. Pembesaran tyroid: ya tidak Masalah Keperawatan :
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 :

8
 - Jenis Luka :
- Lokasi :
- Riwayat amputasi sebelumya ya tidak
Jika ya:
- Tahun :
- Lokasi :
f. ABI : ....................................................
g. Lain-lain:
.................................................................................................................................................................................
.................................................................................................................................................................................
.............................................................................................................................................................................

PENGKAJIAN PSIKOSOSIAL Masalah keperawatan :

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:
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
e. Lain-lain:
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
PERSONAL HYGIENE & KEBIASAAN
Masalah Keperawatan :
Jelaskan :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................
PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah

b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:

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

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

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

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

TERAPI
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..............................................................................................................................................................................................
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DATA TAMBAHAN LAIN :

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..............................................................................................................................................................................................
Jakarta , 09/08/2021

(Margaretha Magdalena Chresia)

10
 PROGRAM STUDI PENDIDIKAN NERS
STIKES ABDI NUSANTARA JAKARTA

ANALISIS DATA

Hari/
DATA ETIOLOGI MASALAH
Tgl/ Jam

11
 PROGRAM STUDI PENDIDIKAN NERS
STIKES ABDI NUSANTARA JAKARTA

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

TANGGAL: .................................
1.

2.

3.

4.

5.

6.

12
13
 RENCANA INTERVENSI

Hari/ Tgl/
No. DIAGNOSA KEPERAWATAN INTERVENSI RASIONAL
Jam
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/
No.
Tgl/ Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
Dx
Shift
Lampiran IV

RESUME KEPERAWATAN
PROFESI NERS STASE KEPERAWATAN MEDIKAL BEDAH

I. IDENTITAS

A. Nama : ……………………………………….
B. Jenis Kelamin : ………………………………………
C. Umur : ………………………………………
D. Agama : ………………………………………
E. Status Perkawinan : ………………………………………
F. Pekerjaan : ………………………………………
G. Alamat rumah :
…………………………………………………

………………………………………………….

…………………………………………………..
II. ALASAN MASUK RUMAH SAKIT
…………………………………………………………………………
……
…………………………………………………………………………
……
…………………………………………………………………………
……

III. PENGKAJIAN FISIK

A. Pernafasan :
………………………………………………………………..
B. Kardiovaskuler :
…………………………………………………………..
C. Persyarafan :
……………………………………………………………….
D. Perkemihan :
………………………………………………………………..
E. Pencarnaan :
……………………………………………………………….
F. Penglihatan :
………………………………………………………………..
G. Muskuloskletal : …..
……………………………………………………..
 H. Integumen :
………………………………………………………………..
I. Endokrin :
…………………………………………………………………..

IV. PENGKAJIAN PSIKOSOSIAL ;

……………………………………………..
V. PENGKAJIAN PERSONAL HYGNE;
……………………………………..
VI. PENGKAJIAN SPRITUAL ;
………………………………………………….
VII. PEMERIKSAAN PENUNJANG ;
……………………………………………
VIII. TERAPI…………………………………………………………………
…

IX. ANALISA DATA

N DATA ETIOLOGI MASALAH
O
DATA SUBJEKTIF
………………………………
………………………………
………………………………
……………………
DATA OBJEKTIF
………………………………
………………………………
………………………………
……………………
 X. DIAGNOSA KEPERAWATAN PRIORITAS
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
………………
XI. NURSING CARE PLANNING
NO DATA TUJUAN JAM ACTION RESPON PARAF
1. DS: 11.00 1. 1
2.
3.
4.
5.

TTD
DO: Perawat