FORMAT ASUHAN KEPERAWATAN KEPERAWATAN MEDIKAL BEDAH

PSIK STIKES WIYATA HUSADA SAMARINDA

Nama mahasiswa : .....................................................

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Tempat praktek : ……………………………………
Tanggal : ……………………………………

I. Identitas diri klien

Nama : .......................................... Suku : …………………………………............

Umur : .......................................... Pendidikan :..........................................................

Jemis kelamin :........................................... Pekerjaan :..........................................................

Alamat :........................................... Lama bekerja :..........................................................

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…………………………………………………....................... Tanggal masuk RS :........................................

Status perkawinan .......................................................... Tanggal Pengkajian : ……………………...........

Agama: ................................................................................ Sumber Informasi : ……………………….......

II. Riwayat penyakit

1. Keluhan utama saat masuk RS:

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2. Riwayat penyakit sekarang:

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 3. Riwayat Penyakit Dahulu

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Genogram:
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4. Diagnosa medik pada saat MRS, pemeriksaan penunjang dan tindakan yang telah dilakukan:

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III. Pengkajian saat ini (mulai hari pertama saudara merawat klien)
 1. Persepsi dan pemeliharaan kesehatan

Pengetahuan tentang penyakit/perawatan

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2. Pola nutrisi/metabolic

Program diit RS:

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Intake makanan:

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Intake cairan:

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3. Pola eliminasi

a. Buang air besar

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b. Buang air kecil

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4. Pola aktifitas dan latihan:

 Kemampuan perawatan diri 0 1 2 3 4

Makan/minum

Mandi

Toileting

Berpakaian

Mobilitas di tempat tidur

Berpindah

Ambulasi/ROM
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4: tergantung total

Oksigenasi:

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5. Pola tidur dan istirahat

(lama tidur, gangguan tidur, perawasan saat bangun tidur)

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6. Pola persepsual

(penglihatan, pendengaran, pengecap, sensasi):

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7. Pola persepsi diri

(pandangan klien tentang sakitnya, kecemasan, konsep diri)

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8. Pola seksualitas dan reproduksi

 (fertilitas, libido, menstuasi, kontrasepsi, dll.)

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9. Pola peran hubungan

(komunikasi, hubungan dengan orang lain, kemampuan keuangan):

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10. Pola managemen koping-stess

(perubahan terbesar dalam hidup pada akhir-akhir ini):

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11. Sistem nilai dan keyakinan

(pandangan klien tentang agama, kegiatan keagamaan, dll)

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IV. Pemeriksaan fisik

(cephalocaudal) yang meliputi : Inspeksi, Palpasi, Perkusi dan Auskultasi keluhan

yang dirasakan saat ini
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TD: mm/H P: x/m N: x/m S: o

C

BB/TB…………………………………………
Kepala:

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Mata dan Telinga (Penglihatan dan pendengaran)

a. Penglihatan

 Berkurang  Ganda  Kabur  Buta/ gelap

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▪ Visus: dioptri

▪ Sklera ikterik : (ya/tidak)

▪ Konjungtiva : (anemis/ tidak anemis)

▪ Nyeri : (ya/tidak), intensitas :

▪ Kornea : jernih/keruh/berbintik

▪ Alat bantu : tidak ada/lensa kontak/kaca mata

b. Pendengaran

 Normal  Berdengung  Berkurang  Alat bantu  Tuli

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Keluhan lain:

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Hidung:

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Mulut/Gigi/Lidah:

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Leher :

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Respiratori
a. Dada :

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b. Batuk : ya/tidak; produktif/tidak produktif

Karakteristik Sputum .......................................................................................................................................

c. Napas bunyi : vesikuler/lainnya, jelaskan

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▪ Sesak napas saat :

➢ Ekspirasi ➢ Inspirasi ➢ Istirahat ➢ Aktivitas

Tipe pernapasan :

 Perut  Dada  Biot

 Kussmaul  Cynestokes  Lainnya

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Frekuensi nafas : x/mnt

Penggunaan otot-otot asesori: (ya/tidak), Napas Cuping Hidung: .....................................

Fremitus: ....................................................................................................................................................

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Sianosis : (ya/ tidak)

▪ Keluhan Lain:

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Kardiovaskular

Riwayat Hipertensi: .............................................................. Masalah jantung……………..

Demam Rematik: ..................................................................

Bunyi Jantung: Frekuensi:................................................. Irama………………….

Kualitas……………………………….. Murmur ………………………..

  Nyeri dada, Intensitas : Palpitasi

 Pusing  Cianosis

▪ Capillary refill :

 Riwayat Keluhan lainnya

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▪ Edema, lokasi : grade :

▪ Hematoma, lokasi :

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Neurologis

Rasa ingin pingsan/ pusing: ...................................................................................................................... Sakit

Kepla: Lokasi nyeri ...................................................................... Frekuensi ...................................

▪ GCS : Eye = Verbal = Motorik =

▪ Pupil : isokor/unisokor ▪ Reflek cahaya :

• Sinistra : +/- cepat/lambat

• Dextra : +/- cepat/lambat

▪ Bicara :

 Komunikatif  Aphasia  Pelo

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▪ Keluhan lain :

 Kesemutan  Bingung  Tremor  Gelisah  Kejang

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▪ Koordinasi ekastemitas

 Normal  Paralisis, Lokasi :  Plegia, Lokasi :

▪ Keluhan lain:
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Integumen

▪ Warna kulit

 Kemerahan  Pucat  Sianosis  Jaundice  Normal

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▪ Kelembaban :

 Lembab  Kering

▪ Turgor : elastis / tidak elastic

 > 2 detik  < 2 detik

Keluhan lain :

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Abdomen

Nyeri Tekan: .......................................................................................................................................................

Lunak/keras: .......................................................................................................................................................

Massa:……………………………..ukuran/ Lingkar Perut: ................................................................................

Bising usus: .........................................................................................................................................................

Asites : ..................................................................................................................................................................

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Keluhan lain: .......................................................................................................................................................

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Muskuloskeletal
 Nyeri otot/tulang, lokasi : intensita
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  Kaku sendi, lokasi :

 Bengkak sendi, lokasi :

 Fraktur (terbuka/tertutup), lokasi :

 Alat bantu, jelaskan :

 Pergerakan terbatas, jelaskan :

 Keluhan lain, jelaskan :

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Seksualitas

Aktif melakukan hubungan seksual: ................................................................................................................

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Penggunaan alat kontrasepsi: ............................................................................................................................

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Masalah/kesulitan seksual: ..................................................................................................................................

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Perubahan terakhir dalam frekuensi: ...............................................................................................................

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Wanita:
Usia Menarche :…………… lamanya siklus:……………..durasi:………………..
Periode menstruasi terakhir:……………………..Menopouse:……………………
Melakukan pemeriksaan payudara sendiri: ...................................................................................................
PAP smear terakhir: ................................................................................................................................................

Pria
Rabas penis :……………………….Gangguan prostat:…………………………… Sirkumsisi
:…………………………Vasektomi:…………………………………..

Impoten :…………………………….Ejakulasi dini:………………………………

V. Program terapi:

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Hasil Pemeriksaan Penunjang dan Laboratorium

(dimulai saat anda mengambil sebagai kasus kelolaan, cantumkan tanggal pemeriksaan, dan

kesimpulan hasilnya)
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Samarinda, ................... 2019

Perawat

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VI. Analisa Data

No Data Penunjang Kemungkinan Penyebab Masalah

1. DS : klien mengatakan nyeri pada Agen pacandera Nyeri akut

bagian perut
fisiologis
D0 : P = Nyeri perut
Q = Seperti tertusuk-tusuk

R = Dibagian perut
 S = Skala nyeri 6
T = Waktunya hilan timbul
TTV : TD =110/80 mmHG
N = 86 x per menit
RR = 20 x per menit
S = 36,5 Celcius

2.
DS : klien mengatakan adanya keluar Tindakan invasive ( bekas Resiko Infeksi
cairan (feses) pada bekas lubang
operasi )
kolostomi

DO : terdapat bekas lubang operasi

kolostomi, dan terdapat bekas jahitan
di bagian operasi di abdomen

TTV : TD =110/80 mmHG

N = 86 x per menit
RR = 20 x per menit
S = 36,5 Celcius

3.
DS : klien mengatakan susah tidur Tindakan operasi Ansietas
pada malam hari karena kawatir
dengan keadaannya pada saat ini

D0 : Klien tampak letih

TTV : TD =110/80 mmHG

N = 86 x per menit
RR = 20 x per menit
S = 36,5 Celcius

VII. Diagnosa Keperawatan

1. Nyeri akut berhubungan dengan agen pancadera fisiologis

2. Resiko infeksi berhubungan dengan tindakan invasive
3. Ansietas berhubungan dengan tindakan operasi
 RENCANA KEPERAWATAN

DIAGNOSA KEPERAWATAN
NO TUJUAN (NOC)/ (SLKI) INTERVENSI (NIC)/ (SIKI)
/MASALAH KOLABORASI

1 Nyeri akut berhubungan dengan agen Tingkat nyeri Manajemen nyeri

pancadera fisiologis Kriteria hasil : Intervensi :

1. Keluhan nyeri (4) 1. Identifikasi nyeri lokasi, karakteristik nyeri.

2. Meringis (4) Durasi, kualitas, dan intensitas nyeri

3. Sikap protektif (4) 2. Menggunakan teknik nafas dalam, dalam

4. Kesulitan tidur (4) megurangi nyeri saat timbul

5. Berfokus pada diri sendiri (4) 3. Berikan Teknik nonfarmakologis untuk

mengurangi rasa nyeri

4. Kontrol lingkungan yang memperberat rasa

nyeri

5. Anjurkan monitor nyeri secara mandiri

6. Kaloborasikan dengan farmakologis

Resiko infeksi berhubungan dengan Tingkat infeksi Pencegahan infeksi

2
tindakan invasive Kriteria hasil : Intervensi :

1. Demam (4) 1. Monitor tanda dan gejala infeksi local dan

2. Kemerahan (4) iskemik
 3. Bengkak (4) 2. Cuci tangan sebelum dan setelah kontak

4. Nyeri (4) dengan pasien maupun lingkungan pasien

5. Cairan berbau busuk (4) 3. Ajarkan klien cuci tangan dengan benar

4. Ajarkan menjaga selalu kebersihan daerah

luka

5. Melakukan perawatn luka pada klien

6. Minta klien lapor apabila adanya tanda-tanda

infeksi

3 Ansietas berhubungan dengan

Tingkat ansietas Reduksi ansietas
tindakan operasi
Kriteria hasil : Intervensi :

1. Verbalisasi kebingungan (4) 1. Ciptakan suasana terapeutik untuk

2. Verbalisasi rasa khawatir yang dihadapi saat ini (4) menumbuhkan kepercayaan

3. Perilaku gelisah (4) 2. Dengarkan keluh pasien dengan penuh

4. Prilaku tegang (4) perhatian

5. Susah tidur (4) 3. Diskusikan rencana realisitis tentang peristiwa

yang akan dating

4. Informasikan secara factual mengenai

penyakit yang diderita

5. Anjurkan keluarga tetap Bersama pasien

6. Anjurkan kegiatan pengalihan untuk

mengurangi ketegangan pada pasien

 DIAGNOSA KEPERAWATAN
NO TUJUAN (NOC)/ (SLKI) INTERVENSI (NIC)/ (SIKI)
/MASALAH KOLABORASI
 DIAGNOSA KEPERAWATAN
NO TUJUAN (NOC)/ (SLKI) INTERVENSI (NIC)/ (SIKI)
/MASALAH KOLABORASI
 Catatan Perkembangan

Nama Klien : Umur :

No RM : Ruang :

Hari/Tgl N. Dx Implementasi Evaluasi Paraf