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 Cimanggis 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 di daerah perut bagian kanan atas dan dibelakang tengah. .

2. Riwayat Penyakit Sekarang

Awalnya pasien merasakan nyeri di daerah perut dan mual, kemudian pasien dibawa ke
RSUP Fatmawati Jakarta pada tanggal 30 Juli 2017 dengan keluhan nyeri pada bagian
perut dan mual.
P : Nyeri semakin berat bila pasien beraktivitas sedang seperti berjalan, dan berkurang
saat pasien tiduran dengan posisi semi fowler(setengah duduk)
Q : Karakteristik nyeri panas
R : nyeri di daerah perut kanan atas dan dibelakang tengah.
S : Skala nyeri 8
T : Intensitas 30 menit, timbul keluhan mendadak
Kemudian pasien dipindah keruangan untuk dilakukan pemeriksaan lebih lanjut
3. Riwayat Kesehatan Yang Lalu
Pasien mengatakan tidak ada riwayat kesehatan yang lalu

4. Riwayat Kesehatan Keluarga

Pasien mengatakan tidak ada keluarga yang memiliki riwayat kesehatan

POLA AKTIVITAS SEHARI-HARI

A. POLA TIDUR/ITIRAHAT

1. Waktu Tidur
: ..................................................................................
..................................................................................
2. Waktu Bangun
: ..................................................................................
..................................................................................
3. Masalah Tidur
: ..................................................................................
..................................................................................
4. Hal-hal yang mempermudah tidur : ....................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
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 :

SMRS : Jumlah makanan habis 1 porsi
MRS : Jumlah makanan habis ½ porsi
2. Waktu pemberian makan :
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
3. Jumlah dan jenis cairan :
SMRS : Jumlah cairan sehari 2 L
MRS : Jumlah cairan sehari kurang lebih 1 1/2 L
4. Waktu pemberian cairan :
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
5. Pantangan :
SMRS : tidak ada
MRS : tidak ada
6. Masalah makan dan minum
a. Kesulitan mengunyah
: ......................................................................
b. Kesulitan menelan
: ......................................................................
c. Mual dan muntah : pasien mual
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 Komuniasi
: .............................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................

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: sedang

B. Tanda-tanda vital
Suhu tubuh : 36.3 C )
Nadi : 128 x/menit
Tekanan darah: 100/70 mmHg Respirasi : 22 x/menit
Tinggi badan : 164 cm BB SMRS : 57 kg
MRS : 59 kg
BBI : 57.6-70.4 kg LILA : 24 cm
lingkar perut : 90 cm
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 dan sclera : konjungtiva anemis, sclera ikterik
d. Pupil : .........................................................
.............
..........................................................................................................................
e. Kornea dan iris
: ......................................................................
..........................................................................................................................
f. Ketajaman penglihatan/visus
: ......................................................................
..........................................................................................................................
g. 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. Denyut nadi carotis
: ..................................................................................

D. Pemeriksaan Integumen (kulit)

a. Kebersihan
: ..................................................................................
b. Kehangatan : akral dingin
c. Warna : pucat
d. Tekstur : .........................................................
.........................
e. Kelembaban : .........................................................
.........................
f. Kelainan pada 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 : …………………………………………………………….
Benjolan/massa : asites
Bayangan pembuluh darah abdomen : .................................................................
...............................................................................................................................
...............................................................................................................................
b. Auskultasi
Peristaltik usus : (+), bising usus 8x/menit
Bunyi jantung anak/BJA : .................................................................................
c. Palpasi
Tanda nyeri tekan : Nyeri tekan di rasakan pada kuadran kanan atas
Benjolan/massa : .................................................................................
.
..................................................................................
Tanda-tanda ascites
: ..................................................................................
..................................................................................
 Hepar : hepar teraba dan terjadi pembesaran
Lien : .................................................................................
.
..................................................................................
Titik McBurney
: ..................................................................................
..................................................................................

d. Perkusi
Suara abodmen : dullness pada daerah kanan atas, timpani pada
kuadran yang lain
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
Compos mentis GCS: 15 (E: 4, M: 6, V: 5)
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 Hasil Nilai Rujukan
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 :
tanggal 30 Juli 2017 kesan: Cor danpulmo dalam batas normal.
 3. ECG :
4. USG :
tanggal 29 Juli 2017 hasil: Sirosis hepatis, splenomegaly dan asites.
5. Lain-lain :

PENATALAKSANAAN DAN TERAPI

Tanggal 30 Juli 2017:
1. Ciprofloxacin 2 x 400 mg (jam 06.00 dan jam 18.00) via drip,
2. Cefotaxime 3 x 1 gr (jam 10.00, jam 18.00 dan 21.00) via IV,
3. Omeprazole 2 x 40 mg (jam 10.00 dan jam 18.00) via IV,
4. Sukralfat 2 x 500 mg (jam 06.00 dan jam 18.00) via oral,
5. Paracetamol 2 x 500 mg (jam 10.00 dan jam 18.00) via oral,
6. Kalium klorida (KSR) 2 x 1200 mg (jam 10.00 dan jam 18.00) via oral,
7. Laktulak 2 x 60 ml (jam 06.00 dan jam 18.00) via oral,
8. Vit K 2 x 10 mg (jam 06.00 dan jam 18.00) via drip.

Tanggal 31 Juli 2017:

1. Furosemide 1 x 40 mg (jam 10.00) via oral,
2. Spironolakton 1 x 100 mg (jam 10.00) via oral.
3. Klien mendapat Diet TKTP 2100 kkal.

Perawat
Umi khoiriyah
NIM:202303102100

ANALISIS DATA

NAMA PASIEN : Tn. Z

UMUR : 32 tahun
NO. REGISTER : 0140568

DATA PENUNJANG INTERPRETASI MASALAH

DATA

DS : Kolestatis kronik Nyeri akut

 P: ↓
1. Pas Sirosis hepatis
ien mengatakan Nyeri daerah ↓
perut, dan Nyeri timbul saat Inflamasi akut
berjalan dan berkurang saat ↓
posisi setengah duduk Nyeri
 Q:
- Karakteristik nyeri panas
 R:
- Nyeri pada perut atas dan
belakang
 T:
- Nyeri timbul saat pasien
berjalan, dan mucul selama
 30 menit keluhan mendadak.

DO :
 S:
- Skala nyeri 8
 Keadaan pasien compos mentis
 Nyeri pada bagian kuadran
kanan atas dan dibelakang
tengah
 TTV :
S : 36,3ºC
N : 128x/menit
TD : 100/70mmHg
RR : 22x/menit
 Pemeriksaan palpasi :
- Terdapat pembesaran hepar
- Terdapat nyeri tekan pada
kuadran kanan atas

DS : Sirosis hepatis Resiko Defisit nutrisi

 Pasien mengatakan mual, ↓
 Pasien mengatakan tidak selera Fungsi hati terganggu
makan dan perut terasa begah ↓
Gangguan
pembentukan empedu
DO : ↓
 BB turun 2 Kg Lemak tak dapat
1 diemulasikan dan tidak
 Makan habis posi dapat diserap oleh usus
2
 TTV : hati
S : 36,3ºC ↓
N : 128x/menit Intake kurang karena
TD : 100/70mmHg mual, nafsu makan
RR : 22x/menit menurun, dan nyeri
 BB dan TB abdomen kanan atas
- BB saat ini : 57 Kg ↓
- BB sebelum sakit : 59 Kg BB turun
- TB : 164 cm ↓
Defisit Nutrisi
 LILA : 24 cm
 Lingkar perut : 90 cm
 Bising usus 8x/menit
 Pemeriksaan palpasi :
- Perut kembung

DS: Sirosis hepatis Hipervolemia

- Pasien mengeluh sesak ꜜ
napas,sering kali timbul Sumbatan aliran darah
dimalam hari ke vena kava inferior
- Pasien tidur dengan 2 ꜜ
bantal untuk mengurangi Resistensi pembuluh
sesak napas darah meningkat
- Pasien mengatakan ꜜ
minum 1 1/2 ltr/hari Tekanan sinusoid
DO: meningkat
- JVP (+) ꜜ
- Permukaan abdomen Hipertensi portal
asites ꜜ
- Reflex hepatojugular (+) Tekanan hidrostatik
 - Kadar Hb: 7,8 gr/dl ꜜ
- Pembesaran hepar dan Ekstravasasi
teraba ꜜ
- Hasil USG: Asites
Sirosis hepar ꜜ
Splene Hypervolemia

DAFTAR DIAGNOSA KEPERAWATAN

NAMA PASIEN : Tn. Z

UMUR : 32 Tahun
NO. REGISTER : 0140658

NO TGL MUNCUL DIAGNOSA KEPERAWATAN TGL TERATASI TT

.
1. 31-07-2017 Nyeri akut b.d inflamasi d.d 1 Agustus 2017
mengeluh nyeri, tampak meringis,
nafsu makan berubah nadi
128x/menit

2. 31-07-2017 Hipervolemia b.d gangguan aliran 1 Agustus 2017

balik vena d.d dyspnea, ortopnea,
PND, asites, JVP (+), Refleks
hepatojugular (+)

3. 31-07-2017 Resiko deficit nutrisi d.d 1 Agustus 2017

kengganan untuk makan
 RENCANA ASUHAN KEPERAWATAN

NAMA PASIEN : Tn. Z

UMUR : 32 Tahun
NO. REGISTER : 0140568

TGL NO. DIAGNOSA SLKI SIKI TT

KEPERAWATAN
31-7- 1. Nyeri akut b.d Agen Luaran utama : Tingkat Nyeri
2017 pencedera fisiologis d.d Setelah dilakukan intervensi selama
mengeluh nyeri, bersikap 24 jam, Tingkat nyeri menurun
protektif dengan dengan kriteria hasil:
menghindari nyeri, - Kemampuan menuntaskan
frekuensi nadi aktivitas meningkat
meningkat, pola napas - Keluhan nyeri menurun
berubah. - Sikap protektif menurun
- Gelisah menurun
- Mual menurun
- Frekuensi nadi membaik
- Pola napas membaik
- Nafsu makan membaik
Intervensi utama : Manajemen Nyeri
Observasi :
- Identifikasi lokasi, karakteristik, durasi, frekuensi, kualitas,
dan intensitas nyeri
- Identifikasi skala nyeri
- Identifikasi respon nyeri non verbal
- Identifikasi faktor memperberat dan memperingan nyeri
- Monitor efek samping penggunaan analgetik
Terapeutik :
- Berikan teknik nonfarmakologis untuk mengurangi rasa
nyeri
- Kontrol lingkungan yang memperberat nyeri
- Fasilitasi istirahat dan tidur
- Pertimbangkan jenis dan sumber nyeri dalam pemilihan
strategi meredakan nyeri

Edukasi :
- Jelaskan penyebab, periode, dan pemicu nyeri
- Jelaskan strategi meredakan nyeri
- Anjurkan menggunakan analgetik yang tepat
- Ajarkan teknik nonfarmakologis untuk
- mengurangi nyeri

31-7- 2. Defisit nutrisi b.d Faktor Luaran utama : Status Nutrisi
2017 psikologis d.d berat Setelah dilakukan intervensi selama
badan menurun 10% 24 jam, Status nutrisi membaik
dibawah rentang ideal, dengan kriteria hasil:
nyeri abdomen, nafsu - Porsi makanan yang dihabiskan
makan menurun meningkat
- Verbalisasi keinginan untuk
meningkatkan nutrisi meningkat
- Pengetahuan tentang standart
asupan nutrisi yang tepat
meningkat
- Nyeri abdomen menurun
- Berat badan membaik
- Indeks Masa Tubuh membaik
- Frekuensi makan membaik
- Nafsu makan membaik
Kolaborasi :
Kolaborasi pemberian analgetik
Luaran utama : Manajemen Nutrisi
Obervasi :
- Identifikasi status nutrisi
- Identifikasi makanan yang disukai
- Identifikasi kebutuhan kalori dan jenis nutrien
- Monitor asupan makanan
- Monitor berat badan
- Monitor hasil pemeriksaan laboratorium
Terapeutik :
- Lakukan oral hygiene sebelum makan
- Fasilitasi menentukan pedoman diet
- Sajikan makanan secara menarik dan suhu sesuai
- Berikan makanan tinggi serat untuk mencegah
konstipasi
- Berikan makanan tinggi kalori dan tinggi protein
- Berikan suplemen makanan
Edukasi :
- Anjurkan posisi duduk
- Anjurkan diet yang diprogramkan
Kolaborasi :
- Kolaborasi pemberian medikasi sebelum makan
Kolaborasi dengan ahli gizi untuk menentukan jumlah kalori
dan jenis nutrien yang dibutuhkan.
 CATATAN KEPERAWATAN

NAMA PASIEN : Tn. Z

UMUR : 32 Tahun
NO. REGISTER : 0140568

NO TGL/JAM NO. TINDAKAN TT

DX.
KEP
1. 31 Juli 2017 1.
08.00  Mengidentifikasi lokasi, karakteristik,
durasi, frekuensi, kualitas, intensitas
nyeri
09.00 WIB
 Lokasi : nyeri perut di kanan atas dan
belakang tengah
Frekuensi :Skala 8
Kualitas :
Intensitas Nyeri : 30 menit

 Mengidentifikasi skala nyeri 8

09.15 WIB
 Memonitor keberhasilan terapi
09.30 WIB komplementer yang telah diberikan
 Memfasilitasi istirahat dan tidur agar
pasien terasa nyeri berkurang
10.00 WIB
 Mengajarkan klien tidur dengan posisi
semi fowler untuk mengurangi rasa
11.00 WIB nyeri pada bagian abdomen
 Memberikan analgesic berupa
paracetamol 2x500 mg via oral
12.00 WIB

2. 31 Juli 2017  Mengidentifikasi status nutrisi

13.00 WIB
 Mengidentifikasi alergi dan intoleran
makanan
13.30 WIB
 Mengidentifikasi makanan yang
disukai berupa sayur dan ikan
14.00 WIB
 Mengidentifikasi kebutuhan kalori dan
jenis nutrient untuk kalori dan nutrisi
15.00 WIB pada tubuh terpenuhi

16.00 WIB  Memonitor asupan makanan

SMRS : 2 kali/hari (porsi sedang, jenis
makanan nasi, ikan, sayur)
MRS : 3 kali/hari (habis ½ porsi)

 Memonitor berat badan 57 kg

17.00 WIB
18.00 WIB  Menyajkan makanan secara menarik
untuk nafsu makan meningkat dan
kebutuhan nutrisi terpenuhi

19.00 WIB  Memberikan makanan tinggi kalori

dan tinggi protein untuk BB naik dan
memenuhi BBI

19.30 WIB  Menganjurkan posisi duduk agar

pasien nyaman
 EVALUASI

NAMA PASIEN : Tn. Z

UMUR : 32 Tahun
NO. REGISTER : 0140568

NO. DX TANGGAL TANGGAL TANGGAL TANGGAL

KEP.
Tanggal 31 Juli 2017 Tanggal 1 Agustus 2017
1.
DS : DS :
 P:  P:
2. Pa 3. Pa
sien mengatakan Nyeri sien mengatakan Nyeri
daerah perut, dan Nyeri daerah perut sudah
timbul saat berjalan dan berkurang
berkurang saat posisi  Q:
setengah duduk - Karakteristik nyeri normal
 Q:  R:
- Karakteristik nyeri panas - Nyeri pada perut atas dan
 R: belakang sudah berkurang
- Nyeri pada perut atas dan  T:
belakang - Nyeri sudah jarang timbul
 T: saat pasien berjalan, dan
- Nyeri timbul saat pasien mucul selama 60 menit
berjalan, dan mucul selama keluhan mendadak.
30 menit keluhan
mendadak. DO :
 S:
DO : - Skala nyeri 2
  S:
- Skala nyeri 8
 Keadaan pasien compos
mentis
 Nyeri pada bagian kuadran
kanan atas dan dibelakang
tengah
 TTV :
S : 36,3ºC
N : 128x/menit
TD : 100/70mmHg
RR : 22x/menit
 Pemeriksaan palpasi :
- Terdapat pembesaran hepar
- Terdapat nyeri tekan pada
kuadran kanan atas
- Abdomen asites
A : Nyeri akut belum teratasi
P : Intervensi dilanjutkan ke
pengkajian nyeri secara
komperhensif
 Kesadaran pasien : sadar
penuh
 TTV :
S : 35ºC
N : 90x/menit
TD : 100/70mmHg
RR : 22x/menit
 Pemeriksaan palpasi :
- Sudah tidak terjadi
pembesaran hepar
- Sudah tidak terdapat nyeri
tekan pada kuadran kanan
atas
- Abdomen asites
A : Nyeri akut teratasi
P : Intervensi dipertahankan