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ALAMAT : JLN. Manila No. 37 Sumberece Kota Kediri Telp. (0354) 7009713 Fax. (0354) 695130

Nama Mahasiswa : ………………………………………………...

NIM : …………………………………………………

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Tanggal MRS : 28 April 2018 Jam Masuk :
Tanggal Pengkajian : 1 Mei 2018 No. RM :
Jam Pengkajian : 11:00 Diagnosa Masuk :
Hari rawat ke :3

IDENTITAS
1. Nama Pasien : Tn. H
2. Umur : 42
3. Suku/ Bangsa : Jawa/Indonesia
4. Agama : Islam
5. Pendidikan :
6. Pekerjaan :-
7. Alamat : Jln. Kaliombo raya No.26 , RT/RW 01/02
8. Sumber Biaya :

KELUHAN UTAMA
1. Keluhan utama : Mudah Lelah ,
Aktifitas berat nafas jadi berat ( sesak nafas ) cepat lelah
RIWAYAT PENYAKIT SEKARANG
1. Riwayat Penyakit Sekarang : Gagal jantung

2. RIWAYAT PENYAKIT DAHULU

1. Pernah dirawat : ya tidak kapan : 2016 dan 2018 diagnosa :
2. Riwayat penyakit kronik dan menular ya tidak jenis……………………
Riwayat kontrol : Rutin setiap bulan
Riwayat penggunaan obat :...
3. Riwayat alergi:
4. Obat ya tidak jenis……………………
Makanan ya tidak jenis……………………
Lain-lain ya tidak jenis……………………

5. Riwayat operasi: ya tidak

- Kapan : ……………………
- Jenis operasi : ……………………

6. Lain-lain:
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis :………………….....................................................................................................................................
- Genogram :

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

OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda tanda vital
S : 360C N: T: RR :
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma

2. Sistem Pernafasan (B1)

a. RR: 20 x/menit
b. Keluhan: sesak nyeri waktu nafas orthopnea
Batuk produktif tidak produktif
Sekret:…….. Konsistensi :......................
Warna:.......... Bau :.................................. Masalah Keperawatan :
c. Penggunaan otot bantu nafas:
d. ...................................................................................................................................................................
..................................................................................................................................................................
e. PCH ya tidak
f. Irama nafas teratur tidak teratur
g. Pleural Friction rub:.....................................................................................................................
h. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot
i. Suara nafas Cracles Ronki Wheezing
j. Alat bantu napas ya tidak

Jenis................ ................................ Flow..............lpm

k. Penggunaan WSD:
- Jenis : .................................................................................................................................................................
- Jumlah cairan : ..................................................................................................................................................
- Undulasi :...................................................................................................................................................
- Tekanan : ..................................................................................................................................................
-
l. Tracheostomy: ya tidak
..................................................................................................................................................................................
..................................................................................................................................................................................
m. Lain-lain:
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................

3. Sistem Kardio vaskuler (B2)

a. TD :120/80 mmhg Masalah Keperawatan :
b. N : 72 x/menit
c. Keluhan nyeri dada: ya tidak
P :...................................................................
Q :...................................................................
R :.................... ...............................................
S :...................................................................
T :...................................................................
d. Irama jantung: reguler ireguler
e. Suara jantung: normal (S1/S2 tunggal) murmur
gallop lain-lain.....
f. Ictus Cordis: .............................................................................................................................................................
g. CRT :.............detik
h. Akral: hangat kering merah basah pucat
panas dingin
i. Sikulasi perifer: normal menurun
j. JVP :.................................
k. CVP :.................................
l. CTR :.................................
m. ECG & Interpretasinya:

STIKes Surya Mitra Husada Kediri

 ..................................................................................................................................................................................
..................................................................................................................................................................................
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n. Lain-lain :
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..........................................................................

4. Sistem Persyarafan (B3)

a. GCS : .................................................. Masalah Keperawatan :
b. Refleks fisiologis patella triceps biceps
c. Refleks patologis babinsky brudzinsky kernig
d. Lain-lain
e. Keluhan pusing ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................

f. 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.: ……..............................................................

g. Pupil anisokor isokor Diameter: ……/......

h. Sclera anikterus ikterus
i. Konjunctiva ananemis anemis
j. Isitrahat/Tidur :................. Jam/Hari Gangguan tidur : ..............................................................
k. Lain-lain:
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5. Sistem perkemihan (B4)

Masalah Keperawatan
a. Kebersihan genetalia: Bersih Kotor
b. Sekret: Ada Tidak
c. Ulkus: Ada Tidak
d. Kebersihan meatus uretra: Bersih Kotor
e. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
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f. Kemampuan berkemih:

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 Spontan Alat bantu, sebutkan: .................................................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
g. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
h. Kandung kemih : Membesar ya tidak
i. Nyeri tekan ya tidak
j. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
k. Balance cairan:
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
l. Lain-lain:
..................................................................................................................................................................................
..................................................................................................................................................................................
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6. Sistem pencernaan (B5) Masalah Keperawatan :
a. TB :............... BB :................................
b. IMT :............... Interpretasi :................................
c.
d. Mulut: bersih kotor berbau
e. Membran mukosa: lembab kering stomatitis
f. Tenggorokan:
sakit menelan kesulitan menelan
pembesaran tonsil nyeri tekan
g. Abdomen: tegang kembung ascites
h. Nyeri tekan: ya tidak
i. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :....... ............
j. Peristaltik:.............. x/menit
k. BAB: 2 x/hari Terakhir tanggal : ............................................................................
l. Konsistensi: keras lunak cair lendir/darah
m. Diet: padat lunak cair
n. Diet Khusus:
o. ...................................................................................................................................................................
...................................................................................................................................................................
p. Nafsu makan: baik menurun Frekuensi:.......x/hari
q. Porsi makan: habis tidak Keterangan:.......................
r. Lain-lain:
..................................................................................................................................................................................
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7. Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Visus
Palpebra

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 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 :
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 :................

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 Keadaan :................
e. Alat bantu dengar: .........................
f. Lain-lain :
..................................................................................................................................................................................
..................................................................................................................................................................................
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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 :................
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
Sepenuhnya Ringan Gangguan
Kelembaban Terus Menerus Sangat Lembab Kadang2 Basah Jarang Basah
Basah
Aktifitas Bedfast Chairfast Kadang2 Jalan Lebih Sering
jalan
Mobilisasi Immobile Sangat Terbatas Keterbatasan Tidak Ada
Sepenuhnya Ringan Keterbatasan
Nutrisi Sangat Buruk Kemungkinan Adekuat Sangat Baik
Tidak Adekuat
Gesekan & Bermasalah Potensial Tidak
Pergeseran Bermasalah Menimbulkan
Masalah
NOTE: Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien beresiko Total Nilai

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 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 :
- 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:
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................

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PERSONAL HYGIENE & KEBIASAAN
Masalah Keperawatan :
Jelaskan :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................
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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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DATA TAMBAHAN LAIN :

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Kediri, ……………..20...

(……………………………)

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ANALISIS DATA

Hari/
DATA ETIOLOGI MASALAH
Tgl/ Jam
1 DS : Penurunan volume paru Ketidakefektifan pola
- Pasien mengatakan mengalami nafas
sesak nafas,
- Pasien mengatakan pusing
- Pasien mengatakan badan terasa
lemas

DO :
- Keadaan umum lemah
- TTV
TTD : 153/80 mmHg, RR : 28
kali/menit
- Mukosa bibir pucat
- Pasien tampak gelisah

2 DS : Gangguan volume sekuncup Penurunan curah

jantung
- Pasien mengatakan mengalami
sesak nafas, tidak berkurang
walaupun saat istirahat
- Pasien mengatakan badan terasa
lemas
DO :
- Keadaan umum lemah
- TTV
TD : 153/80 mmHg
RR: 28 kali/menit
N : 80 kali/menit,
S : 37 0 oC

3 DS :
- Pasien mengatakan nyeri Iskemia jaringan jantung Nyeri akut
dibagian dada kiri dan menjalar
ke perut bagian atas
DO :
- TTV
TD :153/80 mmHg,
RR : 28 kali/menit
N : 80 kali/mnt,
S : 37 oC A
- EKG tidak ada ST elevasi
- Perut tidak simetris

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DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

TANGGAL: .................................
1. Ketidakefektifan pola nafas berhubungan dengan penurunan volume paru

2. Penurunan curah jantung berhubungan dengan gangguan volume sekuncup

3. Nyeri akut berhubungan dengan iskemia jaringan jantung

4.

5.

6.

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 RENCANA INTERVENSI

Hari/ Tgl/ NOC NIC

No. DIAGNOSA KEPERAWATAN
Jam (Nursing Outcome Classification) (Nursing Intervention Classification)
1 Ketidakefektifan pola nafas
berhubungah dengan
penurunan volume paru

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 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

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

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