FORMAT PENGKAJIAN KEPERAWATAN INTERNA

Nama Ruangan : Ruang Interna

Tanggal MRS : 21 November 2022 Jam Masuk : 21.24 WIB

Tanggal Pengkajian : 24 November 2022 No. RM : 506135
Jam Pengkajian : 15.40 WIB Diagnosa Masuk : Hemoroid Interna gr 2 , AML
Hari rawat ke :4

IDENTITAS
1. Nama Pasien : Sdr A
2. Umur : 21 Th
3. Suku/ Bangsa : Indonesia
4. Agama : Islam
5. Pendidikan : SD Sedrajat
6. Pekerjaan : Wiraswasta
7. Alamat : Srono
8. Sumber Biaya :

Biodata Penanggungjawab
a. Nama : Ismail
b. Umur : 53 Th
c. Jenis Kelamin : Laki - Laki
d. Agama : Islam
e. Pekerjaan : Wiraswasta
f. Pendidikan : SD Sedrajat
g. Status Perkawinan : Kawin
h. Suku Bangsa : Indonesia
i. Alamat : Srono

KELUHAN UTAMA
1. Keluhan saat pengkajian:
Nyeri Dubur
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………

RIWAYAT PENYAKIT SEKARANG

1. Riwayat Penyakit Sekarang:
Keluar benjolan dari dubur sejak 1 minggu yang lalu, benjolan bisa keluar masuk, nyeri saat BAB, Tidak ada darah saat
BAB, Badan panas disertai mimisan sejak tadi sore.
...........................................................................................................................................................................................
…………………………………………………………………………………………………………….......................
...........................................................................................................................................................................................
RIWAYAT PENYAKIT DAHULU
1. Pernah dirawat : ya tidak
kapan : 1 Th yang lalu diagnosa : AML
2. Riwayat penyakit kronik dan menular : ya tidak jenis……………………
Riwayat kontrol : .............................
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
- Penyakit Keturunan : DM dari Ibu, CA Mamae adiknya bapak
- Penyakit Menular :-
- Genogram :

PERILAKU YANG MEMPENGARUHI KESEHATAN

Perilaku sebelum sakit yang mempengaruhi kesehatan:
Alkoholyatidakketerangan…………………….........................................................
Merokokyatidakketerangan…………………….........................................................
ObatAdiktif yatidakketerangan…..............................................................………………
Olahragayatidakketerangan…..........................................................…………………

OBSERVASI DAN PEMERIKSAAN FISIK

1.Tanda tanda vital
BP 110/70 mmHg P :......86...x/menitT : 36,5..o CRR 20 x/menit Tingkat nyeri 3
Kesadaran:Compos MentisApatisSomnolenSoporKoma
2. Sistem Pernafasan (B1)
a. RR:..20..x / menit  Normal Bradipnea Takipnea
b. Keluhan: sesak nyeri waktu nafas orthopnea
Batuk produktif tidak produktif
Sekret:…….. Konsistensi :......................
Warna:.......... Bau :..................................
c. Bentuk dada :  Normal chest  Barrel chest  Pigeon chest  Funnel chest
d. Penggunaan otot bantu nafas:
..................................................................................................................................................................................
..................................................................................................................................................................................
e. Pernapasan cuping hidung : ya tidak
f. Irama nafas Reguler Irreguler
g. Pleural FrictionRub:.....................................................................................................................
h. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot
i. Suara nafas tambahan Cracles Ronki Wheezing Masalah Keperawatan :
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 Kardiovaskuler (B2)

a. BP : 110/70 mmHg Masalah Keperawatan :
b. P : 86 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. IctusCordis: .................................................................................................................................. ...........................
g. CRT< 3 detik
h. Akral: hangat kering merah basah pucat
panas dingin
i. Sikulasi perifer: normal menurun
j. JVP :.................................
k. CVP :.................................
l. CTR :................................. Rumus CTR = A+B < ½ ( < 50%)
C
m. ECG & Interpretasinya:
Irama: ...................................................................................................................................................................
HeartRate: ..............................................................................................................................................................
AXIS:........................................................................................................................................................................
Isekmik/Infarct:........................................................................................................................................................
Hipertrophy(Atrium/Ventrikel):...............................................................................................................................
Elektrolit(Hipokalemia/Hiperkalemia):....................................................................................................................
Kesimpulan:..............................................................................................................................................................
n. Lain-lain :
..................................................................................................................................................................................
............................................................................................................................................ ......................................
..................................................................................................................................................................................

4. Sistem Persyarafan (B3)

a. GCS : ................................... E: …… V: ….. M : …….
b. Refleks fisiologis : patella triceps biceps  radius ulna
c. Refleks patologis : babinsky brudzinsky kernig Lain-lain
d. Keluhan pusing : ya tidak
P :................................................................... Masalah Keperawatan :
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................

e. Kejang : ya tidak
Jenis kejang : .............................
f. Kaku : ya tidak
kuduk
g. 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.: ……..............................................................

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

i. Sclera anikterus ikterus
j. Konjunctiva ananemis anemis
k. Isitrahat/Tidur :................. Jam/Hari Gangguan tidur : ..............................................................
l. Lain-lain:
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................

5. Sistem perkemihan (B4)

Masalah Keperawatan
a. Kebersihan genetalia: Bersih Kotor
b. Pus: Ada Tidak
c. Ulkus: Ada Tidak
d. Kebersihanmeatus uretra: Bersih Kotor
e. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
..................................................................................................................................................................................
..................................................................................................................................................................................
................................................................................................................................................ ..................................
f. Kemampuan berkemih:
Spontan Alat bantu, sebutkan: .................................................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
g. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
h. Kandung kemih : Distensi ya tidak
i. Nyeri tekan VU ya tidak
j. Intake cairan oral : ……… cc/hari parenteral................cc/hari
k. Balance cairan:Rumus: Balance cairan = Intake cairan – Output Cairan
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
m. Lain-lain:
..................................................................................................................................................................................
............................................................................................................................................................ ......................
..................................................................................................................................................................................
6. Sistem pencernaan (B5)
a. TB :............... BB :................................ Masalah Keperawatan :
b. IMT :............... Interpretasi :................................

c. Mulut: bersih kotor berbau

d. Membran mukosa: lembab kering stomatitis
e. Tenggorokan:
sakit menelan kesulitan menelan
pembesaran tonsil nyeri tekan
f. Abdomen: Distensi hipertimpani timpani 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................x/menit
j. BAB: ......................x/hari Terakhir tanggal : ...........................
Konsistensi: keras lunak cair lendir/darah
k. Diet: padat lunak cair
l. Diet Khusus:
..................................................................................................................................................................................
..................................................................................................................................................................................
m. Nafsu makan: baik menurun Frekuensi:......x/hari
n. Porsi makan: habis tidak Keterangan:.......................
o. Lain-lain:
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
7. Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
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 :................
e. Penggunaan alat bantu penglihatan : ………….
f. Lain-lain :
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................

8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
......... Aurcicula .........
......... MAE .........
......... Membran .........
......... Tymphani .........
......... Rinne .........
......... Weber .........
 ......... Swabach .........

b. Keluhan nyeri ya tidak

P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
c. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
e. Alat bantu dengar :................
f. Lain-lain :
.................................................................................................................................................................. ................
..................................................................................................................................................................................
..................................................................................................................................................................................
8. Sistem muskuloskeletal (B6) Masalah Keperawatan :
a. Pergerakan sendi: bebas terbatas
b. Kekuatan otot:

c. Kelainan ekstremitas: ya tidak

Jika Ya : ..............
d. Kelainan tulang belakang: ya tidak
Jenis: Lordosis Kifosis  Skoliosis
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. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
l. ROM : .................................................

m. Cardinal Sign : ................................................

 n. Skor Risiko Jatuh (MORSE):
No Pengkajian Nilai
Skala
1 Riwayat jatuh : apakah pasien pernah jatuh dalam 3 bulan terakhir. Tidak 0 0
Ya 25

2 Diagnosa sekunder : Apakah pasien memiliki lebih dari satu penyakit. Tidak 0 15

Ya 15
3 Alat Bantu jalan : 0 0
Bedrest / dibantu perawat
Kruk / tongkat / walker. 15
Berpegangan pada benda – benda sekitar. 30
(Kursi, lemari, meja).
4 Terapi intravena : Apakah saat ini pasien terpasang infus. Tidak 0 20

Ya 20

5 Gaya Berjalan / cara Berpindah: 0 0

Normal / Bedrest / immobile (tidak dapat bergerak sendiri)
Lemah tidak bertenaga. 10
Gangguan atau tidak normal (pincang atau diseret). 20
6 Status mental: 0 15
Lansia menyadari kondisi dirinya.
Lansia mengalami keterbatasan daya ingat. 15

Total skor 50

Keterangan:
Tingkatan Resiko Nilai MPS Tindakan
Tidak Beresiko 0 - 24 Perawatan Dasar
Resiko Rendah 25 - 50 Pelaksanaan Intervensi Pencegahan Jatuh Standar.
Resiko Tinggi ≥51 Pelaksanaan Intervensi Pencegahan Jatuh resiko tinggi

o. Lain-lain:
..................................................................................................................................................................................
.................................................................................................................................. ................................................
..................................................................................................................................................................................

10. Sistem Integumen

a. Penilaian resikodecubitus
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
mengalami dekubisus(pressureulcers)
(15 or 16 = lowrisk, 13 or 14 = moderaterisk, 12 orless = highrisk)
b. Warna kulit:........................................
c. Pittingedema: +/- grade:................ Masalah Keperawatan :
d. Ekskoriasis: ya tidak
e. Psoriasis: ya tidak
f. Pruritus: ya tidak
g. Urtikaria: ya tidak
h. Kulit: Ikterik Sianosis Kemerahan Hiperpigmentasi
i. Turgor Baik Kurang Jelek
 j. 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 score: ........................................................

Rumus

Gambar

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. Konsep diri (pengkajian psikososial):
Harga Diri  Ideal Diri  Citra Diri  Peran Diri  Identitas
Diri Jelaskan :
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................

e. Lain-lain:
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
PERSONAL HYGIENE & KEBIASAAN
MasalahKeperawatan :
Frekuensi Mandi : x sehari
Frekuensi Mencuci rambut : x seminggu
Frekuensi gosok gigi : x sehari
Frekuensigantibaju : x sehari
Dibantu :  Ya  Tidak Jika Ya :  Total  Parsial
Lain-lain :
................................................................................................................................................................................................
........................................................................................................................................................................................... ....

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 atau pemeriksaan penunjang lainnya)

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

PENATALAKSANAAN (hari kelolaan beserta tanggalnya)

................................................................................................................................................................................................
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Banyuwangi, ……………........20....

(……………………………)
 ANALISIS DATA

Hari/
DATA ETIOLOGI MASALAH
Tgl/ Jam
 DAFTAR PRIORITAS DIAGNOSIS KEPERAWATAN

TANGGAL: .................................
No. Diagnosis Keperawatan Kode Tanggal Teratasi Ttd

1.

2.

3.

4.

5.

6
 RENCANA INTERVENSI

Hari/ Tgl/ DIAGNOSIS KEPERAWATAN

No. Kode SLKI Kode SIKI
Jam (SDKI)
 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

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