Pedoman Preklinik

Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

LAMPIRAN
KEPERAWATAN MEDIKAL BEDAH
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Lampiran

KEPERAWATAN MEDIKAL BEDAH

PROGRAM STUDI NERS TA S1 KEPERAWATAN
STIKES TRI MANDIRI SAKTI BENGKULU

FORMAT PENGKAJIAN

Nama Mahasiswa : Tanggal praktek :

Nomor NPM : Tempat praktek :

1. Data Biografi
Identitas Klien:
Nama : ………………….. No Register : ……………….
Umur : …………………..
Suku/ bangsa : …………………..
Status perkawinan : …………………..
Agama : …………………..
Pendidikan : ..............................
Pekerjaan : ..............................
Alamat : ..............................
Tanggal masuk RS : ..............................
Tanggal pengkajian : ..............................
Catatan kedatangan : Kursi roda ( ), Ambulans ( ), Brankar ( )

Keluarga Terdekat yang dapat dihubungi :

Nama/ Umur : ............................. No Telepon : .........................
Pendidikan : .............................
Pekerjaan : .............................
Alamat : .............................
Sumber informasi : .............................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

2. Riwayat Kesehatan/ Keperawatan

1) Keluhan utama/ alasan masuk RS :
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
.......................................................................................................................
2) Riwayat kesehatan sekarang :
Faktor
pencetus : ........................................................................................................
.........................................................................................................................
.........................................................................................................................
................
Sifat keluhan (mendadak/perlahan- lahan/ terus menerus/ hilang timbul
atau berhubungan dengan
waktu) : ..........................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
..............
Lokalisasi dan sifatnya (menjalar/ menyebar/ berpindah- pindah/
menetap):
........................................................................................................................
........................................................................................................................
.......................................................................................................................
Berat ringannya keluhan (menetap/ cenderung bertambah atau berkurang) :
........................................................................................................................
........................................................................................................................
........................................................................................................................
Lamanya
keluhan : ........................................................................................................
................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

........................................................................................................................
........................................................................................................................
Upaya yang telah dilakukan untuk
mengatasi : ....................................................................................................
....................
........................................................................................................................
........................................................................................................................
Keluhan saat pengkajian :
……………………………………………………………............................
..............
………………………………………………………………………………
……......
………………………………………………………………………………
……….……………………………………………….
Diagnosa medik :
......................................... Tanggal .......................................
..........................................Tanggal ........................................

3) Riwayat Kesehatan Dahulu

Penyakit yang pernah dialami (jenis penyakit, lama dan upaya untuk
mengatasi, riwayat masuk
RS) : ..............................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
.........
Alergi : ..........................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
..............
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Obat- obatan Dosis Dosis terakhir Frekuensi

(Resep/ obat
bebas)

4) Riwayat Kesehatan Keluarga :

Penyakit menular atau keturunan dalam
keluarga : .......................................................................................................
........................................................................................................................
........................................................................................................................
................. ......................................................................................................
..................

3. Pola Fungsi Kesehatan (Gordon) :

1) Pola persepsi dan pemeliharaan kesehatan
Persepsi terhadap penyakit
:.......................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Penggunaan :
Tembakau (bungkus/ hari, pipa, cerutu, berapa lama, kapan
berhenti) : ......................................................................................................
..................
Alkohol (jenis,
jumlah/hari/minggu/bulan) : ..........................................................................
..............................................
Alergi (obat-obatan, makanan, plester, dll) :
........................................................................................................................
Reaksi alergi
........................................................................................................................
2) Pola nutrisi dan metabolisme
Diet/ suplemen khusus :
........................................................................................................................
Instruksi diet sebelumnya :
........................................................................................................................
Nafsu makan (normal, meningkat, menurun) :
........................................................................................................................
Penurunan sensasi kecap, mual-muntah, stomatitis : ............................... cc
........................................................................................................................
........................................................................................................................
Fluktuasi BB 6 bulan terakhir (naik/
turun) : ...........................................................................................................
.............
........................................................................................................................
........................................................................................................................
Kesulitan menelan (disfagia) : ......................................................................
Gigi (lengkap/ tidak, gigi palsu) : .................................................................
Riwayat masalah kulit/ penyembuhan (ruam, kering, keringat berlebihan,
penyembuhan
abnormal : ......................................................................................................
.............
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

........................................................................................................................
........................................................................................................................
Jumlah minum/ 24 jam dan jenis (kehausan yang
sangat) ...........................................................................................................
.............
........................................................................................................................
........................................................................................................................
Frekuensi makan : .........................................................................................
Jenis makanan : .............................................................................................
Pantangan/ alergi : .........................................................................................
Lain- lain : .....................................................................................................
3) Pola Eliminasi
Buang air besar (BAB) :
Frekuensi : .................. Waktu :........................
Warna : .................. Konsistensi : .......................
Kesulitan (diare, konstipasi, inkontinensia) :
........................................................................................................................
........................................................................................................................
........................................................................................................................
Buang air kecil (BAK) :
Frekuensi : ..................... Warna : ...................................
Kesulitan (disuria, nokturia, hematuria, retensi,
inkontinensia) : ..................................................................................
..........................
Alat bantu (kateter intermitten, indweling, kateter
eksternal) : .........................................................................................
...................
Lain- lain : ...................................................................................................
4) Pola aktivitas dan latihan
Kemampuan perawatan diri :
0 = Mandiri 3 = Dibantu orang lain dan peralatan
1 = Dengan alat bantu 4 = Ketergantungan/ tidak mampu
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

2 = Dibantu orang lain

Kegiatan/ aktivitas 0 1 2 3 4
Makan/ minum
Mandi
Berpakaian/ berdandan
Toileting
Mobilisasi ditempat tidur
Berpindah
Berjalan
Menaiki tangga
Berbelanja
Memasak
Pemeliharaan rumah

Alat bantu (kruk, pispot, tongkat, kursi roda) : .............................................

Kekuatan otot : ..............................................................................................
Kemampuan ROM :.......................................................................................
Keluhan saat beraktivitas : ............................................................................
Lain- lain : ....................................................................................................

5) Pola istirahat dan tidur

Lama tidur : .................. jam/ malam ................. tidur siang ...........
tidur sore
Waktu : .........................................................................................................
Kebiasaan menjelang tidur :
........................................................................................................................
Masalah tidur (insomnia, terbangun dini, mimpi buruk) :
........................................................................................................................
Lain- lain (merasa segar/ tidak setelah bangun) :
........................................................................................................................

6) Pola kognitif dan persepsi

 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Status mental (sadar/ tidak, orientasi baik/ tidak) :

........................................................................................................................
Bicara : Normal ( ), tak jelas ( ), gagap ( ), aphasia ekspresif ( )
Kemampuan berkomunikasi : Ya ( ), Tidak ( )
Kemampuan memahami : Ya ( ), Tidak ( )
Tingkat ansietas : Ringan ( ), Sedang ( ), berat ( ), panik ( )
Pendengaran : DBN ( ), tuli ( ) kanan/ kiri, tinitus ( ), alat bantu
dengar ( )
Penglihatan (DBN, buta, katarak, kacamata, lensa kontak, dll) :..................
Vertigo : ........................................................................................................
Ketidaknyamanan/ nyeri (akut/ kronik) :
........................................................................................................................
........................................................................................................................
........................................................................................................................
Penatalaksanaan nyeri : .................................................................................
Lain- lain : .....................................................................................................

7) Persepsi diri dan konsep diri

Perasaan klien tentang masalah kesehatan ini :
........................................................................................................................
Lain- lain :
........................................................................................................................

8) Pola peran hubungan

Pekerjaan : .....................................................................................................
Sistem pendukung : pasangan ( ), tetangga/ teman ( ), tidak ada ( ),
keluarga serumah ( ), keluarga tinggal berjauhan ( )
Masalah keluarga berkenaan dengan perawatan di
RS : ................................................................................................................
........ ...............................................................................................................
.........
Kegiatan sosial : ............................................................................................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

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

9) Pola seksual dan reproduksi

Tanggal menstruasi akhir (TMA) : ...............................................................
Masalah menstruasi : ....................................................................................
Pap Smear terakhir : ......................................................................................
Masalah seksual b.d penyakit : .....................................................................
Lain- lain : .....................................................................................................

10) Pola koping dan toleransi stress

Perhatian utama tentang perawatan di RS atau penyakit (finansial,
perawatan
diri) : ..............................................................................................................
.......... .............................................................................................................
...........
Kehilangan/ perubahan besar dimasa lalu :
........................................................................................................................
Hal yang dilakukan saat ada masalah (sumber koping) :
........................................................................................................................
Penggunaan obat untuk menghilangkan stress :
........................................................................................................................
Keadaan emosi dalam sehari- hari (santai/ tegang) :
........................................................................................................................
Lain- lain :
........................................................................................................................

11) Keyakinan dan kepercayaan

Agama : .........................................................................................................
..............
Pengaruh agama dalam kehidupan :
........................................................................................................................
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

........................................................................................................................
........................................................................................................................
4. Pemeriksaan Fisik :
1) Keadaan umum :
Penampilan umum :
........................................................................................................................
Klien tampak sehat/ sakit/ sakit berat :
........................................................................................................................
Kesadaran : ....................................... GCS ......................
BB : ................... Kg
TB : ................... cm
2) Tanda- tanda vital :
TD : ..................... mmHg
ND : ..................... x/menit
RR : ..................... x/menit
S : ..................... oC
3) Kulit
Warna kulit (sianosis, ikterus, pucat, eritema, dll) :
........................................................................................................................
Kelembapan : ................................................................................................
........................
Turgor kulit :
........................................................................................................................
Ada/tidaknya oedema :
........................................................................................................................
4) Kepala/ rambut
Inspeksi : ............................................................................................
Palpasi : .............................................................................................
5) Mata
Fungsi penglihatan : ....................................... Palpebra : terbuka /
tertutup
Ukuran pupil : .............................................. Isokor / an isokor
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Konjungtiva : .............................................. Sklera : .................

Lensa / iris : ............................................................................................
Oedema palpebra : .......................................................................................
6) Telinga
Fungsi pendengaran : ................................. Fungsi keseimbangan ...........
Kebersihan : ................................. Sekret ....................................
Daun telinga : ................................. Mastoid .................................
7) Hidung dan sinus
Inspeksi : ................................................................................
Fungsi penciuman : .................................................................................
Pembengkakan : ...................................... perdarahan : .....................
Kebersihan : ......................................sekret : ..............................
8) Mulut dan tenggorok
Membran mukosa : ........................................................................................
kebersihan mulut ...........................................................................................
Keadaan gigi : ...............................................................................................
Tanda radang (bibir, gusi, lidah) : ................................................................
Trismus : .......................................................................................................
Kesulitan menelan : ......................................................................................
9) Leher
Trakea (simetris/ tidak) : ...............................................................................
Karotid bruit : ...............................................................................................
JVP : .............................................................................................................
Kelenjar limfe : ............................................................................................
Kelenjar tiroid : ............................................................................................
Kaku kuduk : ................................................................................................
10) Thorak / paru
Inspeksi : .............................................................................................
Palpasi : .............................................................................................
Perkusi : .............................................................................................
Auskultasi : ............................................................................................
11) Jantung
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Inspeksi : .............................................................................................
Palpasi : .............................................................................................
Perkusi : ............................................................................................
Auskultasi : ............................................................................................
12) Abdomen
Inspeksi : .............................................................................................
Auskultasi : .............................................................................................
Perkusi : .............................................................................................
Palpasi : .............................................................................................
13) Genetalia : ..............................................................................................
14) Rektal : .............................................................................................
15) Ekstremitas
Ekstremitas atas : ..........................................................................................
Ekstremitas bawah : ......................................................................................
ROM : ..........................................................................................................
Kekuatan otot : .............................................................................................
16) Vaskular perifer
Capilary Refille : .................................................................................
Clubbing : .................................................................................
Perubahan warna (kuku, kulit, bibir) : .........................................................
17) Neurologis
Kesadaran (GCS) : ......................................................................................
Status mental : .............................................................................................
Motorik (kejang, tremor, parese dan paralisis) : ..........................................
Sensorik : ………………………..............................................……………
Tanda rangsang meningeal : ....................................................................
Saraf kranial : ...............................................................................................
Reflek fisiologis : ……………………………………….........................…
Reflek patologis : ………………….............................................................

5. Pemeriksaan Penunjang
(dibuat setiap dilakukan pemeriksaan berdasarkan tanggal dilakukan)
Pemeriksaan diagnostik
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

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Pemeriksaan laboratorium
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6. Penatalaksanaan Pengobatan
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 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

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FORMAT
ANALISA DATA

Nama Pasien : Ruang :

Diagnosa Medis : No. RM :

No Data Etiologi Masalah

 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Lampiran
FORMAT
NURSING CARE PLANNING

Nama Pasien : Ruang :

Diagnosa Medis : No. RM :
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

No Diagnosa Kode SLKI Kode SIKI

Keperawatan
1. Diagnosa: Score
Skala 1 2 3 4 5
outcome
keselurahan

DS :

DO:

2.

Lampiran

FORMAT
CATATAN PERKEMBANGAN
(diisi setiap hari)

Nama Pasien : Ruang :

 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Diagnosa Medis : No. RM :

No Diagnosa Hari/tanggal Jam Implementasi Evaluasi Paraf

Keperawatan
1. S:

O:

A:

P:

2.
3.

Lampiran

FORMAT PENILAIAN
LAPORAN

MAHASISWA
KOMPONEN YANG DINILAI
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

A. LAPORAN PENDAHULUAN (10)

1. Definisi dan Etiologi (0-2)
2. Kelengkapan patofisiologi dan pemeriksaan
penunjang (0-2)
3. Kelengkapan diagnosa awal (0-3)
4. Kelengkapan tindakan keperawatan (0-3)

B. RENCANA KEPERAWATAN
I. Pengkajian (10)
1. Mengumpulkan riwayat keperawatan (0-3)
2. Mengumpulkan data hasil pemeriksaan fisik
(0-4)
3. Mengumpulkan data hasil pemeriksaan
penunjang (0-3)

II. Diagnosa Keperawatan (10)

1. Mengidentifikasi masalah yang potensial dan
actual (0-4)
2. Menetapkan prioritas (0-3)
3. Menetapkan tujuan dan kriteria yang SMART
(0-3)

III. Tindakan Keperawatan (10)

1. Rencana tindakan sesuai dengan diagnosa
keperawatan (0-5)
2. Membuat pencatatan tindakan keperawatan
secara benar (0-5)

IV. Evaluasi (10)

1. Melakukan evaluasi SOAP setiap hari sesuai
diagnosa (0-5)
2. Memodifikasi rencana sesuai evaluasi (0-5)

NILAI TOTAL
NILAI AKHIR = NILAI TOTAL X 2

Lampiran

FORMAT EVALUASI KINERJA KLINIK

NAMA MAHASISWA
KOMPONEN YANG DINILAI
A. KOMUNIKASI (10)
 Pedoman Preklinik
Ilmu Keperawatan
STIKES Tri Mandiri Sakti Bengkulu

Mahasiswa menunjukkan kemampuan :

1. Menciptakan interaksi dengan klien dengan
penuh percaya diri (0-4)
2. Menggunakan komunikasi verbal yang
efektif (0-3)
3. Melakukan dokumentasi secara benar (0-3)

B. KETERAMPILAN DASAR (25)

Mahasiswa menunjukkan kemampuan :
1. Melakukan pengkajian awal (wawancara dan
pemeriksaan fisik) (0-5)
2. Melakukan tindakan yang sudah
direncanakan (0-5)
3. Melakukan tindakan pencegahan terhadap
infeksi (0-5)
4. Menciptakan keamanan dan kenyamanan (0-
5)
5. Memberikan pendidikan kesehatan (0-5)

C. PERILAKU PROFESIONAL (15)

Mahasiswa menunjukkan kemampuan :
1. Menampilkan sikap baik dan sopan (0-3)
2. Melaksanakan kontrak dengan pasien (0-3)
3. Mengambil inisiatif dalam situasi belajar
4. Memperlihatkan sikap selalu tepat waktu (0-
3)
5. Bekerjasama dan berpartisipasi dalam
kegiatan ruangan (0-3)

NILAI TOTAL

NILAI AKHIR = NILAI TOTAL X 2

PENILAI :