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YAYASAN EKA HARAP PALANGKA RAYA SEKOLAH TINGGI ILMU KESEHATAN PROGRAM STUDI S1 KEPERAWATAN Jalan Beliang No.110 Palangka Palangka Raya Telp/Fax. Telp/Fax. (0536) 3327707 FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Ma Mahasiswa NIM Ruang Praktek Tanggal Pr Praktek Tanggal Tanggal & Jam Pengkajian Pengkajian

: …… ………………………………………………………. : ………………………………………………………. : ………………………………………………………. : …… ………………………………………………………. : ……………………… ………………………………… …………………… ……………………. ………….

I. PENGKAJIAN A. IDENTITAS PASIEN Nama : …………………………………………………………….. Umur : …………………………………………………………….. Jenis Kelamin : …………………………………………………………….. Suku/Bangsa : …………………………………………………………….. Agama : …………………………………………………………….. Pekerjaan : …………………………………………………………….. Pendidikan : …………………………………………………………….. Status Perkawinan : ………………………………… …………………………………………………………….. ………………………….. Alamat : ………………………………… …………………………………………………………….. ………………………….. Tgl MRS : ………………………………… …………………………………………………………….. ………………………….. Diagnosa Medis : ………………………………… …………………………………………………………….. ………………………….. B. 1.

2.

RIWAYAT KESEHATAN /PERAWATAN Keluhan Utama : ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… Riwayat Penyakit Sekarang: ................................................................................................................................................................... ... ……… ................................................................................................................................................................... ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ………

3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi) ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… 4. Riwayat Penyakit Keluarga ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ……… ................................................................................................................................................................... ....................................................................................... ............................................................................ ... ………

GENOGRAM KELUARGA:

1 Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA. 2012/2013 2012/2013


C. 1.

2.

PEMERIKASAAN FISIK Keadaan Umum: ................................................................................................................................................................... ... ……… ................................................................................................................................................................... ... ……… ................................................................................................................................................................... ... ……… ................................................................................................................................................................... ... ……… Status Mental : a. Tingkat Kesadaran : …………………. b. Ekspresi wajah : …………………. c. Bentuk badan : …………………. d. Cara berbaring/bergerak : …………………. e. Berbicara : …………………. f. Suasana hati : …………………. g. Penampilan : …………………. h. Fungsi kognitif : Orientasi waktu : …………………. Orientasi Orang : …………………. Orientasi Tempat : …………………. i. Halusinasi :  Dengar/Akustic  Lihat/Visual  Lainnya ........................................................... j. Proses berpikir :  Blocking  Circumstansial  Flight oh ideas  Lainnya k. Insight :  Baik  Mengingkari  Menyalahkan orang lain m. Mekanisme pertahanan diri :  Adaptif  Maladaptif n. Keluhan lainnya : …………………. • • •

3. Tanda-tanda Vital : a. Suhu/T b. Nadi/HR c. Pernapasan/RR d. Tekanan Darah/BP

: ………………. 0C  Axilla : ………………x/mt : …..…………..x/tm : ……...………..mm Hg

4. PERNAPASAN (BREATHING) Bentuk Dada Kebiasaan merokok 

Batuk, sejak



Batuk darah, sejak



Sputum, warna



Sianosis



Nyeri dada



Dyspnoe nyeri dada



Sesak nafas Type Pernafasan



Rektal



Oral

: ................................................................................................. : …………………………………...Batang/hari

.............................................................................……………………………………… .................................................................……………………………………… .......................................................................………………………………………



Orthopnoe



Lainnya …….………..

saat inspirasi  Saat aktivitas  Saat istirahat  Dada  Perut  Dada dan perut  Kusmaul  Cheyne-stokes  Biot  Lainnya Irama Pernafasan  Teratur  Tidak teratur Suara Nafas  Vesukuler  Bronchovesikuler  Bronchial  Trakeal Suara Nafas tambahan  Wheezing  Ronchi kering  Ronchi basah (rales)  Lainnya…………… Keluhan lainnya : ...................................................................................................................................................................... ...................................................................................................................................................................... ...................................................................................................................................................................... Masalah Keperawatan : ...................................................................................................................................................................... ...................................................................................................................................................................... 

5. CARDIOVASCULER (BLEEDING) 

Nyeri dada



Kram kaki



Pucat

2 Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA. 2012/2013




Pusing/sinkop



Clubing finger



Sianosis



Sakit Kepala



Palpitasi



Pingsan



Capillary refill



> 2 detik



< 2 detik



Oedema :



Wajah Anasarka



Ekstrimitas atas Ekstrimitas bawah







Asites, lingkar perut ……………………. cm



Ictus Cordis Vena jugularis Suara jantung

   

Terlihat Tidak meningkat Normal,…………………. Ada kelainan

 

Tidak melihat Meningkat

Keluhan lainnya : ...................................................................................................................................................................... ...................................................................................................................................................................... ...................................................................................................................................................................... Masalah Keperawatan : ...................................................................................................................................................................... ......................................................................................................................................................................

6.

PERSYARAFAN (BRAIN) Nilai GCS :

E : …………………. V : …………………. M : …………………. Total Nilai GCS : …………………… Kesadaran :  Compos Menthis  Somnolent  Apatis  Soporus Pupil :  Isokor  Anisokor  Midriasis  Meiosis Refleks Cahaya :  Kanan  Positif  Kiri  Positif 

Nyeri, lokasi ………………………………..



Vertigo



Gelisah



Bingung



Disarthria

 

Aphasia

Kejang

 

Delirium Coma



Negatif Negatif



Kesemutan



Trernor





Pelo Uji Syaraf Kranial : Nervus Kranial I Nervus Kranial II Nervus Kranial III Nervus Kranial IV Nervus Kranial V Nervus Kranial VI Nervus Kranial VII Nervus Kranial VIII Nervus Kranial IX Nervus Kranial X Nervus Kranial XI Nervus Kranial XII Uji Koordinasi : Ekstrimitas Atas Ekstrimitas Bawah Uji Kestabilan Tubuh Refleks : Bisep Brakioradialis

Babinski Refleks lainnya Uji sensasi

: : : : : : : : : : : :

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

: Jari ke jari Jari ke hidung : Tumit ke jempul kaki :  Positif : : : : :



  

Negatif Negatif Negatif

Kiri +/Skala…………. Trisep Kanan +/ Kiri +/- Skala…………. Skala…………. Patella  Kanan +/ Kiri +/Skala…………. Akhiles  Kanan +/ Kiri +/Skala…………. Refleks  Kanan +/ Kiri +/ Kanan +/ Kiri +/: ..................................................................................................................... : ..................................................................................................................... ..................................................................................................................... 

Kanan +/-

Positif  Positif  Positif Negatif 

 

Keluhan lainnya :



7.

8.

...................................................................................................................................................................... ...................................................................................................................................................................... Masalah Keperawatan : ...................................................................................................................................................................... ...................................................................................................................................................................... ELIMINASI URI (BLADDER) : Produksi Urine : ………….ml…………x/hr Warna : Bau :  Tidak ada masalah/lancer  Menetes  Inkotinen Oliguri Nyeri    Retensi  Poliuri  Panas  Hematuri  Dysuri  Nocturi  Kateter  Cystostomi Keluhan Lainnya : ...................................................................................................................................................................... ...................................................................................................................................................................... Masalah Keperawatan : ...................................................................................................................................................................... ......................................................................................................................................................................

ELIMINASI ALVI (BOWEL) : Mulut dan Faring Bibir : .................................................................................................................................. Gigi : .................................................................................................................................. Gusi : .................................................................................................................................. Lidah : .................................................................................................................................. Mukosa : .................................................................................................................................. Tonsil : .................................................................................................................................. Rectum : Haemoroid : BAB : ……….x/hr Warna :..……… . Konsistensi : ……………. 

Tidak ada masalah



Diare



Konstipasi



Kembung



Feaces berdarah  Melena  Obat pencahar  Lavement Bising usus : ...................................................................................................................... Nyeri tekan, lokasi : ...................................................................................................................... Benjolan, lokasi : ...................................................................................................................... Keluhan lainnya : ...................................................................................................................................................................... ...................................................................................................................................................................... ...................................................................................................................................................................... Masalah Keperawatan : ...................................................................................................................................................................... ......................................................................................................................................................................

9.

TULANG - OTOT – INTEGUMEN (BONE) :  Kemampuan pergerakan sendi  Bebas  Terbatas  Parese, lokasi  Paralise, lokasi  Hemiparese, lokasi  Krepitasi, lokasi  Nyeri, lokasi  Bengkak, lokasi  Kekakuan, lokasi  Flasiditas, lokasi  Spastisitas, lokasi  Ukuran otot  Simetris  Atropi  Hipertropi  Kontraktur  Malposisi Uji kekuatan otot :  Ekstrimitas atas………..  Ekstrimitas bawah……..  Deformitas tulang, lokasi............................................................................................................................  Peradangan, lokasi  Perlukaan, lokasi



Patah tulang, lokasi Tulang belakang 

 

10.

KULIT-KULIT RAMBUT Riwayat alergi

   

Suhu kulit Warna kulit

  

Turgor Tekstur Lesi :

       

Normal Kifosis

 

Skoliosis Lordosis

Obat...................................................................................................... Makanan............................................................................................... Kosametik............................................................................................. Lainnya................................................................................................. Hangat  Panas  Dingin Normal  Sianosis/ biru  Ikterik/kuning Putih/ pucat  Coklat tua/hyperpigmentasi Baik  Cukup  Kurang Halus  Kasar Macula, lokasi Pustula, lokasi....................................................................................... Nodula, lokasi....................................................................................... Vesikula, lokasi..................................................................................... Papula, lokasi........................................................................................ Ulcus, lokasi..........................................................................................

Jaringan parut lokasi Tekstur rambut .................................................................................................................................. Distribusi rambut Bentuk kuku  Simetris  Irreguler  Clubbing Finger  Lainnya Masalah Keperawatan : ...................................................................................................................................................................... ......................................................................................................................................................................

11.

SISTEM PENGINDERAAN : a. Mata/Penglihatan Fungsi penglihatan :



Berkurang



Kabur



Ganda  Buta/gelap Gerakan bola mata :  Bergerak normal  Diam  Bergerak spontan/nistagmus Visus : Mata Kanan (VOD) :........................................................................................... Mata kiri (VOS) :.......................................................................................... ..

Selera

 

Kornea Alat bantu Nyeri Keluhan lain

 

Normal/putih Merah muda Bening Kacamata

   

Kuning/ikterus Pucat/anemic Keruh Lensa kontak

: : ………………………………………………………………… b. Telinga / Pendengaran : Fungsi pendengaran :  Berkurang  Berdengung c. Hidung / Penciuman: Bentuk :  Simetris  Asimetris 

Lesi



Patensi



Obstruksi



Nyeri tekan sinus



Merah/hifema Konjunctiva



Lainnya…….



Tuli



Transluminasi Cavum Nasal Warna………………….. Integritas…………….. Septum nasal  Deviasi  Perforasi  Peradarahan  Sekresi, warna ………………………  Polip  Kanan  Kiri  Kanan dan Kiri Masalah Keperawatan : ...................................................................................................................................................................... ......................................................................................................................................................................



12.

LEHER DAN KELENJAR LIMFE Massa  Ya  Tidak Jaringan Parut  Ya  Tidak Kelenjar Limfe  Teraba  Tidak teraba Kelenjar Tyroid  Teraba  Tidak teraba Mobilitas leher  Bebas  Terbatas 13. SISTEM REPRODUKSI a. Reproduksi Pria Kemerahan, Lokasi Gatal-gatal, Lokasi Gland Penis ..................................................................................... Maetus Uretra ................................................................................. Discharge, warna Srotum ......................................................................................... Hernia ......................................................................................... Kelainan …………………………………………… Keluhan lain …………………………………………. a. Reproduksi Wanita Kemerahan, Lokasi Gatal-gatal, Lokasi Perdarahan ..................................................................................... Flour Albus ................................................................................. Clitoris ............................................................................................. Labis ......................................................................................... Uretra ......................................................................................... Kebersihan :  Baik  Cukup  Kurang Kehamilan : …………………………………… Tafsiran partus : …………………………………… Keluhan lain............................................................................................................................................. ................................................................................................................................................................ ................................................................................................................................................................ Payudara :  Simetris  Asimetris  Sear  Lesi  Pembengkakan  Nyeri tekan Puting :  Menonjol  Datar  Lecet  Mastitis Warna areola .......................................................................................................................................... ASI  Lancar  Sedikit  Tidak keluar Keluhan lainnya....................................................................................................................................... ................................................................................................................................................................ ................................................................................................................................................................ Masalah Keperawatan : ................................................................................................................................................................. D.

POLA FUNGSI KESEHATAN Persepsi Terhadap Kesehatan dan Penyakit : ...................................................................................................................................................................... ...................................................................................................................................................................... ...................................................................................................................................................................... ...................................................................................................................................................................... ...................................................................................................................................................................... 2. Nutrisida Metabolisme TB : Cm BB sekarang : Kg BB Sebelum sakit : Kg Diet :  Biasa  Cair  Saring  Lunak Diet Khusus :  Rendah garam  Rendah kalori  TKTP  Rendah Lemak  Rendah Purin  Lainnya……….  Mual  Muntah…………….kali/hari Kesukaran menelan  Ya  Tidak Rasa haus Keluhan lainnya............................................................................................................................................. 1.



Pola Makan Sehari-hari

Sesudah Sakit

Sebelum Sakit

Frekuensi/hari Porsi Nafsu makan Jenis Makanan Jenis Minuman Jumlah minuman/cc/24 jam Kebiasaan makan Keluhan/masalah

3.

4.

5.

6.

7.

8.

E. 1.

2.

Masalah Keperawatan ………………………………………………………………………………………………… Pola istirahat dan tidur ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Masalah Keperawatan ………………………………………………………………………………………………… Kognitif : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………Masalah Keperawatan ………………………………………………………………………………………………… Konsep diri (Gambaran diri, ideal diri, identitas diri, harga diri, peran ) : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………Masalah Keperawatan ………………………………………………………………………………………………… Aktivitas Sehari-hari ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………Masalah Keperawatan ………………………………………………………………………………………………… Koping –Toleransi terhadap Stress ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………Masalah Keperawatan ………………………………………………………………………………………………… Nilai-Pola Keyakinan ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Masalah Keperawatan …………………………………………………………………………………………………

SOSIAL - SPIRITUAL Kemampuan berkomunikasi ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… ……………………………………………………………… Bahasa sehari-hari ………………………………………………………………………………………………… 7

Pedoman Penyususnan & Penulisan Laporan Studi Kasus Program Studi S1 Keperawatan TA. 2012/2013


…………………………………………………………………………………………………

3.

4.

5.

6.

7.

…………………………………………………………………………………………………………………………………… ……………………………………………………………… Hubungan dengan keluarga : ………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… ……………………………………………………………… ………………………………………………………………………………………………… Hubungan dengan teman/petugas kesehatan/orang lain : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Orang berarti/terdekat : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Kebiasaan menggunakan waktu luang : ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Kegiatan beribadah : ………………………………………………………………………………………………… …………………………………………………………………………………………………

F.

DATA PENUNJANG (RADIOLOGIS, LABORATO RIUM, PENUNJANG LAINNYA)

G.

PENATALAKSANAAN MEDIS

…. …………..…………….. Mahasiswa

( ………………………………)



Lampiran 12 Format Diagnosa Keperawatan

YAYASAN EKA HARAP PALANGKA RAYA SEKOLAH TINGGI ILMU KESEHATAN PROGRAM STUDI S1 KEPERAWATAN Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536) 3327707 ANALISIS DATA DATA SUBYEKTIF DAN DATA OBYEKTIF

KEMUNGKINAN PENYEBAB

MASALAH

Prioritas Masalah



Lampiran 13 Format Intervensi Keperawatan

YAYASAN EKA HARAP PALANGKA RAYA SEKOLAH TINGGI ILMU KESEHATAN PROGRAM STUDI S1 KEPERAWATAN Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536) 3327707 RENCANA KEPERAWATAN Nama Pasien : …………………….. Ruang Rawat : ……………………..

Diagnosa Keperawatan

Tujuan (Kriteria hasil)

Intervensi

Rasional



Lampiran 14 Format Implementasi Dan Evaluasi Keperawatan

YAYASAN EKA HARAP PALANGKA RAYA SEKOLAH TINGGI ILMU KESEHATAN PROGRAM STUDI S1 KEPERAWATAN Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536) 3327707 IMPLEMENTASI DAN EVALUASI KEPERAWATAN Hari/Tanggal Jam

Implementasi

Evaluasi (SOAP)

Tanda tangan dan Nama Perawat




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