Format Pengkajian KMB New 2012

SEKOLAH TINGGI ILMU KESEHATAN NAHDLATUL ULAMA TUBAN PROGRAM STUDI S1 KEPERAWATAN  JL. LETDA SECIPTO NO. 211 TUBAN TELP. 0356-325789 FAX. 333237 333237 Email : [email protected] 

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH Pengkajian tgl. MRS tanggal Diagnosa Masuk Ruangan/kelas

: : : :

Jam No. RM Hari Rawat Ke

: : :

A. IDENTITAS PASIEN Nama : Penanggung jawab biaya : Usia : Nama : Jenis kelamin : Alamat : Suku /Bangsa : Hub. Keluarga : Agama : Telepon : Pendidikan : Status perkawinan Pekerjaan : Alamat : B. RIWAYAT PENYAKIT SEKARANG 1. Keluhan Utama : ...................................................................... ........................................................................................................ ................................................. ............... 2. Riwayat Penyakit Sekarang : ....................................................................... .................................................................................................... ............................. .......................................................................... .......................................... ................................................................ ......................................................................... ......................................... .......................................................................... .......................................... ................................................................ ......................................................................... ......................................... .......................................................................... .......................................... ................................................................... ....................................................................... ...................................... .. .......................................................................... .......................................... ................................................................ ......................................................................... ......................................... .......................................................................... .......................................... ................................................................. ..................................................................... ........................................ .... .......................................................................... .......................................... ................................................................ ......................................................................... ......................................... .......................................................................... .......................................... ................................................................ ......................................................................... ......................................... C. RIWAYAT PENYAKIT DAHULU 1. Pernah di rawat ya, jenis : ....................... tidak  2. Riwayat Penyakit Kronik dan Menular ya, jenis : ....................... tidak  3. Riwayat Penyakit Alergi ya, jenis : ....................... tidak  4. Riwayat Operasi ya, jenis : ....................... tidak  - Kapan : ............................... - Jenis Operasi : ............................... 5. Lain-lain : ......................................................................... ..................................... ..................................................................... ..................................................................... ....................................... ... .......................................................................... ..................................... ..................................................................... ............................................................... ....................................... ........ ......................................................................... ..................................... ..................................................................... ..................................................................... ....................................... ... D. RIWAYAT PENYAKIT KELUARGA ya : ..................................... ........................................ ... GENOGRAM

tidak 

E. PERILAKU YANG MEMPENGARUHI KESEHATAN Perilaku sebelum sakit yang mempengaruhi kesehatan Alkohol ya tidak  Keterangan .......................................................................................................... Merokok ya tidak  Keterangan .......................................................................................................... Obat ya tidak  Keterangan .......................................................................................................... Olahraga ya tidak  Keterangan .......................................................................................................... F. OBSERVASI DAN PEMERIKSAAN FISIK 1. Tanda-tanda vital Kesadaran Compos mentis Apatis Somnolen Sopor Koma S : N: TD : RR : MASALAH KEPERAWATAN : ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. 2. Sistem Pernafasan a. RR : ............................... b. Keluhan : Sesak Nyeri waktu sesak Orthopnea Batuk Produktif Tidak Produktif  Sekret : .................... Konsistensi : ....................... Warna : ................... Bau : .................................... irama: c. Pola nafas  Teratur  Tidak teratur  Dispnoe  Kusmaul  Ceyne Stokes Lain-lain: d. Jenis Pernafasan cuping hidung ada tidak  Septum nasi simetris tidak simetris Lain-lain : e. Bentuk dada simetris asimetris barrel chest Funnel chest Pigeons chest f. Suara napas vesiculer ronchi D/S wheezing D/S rales D/S g. Alat bantu nafas Ya Tidak  Jenis .........................Flow ................Lpm h. Penggunaan WSD : - Jenis : .................................................................................................................... - Jumlah Cairan : ......................................................................................................... - Undulasi : ................................................................................................................. - Tekanan : ................................................................................................................. i. Trakeostomy Ya Tidak  ................................................................................................................................................ ................................................................................................................................................  j. Lain-lain :

................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................  MASALAH KEPERAWATAN : ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. .................................................................................................................................................

3. Sistem Kardiovakuler a. TD : b. N : c. HR : d. Keluhan nyeri dada ya tidak  P : ..................................................................................... Q : ..................................................................................... R : ..................................................................................... S : ..................................................................................... T : ..................................................................................... e. CRT : ............... f. Konjungtiva pucat ya tidak  lain-lain g. Bunyi jantung:  Normal  Murmur  Gallop h. Irama jantung:  Reguler  Ireguler S1/S2 tunggal  Ya  Tidak  i. Akral:  Hangat  Panas  Dingin kering  Dingin basah Normal Menurun  j. Siklus perifer k. JVP : .......................... l. CVP : .......................... m. CTR : .......................... n. ECG & Interpretasinya : ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. Lain-lain : ................................................................................................................................................. ................................................................................................................................................. MASALAH KEPERAWATAN : ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................. 4. Sistem Persarafan a. Kesadaran composmentis apatis somnolen GCS : b. Pupil isokor anisokor c. Sclera Anikterus Ikterus d. Konjungtiva Ananemis Anemis e. Istirahat/Tidur : ................................................. f. IVD : ...................................................... g. EVD : ...................................................... h. ICP : ...................................................... i. Nyeri tidak ya, skala nyeri : lokasi :  biceps  j. Refleks fisiologis:  patella  triceps k. Refleks patologis:  babinsky  budzinsky  kernig l.

Keluhan Pusing

O ya

O Tidak 

P : ..................................................................................... Q : ..................................................................................... R : ..................................................................................... S : ..................................................................................... T : .....................................................................................

sopor

lain-lain: lain-lain

koma

m. Pemeriksaan saraf kranial N1 Normal N2 Normal N3 Normal N4 Normal N5 Normal N6 Normal N7 Normal N8 Normal N9 Normal N10 Normal N11 Normal N12 Normal

Tidak Tidak Tidak Tidak Tidak Tidak Tidak Tidak Tidak Tidak Tidak Tidak

Ket : ........................................................ Ket : ........................................................ Ket : ........................................................ Ket : ........................................................ Ket : ........................................................ Ket : ........................................................ Ket : ........................................................ Ket : ........................................................ Ket : ........................................................ Ket : ........................................................ Ket : ........................................................ Ket : ........................................................

MASALAH KEPERAWATAN : ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... ..................................................................................................................................................... 5. Sistem Perkemihan (B4) a. Kebersihan genetalia : Bersih Kotor b. Sekret : Ada Tidak  c. Ulkus : Ada Tidak  d. Kebersihan Meatus uretera : 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 Warnah : ............................... Bau : ............................... h. Kandung kemih : Membesar Ya Tidak  i. Nyeri Tekan : Ya Tidak   j. Intake Cairan : Oral :....................cc/hari Parenteral : ..............cc/hari k. Balance Cairan : .................................................................................................................. .................................................................................................................................................... .................................................................................................................................................... o. Lain-lain : ..................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... MASALAH KEPERAWATAN : .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... ....................................................................................................................................................

6. Sistem Pencernaan a. TB : ............. cm BB : ..............kg b. IMT : ............. Interpretasi : ......................................... c. LOLA : ............. MASALAH KEPERAWATAN : .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... d. Mulut : e. Mukosa mulut : f. Tenggorokan

Bersih Kotor Lembab Kering Merah stomatitis Nyeri telan Sulit menelan Pembesaran Tonsil Nyeri Tekan g. Abdomen Supel Tegang nyeri tekan, lokasi : Luka operasi Jejas lokasi : Pembesaran hepar ya tidak  Pembesaran lien ya tidak  Ascites ya tidak  Drain Ada Tidak  - Jumlah : ...................... - Warna : ...................... - Kondisi area sekitar insersi : ..................................... Mual ya tidak  Muntah ya tidak  Terpasang NGT ya tidak  Bising usus :..........x/mnt h. BAB :........x/hr, konsistensi : lunak cair lendir/darah konstipasi inkontinensia kolostomi i. Diet padat lunak cair Diet Khusus : ...................................................................................................................... Nafsu Makan Baik Menurun Frekuensi :...............x/hari jumlah:............... jenis : ....................... Lain  – lain : .......................................................................................................................... MASALAH KEPERAWATAN : .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... 7. Sistem Penglihatan a. Pengkajian segmen anterior dan posterior OD

CS Visus Palpebra Conjunctiva Kornea BMD Pupil Iris Lensa TIO

b. Keluhan nyeri Ya Tidak  P : .................................................................. Q : .................................................................. R : .................................................................. T : .................................................................. c. Luka opreasi Ada Tidak  Tanggal operasi : ........................ Jenis Operasi : ........................ Lokasi : ........................ Keadaan : ........................ d. Pemeriksaan penunjang lain .......................................................................................................................................................... e. Lain ................................................................................................................................................. ......................................................................................................................................................... ......................................................................................................................................................... MASALAH KEPERAWATAN ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... ......................................................................................................................................................... 8. Sistem pendengaran a. Pengkajian segmen dan posterior OD

OS Aurcicula MAE Membran Tympani Rinne Webber Swabach

b. Tes audiometri ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... c. Keluhan nyeri Ya Tidak  P : .................................................................. Q : .................................................................. R : .................................................................. S : .................................................................. T : .................................................................. d. Luka opreasi Ada Tidak  Tanggal operasi : ........................ Jenis Operasi : ........................ Lokasi : ........................ Keadaan : ........................ e. Alat bantu dengar : ....................................................... f. Lain-lain. ...................................................................................................................................... ....................................................................................................................................................... MASALAH KEPERAWATAN ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... .......................................................................................................................................................

9. Sistem Muskuloskeletal dan Integumen (B6) a. Kekuatan otot

b. Pergerakan sendi bebas terbatas c. Kelainan ekstremitas ya tidak  d. Kelainan tlg. belakang ya tidak  Frankel : ..................................................................................................................................... e. Fraktur ya tidak  - Jenis :.............................................................. f. Traksi/spalk/gips 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 sindrom ya tidak  k. Kulit ikterik sianosis kemerahan hiperpigmentasi l. Akral hangat panas dingin kering basah m. Turgor baik kurang jelek   Ada  Tidak ada Lokasi n. Odema: o. Luka operasi : jenis :............. luas : ............... bersih kotor p. Tanggal operasi : .................. q. Jenis operasi : .................. r. Lokasi : .................. s. Keadaan : .................. t. Drain : Ada Tidak  u. Jumlah : ................................................... v. Warna : ................................................... w. Kondisi area sekitar insersi : ...................................... x. ROM : .................................................. y. POD : .................................................. z. Cardial Sign : .................................................. Lain-lain : ............................................................................................................... ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. MASALAH KEPERAWATAN : ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... .......................................................................................................................................................

10. Sistem Integumen a. Penilaian risiko decubitus : KRITERIA YANG DINILAI 3 3

Aspek yang dinilai 1

NILAI 4

PERSEPSI SENSORI

TERBATAS SEPENUHNYA

SANGAT TERBATAS

KETERBATASAN RINGAN

TIDAK ADA GANGGUAN

KELEMBABAN

TERUS MENERUS BASAH

SANGAT LEMBAB

KADANG-KADANG BASAH

JARANG BASAH

AKTIVITAS

BEDFAST

CHAIRFAST

KADANG-KADANG JALAN

LEBIH SERING JALAN

MOBILISASI

IMMOBILE SEPENUHNYA

SANGAT TERBATAS

KETERBATASAN RINGAN

TIDAK ADA KETERBATASAN

NUTRISI

SANGAT BURUK

KEMUNGKINAN TIDAK ADEKUAT

ADEKUAT

SANGAT BAIK

GESEKAN & PERGESERAN

BERMASALAH

POTENSIAL BERMASALAH

TIDAK MENIMBULKAN MASALAH

NOTE : Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien beresiko mengalami dekubitus (Pressure ulcers) (15 or 16 =low risk, 13 or 14 = moderate risk, 12 or less= high risk)

TOTAL NILAI

b. c. d. e. f. g.

Warna : ........................................................... Pitting edema : +/- grade : ............................. Ekskoriasis : ya tidak  Psoriasis : ya tidak  Urtikaria : ya tidak  Lain-lain : ............................................................................................................................ .............................................................................................................................................. MASALAH KEPERAWATAN .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. ..............................................................................................................................................

11. Sistem Endokrin a. Pembesaran kelenjar tyroid ya tidak  b. Pembesaran kelenjar getah bening ya tidak   Tidak  Ya Hipoglikemia c. Hiperglikemia  Ya d. Kondisi kaki DM : - Luka gangrene  Ya  Tidak  - Jenis Luka : ..................................................... : ..................................................... - Lama luka - Warna : ..................................................... - Luas Luka : ..................................................... : ..................................................... - Kedalaman - Kulit Kaki : .............................................. - Kuku kaki : .............................................. - Telapak kaki : .............................................. - Jari kaki : .............................................. - Infeksi :  Ya  Tidak  - Riwayat luka sebelumnya :  Ya  Tidak  - Tahun : .................................................. - Jenis Luka : .................................................. : .................................................. - Lokasi - Riwayat amputansi sebelumnya :  Ya  Tidak 

 Tidak 

Jika Ya

-

Tahun : .......................... Lokasi : ......................... Lain-lain : ..................................................................................................... .......................................................................................................................

MASALAH KEPERAWATAN :

................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ G. PENGKAJIAN PSIKOSOSIAL 1. Persepsi klien terhadap penyakitnya cobaan Tuhan hukuman 2. Ekspresi klien terhadap penyakitnya murung gelisah tegang 3. Reaksi saat interaksi kooperatif 4. Gangguan konsep diri ya

lainnya marah/menangis tak kooperatif tidak 

curiga

MASALAH KEPERAWATAN : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................

H. PENGKAJIAN SPIRITUAL a. Kebiasaan beribadah - Sebelum sakit sering kadang-kadang tidak pernah - Selama sakit sering kadang-kadang tidak pernah b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... MASALAH KEPERAWATAN : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... I.

PERSONAL HYGIEN a.

Kebersihan diri :

............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... b.

Kemampuan klien dalam pemenuhan kebutuhan : Mandi : Dibantu seluruhnya Ganti pakaian : Dibantu seluruhnya Keramas : Dibantu seluruhnya Sikat gigi : Dibantu seluruhnya Memotong kuku: Dibantu seluruhnya Berhias : Dibantu seluruhnya Makan : Dibantu seluruhnya

dibantu sebagian dibantu sebagian dibantu sebagian dibantu sebagian dibantu sebagian dibantu sebagian dibantu sebagian

mandiri mandiri mandiri mandiri mandiri mandiri mandiri

MASALAH KEPERAWATAN : ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................

J. PEMERIKSAAN PENUNJANG (Laboratorium, radiologi, EKG, USG)

K. TERAPI

Tuban,................................. Perawat Primer,

(.............................................)

ANALISA DATA DATA

ETIOLOGI

MASALAH

DIAGNOSA KEPERAWATAN 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

INTERVENSI, IMPLEMENTASI No Dx

Kriteria Hasil/ Tujuan

Tgl/jam

Intervensi

Rasional

Implementasi

Tgl/jam

TTD

EVALUASI No

Diagnosa

Tgl/jam

SOAP

TTD

EVALUASI No

Diagnosa

Tgl/jam

SOAP

TTD

EVALUASI No

Diagnosa

Tgl/jam

SOAP

TTD