92679114 format pengkajian kmb new 2012

7/22/2019 92679114 Format Pengkajian KMB New 2012

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SEKOLAH TINGGI ILMU KESEHATAN NAHDLATUL ULAMA TUBAN

PROGRAM STUDI S1 KEPERAWATAN

JL. LETDA SECIPTO NO. 211 TUBAN TELP. 0356-325789 FAX. 333237 Email :[email protected]

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Pengkajian tgl. : Jam :

MRS tanggal : No. RM :

Diagnosa Masuk : Hari Rawat Ke :

Ruangan/kelas :

A. IDENTITAS PASIENNama : Penanggung jawab biaya :

Usia : Nama :

Jenis kelamin : Alamat :

Suku /Bangsa : Hub. Keluarga :Agama : Telepon :

Pendidikan :

Status perkawinan

Pekerjaan :

Alamat :

B. RIWAYAT PENYAKIT SEKARANG1. Keluhan Utama : .......................................................................................................................2. Riwayat Penyakit Sekarang : ....................................................................................................

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C. RIWAYAT PENYAKIT DAHULU1. Pernah di rawat ya, jenis : ....................... tidak2. Riwayat Penyakit Kronik dan Menular ya, jenis : ....................... tidak3. Riwayat Penyakit Alergi ya, jenis : ....................... tidak4. Riwayat Operasi ya, jenis : ....................... tidak

- Kapan : ...............................- Jenis Operasi : ...............................

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

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D. RIWAYAT PENYAKIT KELUARGAya : ........................................ tidak

GENOGRAM
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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E. PERILAKU YANG MEMPENGARUHI KESEHATANPerilaku sebelum sakit yang mempengaruhi kesehatan

Alkohol ya tidak

Keterangan ..........................................................................................................

Merokok ya tidak

Keterangan ..........................................................................................................

Obat ya tidakKeterangan ..........................................................................................................

Olahraga ya tidak

Keterangan ..........................................................................................................

F. OBSERVASI DAN PEMERIKSAAN FISIK1. Tanda-tanda vital

Kesadaran Compos mentis Apatis Somnolen Sopor Koma

S : N : TD : RR :

MASALAH KEPERAWATAN :

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2. Sistem Pernafasana. RR : ...............................b. Keluhan : Sesak Nyeri waktu sesak Orthopnea

Batuk Produktif Tidak Produktif

Sekret : .................... Konsistensi : .......................

Warna : ................... Bau : ....................................

c. Pola nafas irama: Teratur Tidak teraturd. Jenis Dispnoe Kusmaul Ceyne Stokes Lain-lain:

Pernafasan cuping hidung ada tidak

Septum nasi simetris tidak simetris

Lain-lain :

e. Bentuk dada simetris asimetris barrel chestFunnel chest Pigeons chest

f. Suara napas vesiculer ronchi D/S wheezing D/S rales D/Sg. Alat bantu nafas Ya Tidak

Jenis .........................Flow ................Lpm

h. Penggunaan WSD :- Jenis : ....................................................................................................................- Jumlah Cairan : .........................................................................................................- Undulasi : .................................................................................................................- Tekanan : .................................................................................................................

i. Trakeostomy Ya Tidak................................................................................................................................................

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

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

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3. Sistem Kardiovakulera. TD :b. N :c. HR :d. Keluhan nyeri dada ya tidak

P : .....................................................................................

Q : .....................................................................................R : .....................................................................................

S : .....................................................................................

T : .....................................................................................

e. CRT : ...............f. Konjungtiva pucat ya tidakg. Bunyi jantung: Normal Murmur Gallop lain-lainh. Irama jantung: Reguler Ireguler S1/S2 tunggal Ya Tidaki. Akral: Hangat Panas Dingin kering Dingin basahj. Siklus perifer Normal Menurunk. JVP : ..........................l. CVP : ..........................m. CTR : ..........................n. ECG & Interpretasinya :

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

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4. Sistem Persarafana. Kesadaran composmentis apatis somnolen sopor koma

GCS :

b. Pupil isokor anisokorc. Sclera Anikterus Ikterusd. Konjungtiva Ananemis Anemise. Istirahat/Tidur : .................................................f. IVD : ......................................................g. EVD : ......................................................h.

ICP : ......................................................

i. Nyeri tidak ya, skala nyeri : lokasi :j. Refleks fisiologis: patella triceps biceps lain-lain:k. Refleks patologis: babinsky budzinsky kernig lain-lainl. Keluhan Pusing O ya OTidak

P : .....................................................................................

Q : .....................................................................................

R : .....................................................................................

S : .....................................................................................

T : .....................................................................................


4/18

m. Pemeriksaan saraf kranialN1 Normal Tidak Ket : ........................................................

N2 Normal Tidak Ket : ........................................................




N6 Normal Tidak Ket : ........................................................N7 Normal Tidak Ket : ........................................................







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5. Sistem Perkemihan (B4)a. Kebersihan genetalia : Bersih Kotorb. Sekret : Ada Tidakc. Ulkus : Ada Tidakd. Kebersihan Meatus uretera : Bersih Kotore. Keluhan Kencing Ada Tidak

Bila ada jelaskan :

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f. Kemampuan berkemihSpontan Alat bantu, sebutkan : ...................................................................

Jenis : ........................................................................................

Ukuran : ........................................................................................

Hari Ke: ........................................................................................

g. Produksi urine : ...........................ml/jamWarnah : ...............................

Bau : ...............................

h. Kandung kemih : Membesar Ya Tidaki. Nyeri Tekan : Ya Tidakj. Intake Cairan : Oral :....................cc/hari Parenteral :

..............cc/hari

k. Balance Cairan : ......................................................................................................................................................................................................................................................................

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

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6. Sistem Pencernaana. TB : ............. cm BB : ..............kgb. IMT : ............. Interpretasi : .........................................c. LOLA : .............MASALAH KEPERAWATAN :

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d. Mulut : Bersih Kotore. Mukosa mulut : Lembab Kering Merah stomatitisf. Tenggorokan 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/darahkonstipasi inkontinensia kolostomi

i. Diet padat lunak cairDiet Khusus : ......................................................................................................................

Nafsu Makan Baik Menurun

Frekuensi :...............x/hari jumlah:............... jenis : .......................

Lainlain : ..........................................................................................................................


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7. Sistem Penglihatana. Pengkajian segmen anterior dan posterior

OD CS

Visus

Palpebra

Conjunctiva

Kornea

BMD

Pupil

Iris

Lensa

TIO


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b. Keluhan nyeri Ya TidakP : ..................................................................

Q : ..................................................................

R : ..................................................................

T : ..................................................................

c. Luka opreasi Ada TidakTanggal operasi : ........................Jenis Operasi : ........................

Lokasi : ........................

Keadaan : ........................

d. Pemeriksaan penunjang lain..........................................................................................................................................................

e. Lain ..........................................................................................................................................................................................................................................................................................................

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MASALAH KEPERAWATAN

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8. Sistem pendengarana. Pengkajian segmen dan posterior

OD OS

Aurcicula

MAE

Membran Tympani

Rinne

Webber

Swabach

b. Tes audiometri.......................................................................................................................................................

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c. Keluhan nyeri Ya TidakP : ..................................................................Q : ..................................................................

R : ..................................................................

S : ..................................................................

T : ..................................................................

d. Luka opreasi Ada TidakTanggal operasi : ........................

Jenis Operasi : ........................

Lokasi : ........................

Keadaan : ........................

e. Alat bantu dengar : .......................................................f. Lain-lain. .............................................................................................................................................................................................................................................................................................

MASALAH KEPERAWATAN

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

b. Pergerakan sendi bebas terbatasc. Kelainan ekstremitas ya tidakd.

Kelainan tlg. belakang ya tidakFrankel : .....................................................................................................................................

e. Fraktur ya tidak- Jenis :..............................................................

f. Traksi/spalk/gips ya tidak- Jenis : ............................................- Beban : ............................................- Lama pemasangan : ...........................................

g. Penggunaan spalk/gips ya tidakh. Keluhan nyeri : ya tidak

P : ..................................................................

Q : ..................................................................

R : ..................................................................

S : ..................................................................

T : ..................................................................

i. Sirkulasi perifer : ...........................................j. Kompartemen sindrom ya tidakk. Kulit ikterik sianosis kemerahan hiperpigmentasil. Akral hangat panas dingin kering basahm. Turgor baik kurang jelekn. Odema: Ada Tidak ada Lokasio. Luka operasi : jenis :............. luas : ............... bersih kotorp. Tanggal operasi : ..................q. Jenis operasi : ..................r. Lokasi : ..................s. Keadaan : ..................t. Drain : Ada Tidaku. Jumlah : ...................................................v. Warna : ...................................................w. Kondisi area sekitar insersi : ......................................x. ROM : ..................................................y. POD : ..................................................z. Cardial Sign : ..................................................

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

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10.Sistem Integumena. Penilaian risiko decubitus :

Aspek yang dinilai KRITERIA YANG DINILAI NILAI

1 3 3 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-KADANGJALAN

LEBIH SERINGJALAN

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 ri sk, 13 or 14 = moderate r isk, 12 or less= high r isk)

TOTAL NILAI

b. Warna : ...........................................................c. Pitting edema : +/- grade : .............................d. Ekskoriasis : ya tidake. Psoriasis : ya tidakf. Urtikaria : ya tidakg. Lain-lain : ............................................................................................................................

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MASALAH KEPERAWATAN

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11.Sistem Endokrina. Pembesaran kelenjar tyroid ya tidakb. Pembesaran kelenjar getah bening ya tidakc. Hiperglikemia Ya Tidak Hipoglikemia Ya Tidakd. 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 TidakJika Ya

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

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G. PENGKAJIAN PSIKOSOSIAL1.

Persepsi klien terhadap penyakitnya

cobaan Tuhan hukuman lainnya

2. Ekspresi klien terhadap penyakitnyamurung gelisah tegang marah/menangis

3. Reaksi saat interaksi kooperatif tak kooperatif curiga4. Gangguan konsep diri ya tidak


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H. PENGKAJIAN SPIRITUALa. 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 :...............................................................................................................................................

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I. PERSONAL HYGIENa. Kebersihan diri :

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b. Kemampuan klien dalam pemenuhan kebutuhan :- Mandi : Dibantu seluruhnya dibantu sebagian mandiri- Ganti pakaian : Dibantu seluruhnya dibantu sebagian mandiri- Keramas : Dibantu seluruhnya dibantu sebagian mandiri- Sikat gigi : Dibantu seluruhnya dibantu sebagian mandiri- Memotong kuku: Dibantu seluruhnya dibantu sebagian mandiri- Berhias : Dibantu seluruhnya dibantu sebagian mandiri- Makan : Dibantu seluruhnya dibantu sebagian mandiri


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10/18

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

K. TERAPI

Tuban,.................................

Perawat Primer,

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


11/18

ANALISA DATA

DATA ETIOLOGI MASALAH


12/18


13/18


14/18

INTERVENSI, IMPLEMENTASI

No

Dx

Kriteria Hasil/ Tujuan Tgl/jam Intervensi Rasional Implementasi Tgl/jam TTD


15/18


16/18

EVALUASI

No Diagnosa Tgl/jam SOAP TTD


17/18


18/18

92679114 format pengkajian kmb new 2012

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