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PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :

NIM :Kelompok :

Tgl praktik/mgg ke :

Tanggal/jam Pengkajian : Tanggal/jam MRS :

Identitas Pasien :

Nama : Suku :

Umur : Agama :

enis Kelamin : Status Perkawinan :

Alamat : Pekerjaan :

Pen!i!ikan terakhir : No Rekam Me!ik :

Kea!aan Umum :

Keluhan Utama :

"iagnosa Me!is :

Riwa#at me!ik !an sosial

; Ke$elakaan %

; "irawat %%%

; &perasi %%%

; Alergi %%

; Pen#akit %%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

; 'ain(lain %

%

Riwa#at pengo)atan

; Se)elumn#a %%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

; Saat ini

; Persepsi klien tentang kesehatan

1. Pola Persepsi Keseatan dan Penan!anan Keseatan

Alasan masuk rumah sakit:

Riwa#at pen#akit sekarang :

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". Pola N#trisi $ Meta%oli&

Intake Nutrisi se)elum !an saat sakit

; Makanan

; Minuman

; Na*su makan

; Muntah

; Keluhan/masalah #ang mempengaruhi asupan nutrisi

; Perawatan kulit+ ram)ut !an kuku

,, : T, : Suhu :

; Kelem)a)an kulit%%-arna kulit %%%%%%%%%%%%%Turgor

; Kon!isi kulit%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%

; Kuku%

; Ram)ut !an kepala %%%%%%%%%%%%%%%%%%%%%%%%%%%%

; Kelenjar tiroi! %

; .P %%

; Kaku ku!uk %

; Mukosa )i)ir %%%

; Ke)ersihan mulut

; Pera!angan tonsil

; igi %%

; Penggunaan NT

; Terapi intra0ena / parenteral %%%%

; 'ain(lain %%

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'. Pola Eli(inasi

; Tanggal !e*ekasi terakhir :

; 1rekuensi !e*ekasi Konsistensi

-arna; Masalah !e*ekasi

%%%%%%%%%%%%%%%%%%%%%%%

; Penggunaan alat )antu 2laksati*/pispot3%%%

; ,ising usus %%

; Struktur a)!omen

%%%%%%%%%%%%%%%%%%%%%%%%

; "istensi %%%

; N#eri tekan %

%

; 'ain(lain %%

; 1rekuensi )erkemih%%%%%%umlah%%

-arna%

; Penggunaan alat )antu )erkemih%

; Keluhan /masalah )erkemih %%%%%%%%%%%%%%%%%%%%%%%%%%%

; Sakit pinggang%

; Palpasi ginjal%%

%%

; Perkusi ginjal%%%

; Kon!isi )last%%%%%%%%%%%%%%%%%%%%%%%%%%%%

; 'ain(lain%%%

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). Pola A&ti*itas $ Latian

Kemampuan perawatan !iri:

Akti0itas SMRS MRS4 5 6 7 8 4 5 6 7 8

Man!i

,erpakaian/)er!an!an

9liminasi/toileting

Mo)ilitas !i tempat

ti!ur

,erpin!ah

,erjalan

Naik tangga

,er)elanjaMemasak

Pemeliharaan rumah

Skor:

4 man!iri 5 alat )antu 6 !i)antu orang lain 7 !i)antu

orang lain ; alat

8 tergantung/ti!ak mampu

Ke)ersihan !iri:

Di rumah

; Man!i : %%%%%%%%%%%%%%%%%%%%%%%% /hr; osok gigi : %%%%%%%%%%%%%%%%%%%%%%%% /hr

; Keramas : %%%%%%%%%%%%%%%%%%%% /mgg

; Potong kuku : %%%%%%%%%%%%%%%%%%%% /mgg

Di rumah sakit

; Man!i : %%%%%%%%%%%%%%%%%%%%%%%% /hr

; osok gigi : %%%%%%%%%%%%%%%%%%%%%%%% /hr

; Keramas : %%%%%%%%%%%%%%%%%%%% /mgg

; Potong kuku : %%%%%%%%%%%%%%%%%%%% /mgg

Pernapasan

; 1rekuensi napas : % ke!alaman : irama : %

; ,un#i napas%%%%%%%%%%%%%%%%%%%%%%%%%%%

; Riwa#at

merokok%%

; Riwa#at asma/)ron$hitis/em*isema %

; Riwa#at pen#akit paru !alam keluarga %%%

; ,atuk

%; Penggunaan otot )antu napas%%%

; Suara napas tam)ahan%%%%%%%%%%%%%%%%%%%%%%%%%%%

; A!an#a sputum%

(

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Sirkulasi

; 1rekuensi na!i %%%%%irama %%%%%%%%%%%%%%%%%%%T"

; Perkusi !a!a%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

; N#eri !a!a %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

;

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; Tinnitus

; Keluhan n#eri%%

; Penggunaan alat )antu !engar%

; 1ungsi

pen$iuman

; Kon!isi hi!ung

;

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1. Pola Peran $ H#%#n!an

; Peran !alam keluarga

; =u)ungan !engan orang ter!ekat%

; Interaksi !engan pasien lain%%

;

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P9M9RIKSAAN P9NUNAN

1; 'a)oratorium

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2; 1oto

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T9RAPI M9"IS

Tan!!al Jenis Terapi R#te Terapi Dosis Indi&asi Terapi

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Martapura+ %%%%%%%%%%%%%%%%%%%%%

Mahasiswa

2%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%3

ANALI0A DATA

Nama klien : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Umur : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Ruangan/kamar : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

No% RM : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

No% "ata 2S#mptom3 Pen#e)a) 29tiologi3 Masalah 2Pro)lem3

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No% "ata 2S#mptom3 Pen#e)a) 29tiologi3 Masalah 2Pro)lem3

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PRI5RITA0 MA0ALAH

Nama klien : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Umur : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

Ruangan/kamar : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

No% RM : %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

No% Masalah KeperawatanTanggal

2Nam"itemukan Teratasi

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REN6ANA KEPERAWATAN

No% "iagnosa

Keperawatan

Tujuan "an Kriteria =asil Inter0ensi

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TINDAKAN KEPERAWATAN DAN 6ATATAN PERKEMBANGAN

No%

"> Kep

-aktu

Tgl/jam Tin!akan TT

-aktu

Tgl/jam

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