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PROGRAM STUDI PENDIDIKAN NERSSTIKES SURYA MITRA HUSADA KEDIRIPROGRAM PENDIDIKAN PROFESI NERSALAMAT : JLN. Manila No. 37 Sumberece Kota Kediri Telp. (0354) 7009713 Fax. (0354) 695130

Nama MahasiswaNIM

: ...:

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Tanggal MRSTanggal Pengkajian

: :

Jam MasukNo. RM

::

Jam PengkajianHari rawat ke

IDENTITAS1. Nama Pasien2. Umur3. Suku/ Bangsa4. Agama5. Pendidikan6. Pekerjaan7. Alamat8. Sumber Biaya

::::::::

::

Diagnosa Masuk :

KELUHAN UTAMA

1.

Keluhan utama:..

RIWAYAT PENYAKIT SEKARANG1. Riwayat Penyakit Sekarang:.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................RIWAYAT PENYAKIT DAHULU

1. Pernah dirawat

: ya

tidak

kapan :

diagnosa :

2. Riwayat penyakit kronik dan menular

ya

tidak

jenis

Riwayat kontrol : .............................Riwayat penggunaan obat :..............3. Riwayat alergi:

ObatMakananLain-lain

4. Riwayat operasi:

yayaya

tidaktidaktidak

jenisjenisjenis

yatidak

-

Kapan

:

-

Jenis operasi :

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

STIKes Surya Mitra Husada Kediri

RIWAYAT KESEHATAN KELUARGA

Ya

tidak

-

Jenis

:.....................................................................................................................................

-

Genogram :

PERILAKU YANG MEMPENGARUHI KESEHATANPerilaku sebelum sakit yang mempengaruhi kesehatan:

Masalah Keperawatan :

AlkoholMerokok

yaya

tidaktidak

keterangan.....................

keterangan.........................................................

Obat

ya

tidak

keterangan..............................................................

Olah raga

ya

tidak

keterangan..........................................................

OBSERVASI DAN PEMERIKSAAN FISIK

1.

Tanda tanda vital

S:

N:

T:

RR :

Kesadaran

Compos Mentis

Apatis

Somnolen

Sopor

Koma

2.

Sistem Pernafasan (B1)a. RR:................................

b. Keluhan:Batuk

sesakproduktif

nyeri waktu nafastidak produktif

orthopnea

Sekret:..Warna:..........

Konsistensi :......................Bau :..................................

c. Penggunaan otot bantu nafas:....................................................................................................................................................................................................................................................................................................................................................................

d. PCHe. Irama nafas

yateratur

tidaktidak teratur

f. Pleural Friction rub:.....................................................................................................................

g. Pola nafash. Suara nafasi. Alat bantu napas

DispnoeCraclesya

KusmaulRonkitidak

Cheyne StokesWheezing

Biot

Jenis................................................ Flow..............lpm

j. Penggunaan WSD:

--

Jenis : .................................................................................................................................................................Jumlah cairan : ...................................................................................................................... ............................

--

UndulasiTekanan

:...................................................................................................................................................: ..................................................................................................................................................

k. Tracheostomy:

ya

tidak

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


3.

Sistem Kardio vaskuler (B2)

a. TD :b. N :c. HR :


d. Keluhan nyeri dada:

ya

tidak

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

e. Irama jantung:

reguler

ireguler

f. Suara jantung:

normal (S1/S2 tunggal)gallop

murmurlain-lain.....

g. Ictus Cordis: .............................................................................................................................................................h. CRT :.............detik

i.

Akral:

hangat

kering

merah

basah

pucat

panas

dingin

j. Sikulasi perifer:

normal

menurun

k. JVPl. CVPm. CTR

:.................................:.................................:.................................

n. ECG & Interpretasinya:.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ ..............................................o. Lain-lain :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4.

Sistem Persyarafan (B3)

a. GCS : ..................................................b. Refleks fisiologis patella

triceps

biceps


c. Refleks patologis

babinsky

brudzinsky

kernig

Lain-lain

d. Keluhan pusing

ya

tidak

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

e. Pemeriksaan saraf kranial:

N1 :N2 :N3 :N4 :N5 :N6 :N7 :N8 :N9 :N10 :N11 :N12 :

normalnormalnormalnormalnormalnormalnormalnormalnormalnormalnormalnormal

tidaktidaktidaktidaktidaktidaktidaktidaktidaktidaktidaktidak

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

f. Pupilg. Sclerah. Konjunctiva

anisokoranikterusananemis anemis

isokorikterus

Diameter: /......


i. Isitrahat/Tidur :................. Jam/Hari

Gangguan tidur : ..............................................................

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

5.

Sistem perkemihan (B4)a. Kebersihan genetalia:b. Sekret:c. Ulkus:d. Kebersihan meatus uretra:

BersihAdaAdaBersih

KotorTidakTidak

Kotor

Masalah Keperawatan

e. Keluhan kencing:

Ada

Tidak

Bila ada, jelaskan:............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ ......................................................................................................................................................................................................................................................................................................................................................................................... .....

f. Kemampuan berkemih:

Spontan

Alat bantu, sebutkan: .................................................................................................

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

UkuranHari ke

:............................................:............................................

g. Produksi urine : ..Warna :............

ml/jam

Bau

:........

h. Kandung kemih :i. Nyeri tekanj. Intake cairan

Membesarya tidakoral : cc/hari

ya tidak

parenteral : cc/hari

k. Balance cairan:....................................................................................................................................................................................................................................................................................................................................... ...............................................................................................................................................................................................................k. Lain-lain:......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

6.

Sistem pencernaan (B5)a. TB :...............b. IMT :................

c. Mulut:d. Membran mukosa:

BBInterpretasi

bersihlembab

:................................:................................

kotor stomatitisberbau kering

Masalah Keperawatan : e Tenggorokansakit menelanpembesaran tonsil

kesulitan menelannyeri tekan

f. Abdomen:g. Nyeri tekan:h. Luka operasi:Tanggal operasiJenis operasiLokasiKeadaan

tegangyaada:................:................:................:................

kembungtidaktidak

ascites

Drain

:

ada

tidak

i.j.

---

JumlahWarnaKondisi area sekitar insersiPeristaltik:.............. x/menitBAB: ......................x/hari

:...................:...................:...................

Terakhir tanggal : ............................................................................

k.

Konsistensi:

keras

lunak

cair

lendir/darah


l.

Diet:

padat

lunak

cair

m.

Diet Khusus:....................................................................................................................................................................................................................................................................................................................................................................

n.o.

Nafsu makan:Porsi makan:

baikhabis

menuruntidak

Frekuensi:.......x/hariKeterangan:.......................

p.

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

7.

Sistem Penglihatana. Pengkajian segmen anterior dan posterior


OD

VisusPalpebraConjunctivaKorneaBMDPupilIrisLensaTIO

OS

b. Keluhan nyeri

ya

tidak

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

c. Luka operasi:Tanggal operasiJenis operasiLokasiKeadaan

ada:................:................:................:................

tidak

d. Pemeriksaan penunjang lain : .........................e. Lain-lain :............................................................................................................................................................................. .........................................................................................................................................................................................................................................................................................................................................................................

8. Sistem pendengaran

a.

Pengkajian segmen anterior dan posterior

OD

OS


AurciculaMAEMembranTymphaniRinneWeberSwabach


b.

Tes Audiometri................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................ ............................................

c. Keluhan nyeri

ya

tidak

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

d. Luka operasi:Tanggal operasiJenis operasiLokasiKeadaan

ada:................:................:................:................

tidak

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

8.

Sistem muskuloskeletal (B6)

a. Pergerakan sendi:b. Kekuatan otot:

c. Kelainan ekstremitas:

bebas

ya

tidak

terbatas


d. Kelainan tulang belakang: ya

tidak

Frankel: ................................................................................

e. Fraktur: ya

tidak

-

Jenis

:...................

f. Traksi: ya

tidak

---

JenisBebanLama pemasangan

:...................:...................:...................

g. Penggunaan spalk/gips:

ya

tidak

h. Keluhan nyeri:

ya

tidak

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

i.

Sirkulasi perifer: ..............................................

j.

Kompartemen syndrome ya

tidak

k.l.m.

Kulit:TurgorLuka operasi:

ikterikbaikada

sianosiskurangtidak

kemerahanjelek

hiperpigmentasi

Tanggal operasiJenis operasiLokasiKeadaan

:................:................:................:................

Drain

:

ada

tidak

---

JumlahWarnaKondisi area sekitar insersi

:...................:...................:...................

n. ROM

: .................................................


o. PODp. Cardinal Sign

: ................................................: ................................................

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

10.

Sistem Integumena. Penilaian resiko decubitus

b.c.

WarnaPitting edema: +/- grade:................


d.e.f.g.h.

Ekskoriasis:Psoriasis:Pruritus:Urtikaria:Lain-lain:

yayayaya

tidaktidaktidaktidak

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

11. Sistem Endokrina. Pembesaran tyroid:b. Pembesaran kelenjar getah bening:c. Hipoglikemia:d. Hiperglikemia:

yayayaya

tidaktidaktidaktidak


e. Kondisi kaki DM

- Luka gangren

ya

tidak

Jenis ................................................................................................................

- Lama luka- Warna- Luas luka- Kedalaman- Kulit kaki- Kuku kaki- Telapak kaki- Jari kaki

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

- Infeksi- Riwayat luka sebelumyaJika ya:

yaya

tidaktidak

---

TahunJenis LukaLokasi

:::

- Riwayat amputasi sebelumyaJika ya:

ya

tidak

--

TahunLokasi

::

f. ABI : ....................................................g. Lain-lain:....................................................................................................................................... ...............................................................................................................................................................................................................................................................................................................................................................................................................

STIKes Surya Mitra Husada KediriAspek YangDinilaiKriteria PenilaianNilaiAspek YangDinilai1234Persepsi SensoriTerbatasSepenuhnyaSangat TerbatasKeterbatasanRinganTidak AdaGangguanKelembabanTerus MenerusBasahSangat LembabKadang2 BasahJarang BasahAktifitasBedfastChairfastKadang2 JalanLebih SeringjalanMobilisasiImmobileSepenuhnyaSangat TerbatasKeterbatasanRinganTidak AdaKeterbatasanNutrisiSangat BurukKemungkinanTidak AdekuatAdekuatSangat BaikGesekan &PergeseranBermasalahPotensialBermasalahTidakMenimbulkanMasalahNOTE: Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien beresikomengalami dekubisus (pressure ulcers)(15 or 16 = low risk, 13 or 14 = moderate risk, 12 or less = high risk)Total Nilai

PENGKAJIAN PSIKOSOSIALa. Persepsi klien terhadap penyakitnya:.............................................................................................................................................................................................................................................................................................................................................................................................

b. Ekspresi klien terhadap penyakitnya

Masalah keperawatan :

Murung/diamc. Reaksi saat interaksi

gelisahkooperatif

tegangtidak kooperatif

marah/menangiscuriga

d. Gangguan konsep diri:.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................e. Lain-lain:.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

PERSONAL HYGIENE & KEBIASAANJelaskan :


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

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:.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)............................................................................................................................................................................................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

TERAPI................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................


DATA TAMBAHAN LAIN :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Kediri, ..20...

()


PROGRAM STUDI PENDIDIKAN NERSSTIKES SURYA MITRA HUSADA KEDIRI

ANALISIS DATA

STIKes Surya Mitra Husada KediriHari/Tgl/ JamDATAETIOLOGIMASALAH

PROGRAM STUDI PENDIDIKAN NERSSTIKES SURYA MITRA HUSADA KEDIRI

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

TANGGAL: .................................1.

2.

3.

4.

5.

6.


RENCANA INTERVENSI

STIKes Surya Mitra Husada KediriNo.Hari/ Tgl/JamDIAGNOSA KEPERAWATANNOC(Nursing Outcome Classification)NIC(Nursing Intervention Classification)

IMPLEMENTASI DAN EVALUASI KEPERAWATAN

STIKes Surya Mitra Husada KediriHari/Tgl/ShiftNo.DxJamImplementasiParafJamEvaluasi (SOAP)Paraf


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