SEKOLAH TINGGI ILMU KESEHATAN NAHDLATUL ULAMA TUBAN PROGRAM STUDI S1 KEPERAWATANJL. LETDA SECIPTO NO. 211 TUBAN TELP. 0356-325789 FAX. 333237 Email : STIKES-NU@Yahoo.Co.Id

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 : .................................... c. Pola nafas irama: Teratur Tidak teratur d. 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 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 g. Bunyi jantung: Normal Murmur Gallop lain-lain h. Irama jantung: Reguler Ireguler S1/S2 tunggal Ya Tidak i. Akral: Hangat Panas Dingin kering Dingin basah j. Siklus perifer Normal Menurun 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 : j. Refleks fisiologis: patella triceps biceps k. Refleks patologis: babinsky budzinsky kernig l. Keluhan Pusing O ya O Tidak P : ..................................................................................... Q : ..................................................................................... R : ..................................................................................... S : ..................................................................................... T : .....................................................................................

sopor

koma

lain-lain: lain-lain

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 : .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... 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 d. Mulut : e. Mukosa mulut : f. Tenggorokan

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 n. Odema: Ada Tidak ada Lokasi 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 PERSEPSI SANGAT KETERBATASAN SENSORI TERBATAS RINGAN KELEMBABAN SANGAT LEMBAB KADANG-KADANG BASAH AKTIVITAS CHAIRFAST KADANG-KADANG JALAN MOBILISASI IMMOBILE SANGAT KETERBATASAN SEPENUHNYA TERBATAS RINGAN NUTRISI SANGAT BURUK KEMUNGKINAN ADEKUAT TIDAK ADEKUAT GESEKAN & BERMASALAH POTENSIAL TIDAK PERGESERAN BERMASALAH 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) Aspek yang dinilai 1 TERBATAS SEPENUHNYA TERUS MENERUS BASAH BEDFAST NILAI 4 TIDAK ADA GANGGUAN JARANG BASAH LEBIH SERING JALAN TIDAK ADA KETERBATASAN SANGAT BAIK

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 c. Hiperglikemia Ya Tidak Hipoglikemia 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 HYGIENa. 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 KEPERAWATAN1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

No Dx

Kriteria Hasil/ Tujuan

Tgl/jam

INTERVENSI, IMPLEMENTASI Intervensi Rasional

Implementasi

Tgl/jam

TTD

No

Diagnosa

EVALUASI Tgl/jam

SOAP

TTD