kelompok 4 pengkajian

7/26/2019 KELOMPOK 4 PENGKAJIAN

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Sekolah Tinggi Ilmu Kesehatan Stella MarisJl. MAIPA NO.19 MAKASSAR

Program S1 Keperawatan an Ners

KAJIAN K!P!RA"ATAN M!#IKA$%&!#A'

Unit : .. Autoanamnese

Kamar : .. Alloanamnese .................................

Tgl masuk RS: ..........................................

Tgl pengkajian: .........................................

I. IDENTIFIKASI

A. PASIEN

Nama initial! : .......................................................................................................

Umur : .......................................................................................................

"enis kelamin : ......................................................................................................

Status perka#inan : .................................................................................................

"umla$ anak : .......................................................................................................

Agama% suku : .......................................................................................................

&arga negara : .......................................................................................................

'a$asa (ang )igunakan : ........................................................................................

Pen)i)ikan : ........................................................................................................

Pekerjaan : ........................................................................................................

Alamat ruma$ : ........................................................................................................

'. PENAN**UN* "A&A'

Nama : ...................................................................................................................

Umur : ...................................................................................................................

Alamat : ...................................................................................................................

+u,ungan )engan pasien : .....................................................................................

II. DATA -EDIK

A. Diagnosa -e)ik

Saat masuk : ..........................................................................................................

Saat pengkajian : .........................................................................................................

1Pengkajian Medikal Bedah STIK Stella Maris Program S1 Keperawatandan Ners

Nama -a$asis#a ang -engkaji: NI-:


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'. Pemeriksaan Diagnostik

/. 0a,oratorium

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1. US*

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2. 0ain3lain

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.4. T$erapi

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III. KEADAAN U-U-

A. KEADAAN SAKIT

Pasien tampak sakit ringan% se)ang % ,erat % ti)ak tampak sakit

Alasan : ................

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'. TANDA3TANDA 5ITA0

/. Kesa)aran :

Skala koma glasgo#



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Respon motorik :

Respon ,i6ara :

Respon mem,uka mata :

"umla$ :

Kesimpulan :

1. Tekanan )ara$ : .mm+g

Posisi : )u)uk ,aring ,er)iri

+ipotensi ortostatik : ...

-AP : .mm+g

Kesimpulan :

2. Su$u :..74

0okasi : oral a8illa re6tal9. Pernapasan : .8%menit

Irama : teratur kusmaul 6$e(nes3stokes

"enis : )a)a perut

. Na)i : ..8%menit

Irama : reguler irreguler

Kekuatan : kuat lema$

4. ANTR;P;-ETRI

/. 0ingkar 0engan Atas : ...............................................

1. Tinggi ,a)an : ...............................................

2. 'erat ,a)an : ...............................................

9. In)eks -assa Tu,u$ I-T! : ...............................................

Kesimpulan : 'erat ,a)an ,erle,i$

D. *EN;*RA-



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I5. PEN*KA"IAN P;0A KESE+ATAN

A. P;0A PERSEPSI KESE+ATAN DAN PE-E0I+ARAAN KESE+ATAN

/. Kea)aan Se,elum Sakit

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1. Ri#a(at Pen(akit Saat inia. Kelu$an utama : .

,. Ri#a(at kelu$an utama : .

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6. Ri#a(at pen(akit (ang perna$ )ialami

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). Ri#a(at kese$atan keluarga

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2. Pemeriksaan Fisik :

a. Ke,ersi$an ram,ut : ..

,. Ke,ersi$an kulit kepala: .

6. Ke,ersi$an kulit : ..

). Ke,ersi$an rongga mulut : ..

e. Ke,ersi$an genetalia : ..


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a. Kea)aan ram,ut : ................................................................................................

,. +i)rasi kulit : ................................................................................................

6. Palpe,ra%6onjungti=a : ................................................................................................

). S6lera : ................................................................................................

e. +i)ung : ................................................................................................


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1. Kea)aan Sejak Sakit

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2. ;,ser=asi

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9. Pemeriksaan


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2. ;,ser=asi

a. Akti=itas $arian :

makan :

man)i :

pakaian :

kerapi$an :

,uang air ,esar :

,uang air ke6il :

mo,ilisasi )i tempat ti)ur :

Kesimpulan : ..

,. Postur tu,u$ : ..

6. *a(a jalan : ..

). Anggota gerak (ang 6a6at : ..

e. Fiksasi :..............


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9. Pemeriksaan Fisik:

a. "5P : . 6m+1;

Kesimpulan : ..

,. Per


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'un(i jantung I T

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'un(i jantung I -

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'un(i jantung II irama gallop : ...............................................................................

-urmur : ....................................................................................

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+R : ....................................................................................

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'ruit Aorta

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A. Renalis: .....................................................................................

A. Femoralis

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e. 0engan )an tungkai

Atro


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Re I5 > 5I : .............................................................................................

N.5III Rom,erg Test : .............................................................................................

N. ?I : .............................................................................................

Kaku ku)uk : .............................................................................................

E. P;0A TIDUR DAN ISTIRA+AT


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2. ;,ser=asi

ekspresi #aja$ mengantuk

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,an(ak menguap

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palpe,ra in


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2. ;,ser=asi

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a. pengli$atan

kornea : ............................................................................................................

=isus : ............................................................................................................

pupil : ............................................................................................................

lensa mata: ............................................................................................................

tekanan intra okuler TI;!: .....................................................................................

,. pen)engaran

pina : ............................................................................................................

kanalis : ............................................................................................................

mem,ran timpani : .................................................................................................

test pen)engaran : .................................................................................................

6. pengenalan rasa pa)a gerakan lengan )an tungkai......................................................................................................................................

). N.I : ............................................................................................................

e. N.II : ............................................................................................................


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3 Klien mengatakan sering merasa ti)ak enak )alam )irin(a seperti ti)ak mampu

mena


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3 Klien mengatakan )ia ti)ak merasa )iku6ilkan )ari orang3orang )an ,a$kan teman

> teman men)oakan agar )ia )apat sem,u$.

2. ;,ser=asi

3 Ti)ak a)a gangguan )alam iteraksi )engan anggota keluarga atau orang lain.

3 Ti)ak a)a gangguan komunikasi =er,al seperti pelo@gagap@lata@ suara sengau@ )an

ti)ak ,isa mengu6apkan BRB

I. P;0A REPR;DUKSI DAN SEKSUA0ITAS


3 Klien mengatakan ,a$#a )irin(a masi$ ingin memiliki anak laki3laki karena 2

anakn(a semua perempuan.Kea)aan Sejak Sakit

3 Klien mengatakan su)a$ lama ti)ak melakukan $u,ungan suami istri )ikarenakan

klien )alam kea)aan sakit.

1. ;,ser=asi

Ti)ak a)a perilaku (ang men(impang )an ti)ak sesuai )engan jenis kelamin.

2. Pemeriksaan Fisik

a. Inspeksi Pa(u)ara )an Puting

Simetris : SimetrisKontur : ti)ak a)a

Ruam : ti)ak a)a

Ulkus : ti)ak a)a

Ra,as puting : ti)ak a)a

,. Palpasi Pa(u)ara )an Puting

-assa : ti)ak a)a

Elastisitas : elastisitas.

N(eri tekan : ti)ak a)a

6. Palpasi Kelenjar *eta$ 'ening

Pa(u)ara : ti)ak tera,a a)an(a ,enjolan

A8illa : ti)ak tera,a a)an(a ,enjolan

". P;0A -EKANIS-E K;PIN* DAN T;0ERANSI TER+ADAP STRES


3 Klien )apat mengontrol amara$ )an emosin(a seperti )iam sejenak!

3 Klien mengatakan ,a$#a jika a)a masala$ selalu ter,uka )engan anggota keluarga

)an jika a)a masala$ selalu )iselesaikan ,ersama3sama.



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3 Klien mengatakan )ia 6emas )engan kon)isin(a (ang sekarang.

3 Klien mengatakan )irin(a masi$ ,isa ter,uka )engan keluarga )an setiap masala$

)apat )iselesaikan )engan anggota keluargan(a.

2. ;,ser=asi

3 Ekspresi #aja$n(a meringis

K. P;0A SISTE- NI0AI KEPER4AAAN


3 Klien mengatakan )ia rutin melakukan i,a)a$ )i gereja setiap $ari minggu )an

mengikuti kegiatan )igereja.

1. Kea)aan Sejak Sakit3 Klien mengatakan ti)ak )apat pergi ke gereja )an mengikuti i,a)a$ krna kon)isin(a

(ang sekarang@ tapi pasien masi$ sering ,er)oa.

2. ;,ser=asi

3 Tampak a)a alkita, )i sisi kanan tempat ti)ur

3 Tampak pasien menggunakan kalung sali,

-akassar@ .....................................................i

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17Pengkajian Medikal Bedah STIK Stella Maris Program S1 Keperawatan

kelompok 4 pengkajian

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