ASUHAN KEPERAWATAN MEDIKAL BEDAH

Nama Mahasiswa :

Nim :

Tempat Praktik :

Tanggal :

PENGKAJIAN

Identitas

1. Identitas Klien

Nama :...........................................................................L/P Usia (......)

Tempat & tgl Lahir :.....................................................................................................

Golongan Darah : O/ A/ B/ AB

Agama : Islam/ Protestan/ Katolik/ Hindu/ Budha/ Konghuchu

Suku :.....................................................................................................

Status Perkawinan : Kawin/ Belum kawin/ Janda/ Duda (Cerai: Hidup/ Mati)

Pendidikan Terakhir : .....................................................................................................

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

TB/ BB :..........................Cm ..............................Kg..................................

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

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Telp. ................................/.....................................

2. Identitas Penanggungjawab

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

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

Jenis Kelamin : P/L

Agama : Islam/ Protestan/ Katolik/ Hindu/ Budha/ Konghuchu

Suku : .....................................................................................................

Hubungan dg Pasien : .....................................................................................................

Pendidikan Terakhir : .....................................................................................................

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

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

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

Telp. ................................/.....................................

RIWAYAT KELUARGA

Genogram

Keterangan:

RIWAYAT LINGKUNGAN HIDUPTipe Tempat tinggal : .....................................................................................................Jumlah Kamar : .....................................................................................................Kondisi Tempat Tinggal :......................................................................................................Jumlah Orang Yang Tinggal Di Rumah: Laki-Laki :............orang Perempuan :......... orang

STATUS KESEHATAN Status Kesehatan Saat Ini Alasan Masuk Rumah Sakit/ Keluhan Utama :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Faktor Pencetus:........................................................................................................................... ......................................................................................................................................................Timbulnya Keluhan : ( ) Bertahap ( ) MendadakFaktor yang memperberat: .................................................................................................................................................................................................................................................................Pemahaman & Penatalaksanaan Masalah KesehatanUpaya Yang Dilakukan Untuk Mengatasinya:Diagnosa Medik :Tanggal :

Tanggal :Tanggal :Status Kesehatan Masa LaluPenyakit yang Pernah Dialami : ..................................................................................................Kecelakaan :Pernah Dirawat :Penyakit :Waktu :Operasi : Alergi : Agen:

Reaksi Spesifik:Obat-obatan :Makanan :Faktor Lingkungan :Satus Imunisasi :Tetanus, Desentri : influinza:Pnemovaks :Kebiasaan : Merokok/ kopi/ obat/ alkohol, lain-lain yang merugikan

kesehatan:.................................................................................Obat-Obatan

No Nama Dosis Keterangan

TINJAUAN SISTEMKeadaan Umum :..................................................................................................

...................................................................................................Tingkat kesadaran :Composmentis, Apatis, Somnolen, Suporus, ComaSkala GCS : Eye .................. Verbal .............. Motorik................Tanda- Tanda Vital : TD:................. N:............... RR:................. S:.......................

1. Sistem Pernafasan Gejala (Subjektif):a. Dispnea:b. Riwayat Penyakit Sistem pernafasan : ( ) Bronkhitis

( ) Asma ( ) TBC ( )Emfisema ( ) Pneumonia ( ) Lain-lain..................

c. Perokok : ..................... Pak/ Hari Lama: .................. (Bulan/ Tahun)

d. Penggunaan Alat bantu :.........................................................................................

Tanda (Objektif) a. Pernafasan : 1) Frekwensi:............. 2) Kedalaman: ............... 3) Simetris :.................b. Penggunaan Otot bantu nafas: ..................................... Cuping Hidung:......................c. Batuk :.................. Sputum (Karakteristik Sputum):.....................................................

d. Bunyi Nafas :................................................................................................................e. Sianosis:........................................................................................................................f. Gelisah :.......................................................................................................................

..2. Sistem Kardiovaskuler

a. Tekanan Darah (TD) b. Nadi Palpasi :c. Bunyi jantung :................Irama:....................... Kualiltas...................... Murmur............d. Ekstrimitas: Akral:.................... Warna................ CRT.................... Plebitis.................e. Warna: Membran Mukosa:..................... Bibir................. Konjungtiva..................

Punggung kuku........................... Skela................................3. Sistem Integumen

Gejala ( Subjektif)a. Riwayat gangguan kulit:b. Keluhan klien:

Tanda (Objektif)a. Lesi kulit:b. Jumlah lesi:c. Penyebaran lesi:d. Abnormalitas kuku:e. abnormalitas

4. Sistem Perkemihan

Gejala Subjektif a. Riwayat penyakit ginjal/ kandung kemih: .................................................................b. Riwayat penggunaan deuritik:....................................................................................c. Rasa nyeri/ rasa terbakar saat kencing:......................................................................d. Konsultasi BAK:........................................................................................................Tanda (objektif)a. Pola BAK: .............................. Frekuensi:.............................Retensi.....................b. Perubahan kandung kemih:.......................... Distensi Kandung Kemih:...................c. Karakteristik urine: Warna...................... Jumlah.................... Bau...........................

5. Sistem GastrointestinalGejala (subjektif)

a. Diit biasa (tipe):.......................................... Jumlah makan per hari:.......................b. Pola diit:....................................................... Makan terakhir:...................................c. Nafsu/ selera makan:...................................Mual/ Muntah:.....................................d. Nyeri Ulu Hati:............................................................................................................e. Alergi Makanan:...........................................................................................................f. Masalah mengunyah/ menelan:....................................................................................Tanda (objektif)

a. BB:.................................................TB:.....................................b. Turgor kulit:............................................. Tonus Otot:...............................................c. Edema:....................................................... Acites:.......................................................

d. Kondisi Mulut: Gigi.................. Mukosa Mulut: ............................Lidah:..................e. Bising Usus:.................................................................................................................

6. Sistem Eliminasi Gejala (subjektif) a. Pola BAB:..................................................................................................................b. Kesulitan BAB: Konstipasi:................................. Diare:...........................................c. Penggunaan Laksantif:...............................................................................................d. BAB terakhir:.............................................................................................................e. Riwayat perdarahan:...................................................................................................f. Riwayat inkontinensia alvi:........................................................................................

Tanda (objektif) a. Abdomen : Nyeri tekan:................................... Lunak/ Keras:.............................

Massa:............................. Lingkar Abdomen: ............... Bising Usus:.................Integritas kulit perut:.............................................................................................

b. Hemoroid:

7. Sistem Endokrin Gejala (subjektif) .................................................................................................................................................................................................................................................................................................................................................................................................................................Tanda (objektif) .................................................................................................................................................................................................................................................................................................................................................................................................................................

8. Sistem ImuneGejala (subjektif).................................................................................................................................................................................................................................................................................................................................................................................................................................Tanda (objektif) .................................................................................................................................................................................................................................................................................................................................................................................................................................

9. Sistem MuskuloskeletalGejala (subjektif) Keluhan:......................................................................................................................................................................................................................................................................

Tanda (objektif)

Kekuatan otot :Tonus otot :Kemampuan aktifitas :Deformitas :

10. Sistem Reproduksi Gejala (subjektif)

Tanda (objektif)

11. Sistem PersyarafanGejala (subjektif)

Tanda (objektif) GCS : Nervous Cranial 1-12 :Reflek normal :Reflek Patologis :

12. Sistem PenglihatanGejala (subjektif)

Tanda (objektif) Konjungtiva :Pupil :Sklera :Penampilan Bola Mata :Pergerakan bola Mata :

13. Sistem Pendengaran Gejala (subjektif)

Tanda (objektif) Daun Telinga : Liang telinga :Fungsi Pendengaran :

14. Sistem PengecapanGejala (subjektif)

Tanda (objektif) Membedakan rasa:Warna lidah:

15. Sistem Penciuman

Gejala (subjektif)

Tanda (objektif) Membedakan Bau:

DATA TAMBAHAN POLA SEBELUM DI RS SESUDAH DI RS

Pola istirahat tidur WaktuLama TidurKebiasaan Pengantar TidurKesulitan Tidur Pola Aktifitas Dan Latihan Kegiatan Sehari-hariOlah ragaKegiatan waktu luangPola Bekerja Jenis PekerjaanJumlah Jam KerjaJadwal Kerja

ASPEK PSIKOSOSIALPola Pikir dan Persepsi:Konsep Diri:Komunikasi/ hubungan:Mekanisme koping:Sistem dan nilai kepercayaan:

PERSEPSI KLIEN TENTANG PENYAKIT

A. Harapan Klien:

B. Analisa Data No Data Etiologi Problem

C. RENCANA KEPERAWATANNo RM: Nama: Usia:No. Dx

Kep

Hari& Tanggal Pukul

Tujuan Tindakan Rasional

D. IMPLEMENTASI DAN EVALUASI No RM: Nama: Usia:No. Dx

Kep

Hari& Tanggal Pukul

TindakanTanda Tangan

Hari& Tanggal Pukul

EvaluasiTanda Tangan