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BAB II
ASUHAN KEPERAWATAN
PENGKAJIAN
Tgl. Pengkajian : 25 Agustus
2015
Jam Pengkajian : 15.00
Ruang/Kelas : Seruni/III
No. Register : 1504010089
Tgl. MRS : 24 Agustus
2015
I. IDENTITAS
1. Identitas Pasien
2. Identitas Penanggung Jawab
Nama : Ny. N Nama : Tn. T
Umur : 49 Tahun Umur : 54 Tahun
Jenis Kelamin : Perempuan Jenis
Kelamin : Laki-Laki
Agama : Islam Agama : Islam
Pendidikan : PT Pekerjaan
: Swasta
Pekerjaan : IRT Alamat : RST
Alamat : RST dr. SOEPRAOEN MALANG Hubungan dengan
Klien : Suami
II. KELUHAN UTAMA
1. Keluhan Utama Saat MRS
Nyeri
2. Keluhan Utama Saat Pengkajian
Ny. N mengatakan nyeri pada luka bekas operasi dileher, saat
digerakkan semakin sakit, nyeri seperti tertusuk dengan skala 4.
Ny. N juga mengatakan mengalami kesulitan tidur selama MRS,
biasanya dirumah lama tidur 6-8 jam. Namun, pada saat di RS
Ny. N mengatakan tidur kurang dari 3 jam, karena terbangun
mendengar suara pasien yang lain.
III. DIAGNOSA MEDIS
Non Toxic Nodular Gorter
IV. RIWAYAT KESEHATAN
1. Riwayat Penyakit Sekarang
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2. Riwayat Kesehatan Yang Lalu
Ny. N mengatakan dahulu mempunyai riwayat penyakit maag
akut., tetapi sekarang sudah pulih.
3. Riwayat Kesehatan Keluarga
Ibu Ny. N mempunyai riwayat penyakit DM dan adik dari Ny. N
mempunyai riwayat Asma.
V. RIWAYAT KEPERAWATAN KLIEN1. Pola Aktifitas Sehari-hari (ADL)
ADL Di Rumah Di Rumah Sakit
Pola pemenuhan
kebutuhan nutrisi dan
cairan
makan 3x/hari., habis 1
porsi. Nasi, lauk, sayuran
dan buah. Tidak ada
gangguan menelan.
Minum 5-6 gelas perhari.
makan 3x/sehari, tetapi
setengah porsi. Karena
kurang menyukai
makanan dari RS.
Terkadang makan
pisang.
Minum 3-4 gelas
perhari.
Pola Eliminasi
Pola Istirahat Tidur
Pola Kebersihan Diri
(PH
Aktivitas Lain
2. Riwayat Psikologi
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3. Riwayat sosial
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4. Riwayat spiritual
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VI. PEMERIKSAAN FISIKA. PEMERIKSAAN TANDA-TANDA VITAL
a. Tensi : …………… e. BB : ................................
b. Nadi : …………… f. TB : ................................
c. RR : …………… g. LLA : ................................
d. Suhu : ……………… h. Pasien termasuk : ( Kurus / Ideal / Gemuk )
B. KEADAAN UMUM
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C. PEMERIKSAAN INTEGUMENT, RAMBUT DAN KUKU
1. Pemeriksaan Integument
Inspeksi :
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Palpasi :
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2. Pemeriksaan Rambut
Inspeksi dan Palpasi :
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3. Pemeriksaan Kuku
Inspeksi dan palpasi :
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Keluhan yang dirasakan oleh klien yang berhubungan dengan Px. Kulit :
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D. PEMERIKSAAN KEPALA, WAJAH DAN LEHER
1. Pemeriksaan Kepala
Inspeksi :
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Palpasi :
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2. Pemeriksaan Mata
Inspeksi :
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3. Pemeriksaan Telinga
Inspeksi dan palpasi :
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4. Pemeriksaan Hidung
Inspeksi dan palpasi :
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5. Pemeriksaan Mulut dan Faring
Inspeksi dan Palpasi :
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6. Pemeriksaan Leher
Inspeksi :
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Palpasi :
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Keluhan yang dirasakan klien terkait dengan Px. Kepala, wajah,
leher: ..........................................................................................................................
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E. PEMERIKSAAN PAYUDARA DAN KETIAK
a. Inspeksi
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b. Palpasi
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Keluhan lain yang terkait dengan Px. Payudara dan ketiak :
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F. PEMERIKSAAN TORAK DAN PARU
a. Inspeksi
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b. Palpasi
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c. Perkusi
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d. Auskultasi
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Keluhan lain yang dirasakan terkait Px. Torak dan Paru :
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G. PEMERIKSAAN JANTUNG
a. Inspeksi
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b. Palpasi
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c. Perkusi
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d. Auskultasi
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Keluhan lain terkait dengan jantung :
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H. PEMERIKSAAN ABDOMEN
a. Inspeksi
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b. Auskultasi
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c. Palpasi
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Keluhan lain yang dirasakan terkait dengan Px. Abdomen :
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I. PEMERIKSAAN GENETALIA
Genetalia Pria
a. Inspeksi :
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b. Palpasi :
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Keluhan lain yang dirasakan terkait dengan Px. Genetalia :
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J. PEMERIKSAAN ANUS
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Keluhan lain yang dirasakan terkait dengan Px. Anus :
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K. PEMERIKSAAN MUSKULOSKELETAL ( EKSTREMITAS )
a. Inspeksi
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b. Palpasi
Oedem :
Lingkar lengan :
Lakukan uji kekuatan otat :
Keluhan lain yang dirasakan terkait dengan Px. Muskuloskeletal :
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L. PEMERIKSAAN NEUROLOGIS
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MEMERIKSA REFLEK KEDALAMAN TENDON
1. Reflek fisiologis
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2. Reflek Pathologis
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Keluhan lain yang terkait dengan Px. Neurologis :
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M. PEMERIKSAAN LABORATORIUM
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N. PEMERIKSAAN PENUNJANG
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O. TERAPI YANG TELAH DIBERIKAN
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TTD PERAWAT
( )
ANALISA DATA
No
Tgl/
DATA ETIOLOGI
MASALAH
jam
1
DIAGNOSA KEPERAWATAN DAN PRIORITAS DIAGNOSA
No
Tgl/ Jam
DIAGNOSA
1
2
3
Nyeri akut berhubungan dengan agen cidera fisik (prosedur operasi)
Resiko Infeksi berhubungan dengan prosedur invasif
Gangguan pola tidur berhubungan dengan restrain fisik dan kurang privasi
RENCANA KEPERAWATAN
NoDx
Tgl/ jam
NOC NIC
1 25.8.15/
Setelah dilakukan tindakan keperawatan selama 3x24
Manajemen Nyeri1. Lakukan pengkajian nyeri
16.00 jam diharapkan klien dapat mengontrol nyeri yang adekuat dengan kriteria hasil sebagai berikut :1. Melaporkan nyeri sudah
terkontrol (5)2. Mengenali gejala nyeri
(5)3. Gunakan analgesik sesuai
saran (5)4. Gunakan teknik
nonfarmakologi (5)
meliputi lokasi, karakteristik, durasi, frekuensi, kualitas dan faktor presipitasi
2. Observasi reaksi nonverbal dari ketidaknyamanan
3. Kontrol lingkungan yang dapat mempengaruhi nyeri seperti suhu ruangan, pencahayaan dan kebisingan
4. Kurangi faktor presipitasi nyeri
5. Ajarkan teknik non farmakologi
6. Berikan analgetik untuk mengurangi nyeri
2. Setelah dilakukan tindakan keperawatan selama 3x24 jam diharapkan klien dapat menunjukkan kontrol infeksi yang adekuat dengan kriteria hasil :1. Tanda dan gejala infeksi
tidak muncul (5)2. Mencegah timbulnya
infeksi (5)
Proteksi Terhadap Infeksi1. Monitor tanda dan gejala
infeksi sistemik dan lokal2. Monitor hitung granulosit,
WBC3. Monitor kerentanan
terhadap infeksi4. Berikan perawatan kulit
pada area epidema5. Inspeksi kulit dan membran
mukosa terhadap kemerahan, panas, drainase
6. Inspeksi kondisi luka / insisi bedah
7. Dorong masukkan nutrisi dan cairan yang cukup
8. Dorong klien untuk istirahat9. Instruksikan klien untuk
minum antibiotik sesuai resep
10. Ajarkan klien dan keluarga tanda dan gejala infeksi
11. Laporkan kecurigaan infeksi
3. Setelah dilakukan tindakan keperawatan selama 2x24 jam, diharapkan klien dapat
Peningkatan tidur1. Pantau pola tidur2. Monitor TTV
menunjukkan pola tidur yang adekuat dengan kriteria hasil :1. Ju
mlah jam tidur dalam batas normal 6-8 jam/hari (5)
2. Pola tidur, kualitas dalam batas normal (5)
3. Perasaan segar sesudah tidur atau istirahat (5)
4. Mampu mengidentifikasi hal-hal yang meningkatkan tidur (5)
3. Kaji fakor penyebab gangguan tidur
4. Ciptakan lingkungan yang nyaman
5. Monitor waktu makan dan minum dengan waktu tidur
6. Monitor kebutuhan tidur klien
IMPLEMENTASI DAN EVALUASINo. Dx
Tgl/ Jam/ TTD
IMPLEMENTASITgl/ Jam/ TTD
EVALUASI
