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STIKes Eka Harap Palangka Raya
YAYASAN EKA HARAP PALANGKA RAYASEKOLAH TINGGI ILMU KESEHATANPROGRAM STUDI S1 KEPERAWATAN
Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536) 3327707
FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH
Nama Mahasiswa : ……………………………………………………….NIM : ……………………………………………………….Ruang Praktek : ……………………………………………………….Tanggal Praktek : ……………………………………………………….Tanggal & Jam Pengkajian : ……………………………………………………….
I. PENGKAJIANA. IDENTITAS PASIEN
Nama : ……………………………………………………………..Umur : ……………………………………………………………..Jenis Kelamin : ……………………………………………………………..Suku/Bangsa : ……………………………………………………………..Agama : ……………………………………………………………..Pekerjaan : ……………………………………………………………..Pendidikan : ……………………………………………………………..Status Perkawinan : ……………………………………………………………..Alamat : ……………………………………………………………..Tgl MRS : ……………………………………………………………..Diagnosa Medis : ……………………………………………………………..
B. RIWAYAT KESEHATAN /PERAWATAN1. Keluhan Utama :
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2. Riwayat Penyakit Sekarang:...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …......................................................................................................................................................................……............................................................................................................................................................... …...................................................................................................................................................................... …......................................................................................................................................................................……............................................................................................................................................................... …...................................................................................................................................................................... …......................................................................................................................................................................……............................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …......................................................................................................................................................................……............................................................................................................................................................... …
3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi)
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
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4. Riwayat Penyakit Keluarga...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …...................................................................................................................................................................... …......................................................................................................................................................................
GENOGRAM KELUARGA:
C. PEMERIKASAAN FISIK1. Keadaan Umum:
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2. Status Mental :a. Tingkat Kesadaran : ………………….b. Ekspresi wajah : ………………….c. Bentuk badan : ………………….d. Cara berbaring/bergerak : ………………….e. Berbicara : ………………….f. Suasana hati : ………………….g. Penampilan : ………………….h. Fungsi kognitif :
Orientasi waktu : …………………. Orientasi Orang : …………………. Orientasi Tempat : ………………….
i. Halusinasi : Dengar/Akustic Lihat/Visual Lainnya ...........................................................j. Proses berpikir : Blocking Circumstansial Flight oh ideas Lainnya
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
k. Insight : Baik Mengingkari Menyalahkan orang lainm. Mekanisme pertahanan diri : Adaptif Maladaptifn. Keluhan lainnya : ………………….
3. Tanda-tanda Vital :a. Suhu/T : ……………….0C Axilla Rektal Oralb. Nadi/HR : ………………x/mtc. Pernapasan/RR : …..…………..x/tmd. Tekanan Darah/BP : ……...………..mm Hg
4. PERNAPASAN (BREATHING)Bentuk Dada : .................................................................................................Kebiasaan merokok : …………………………………...Batang/hari Batuk, sejak .............................................................................……………………………………… Batuk darah, sejak .................................................................……………………………………… Sputum, warna .......................................................................……………………………………… Sianosis Nyeri dada Dyspnoe nyeri dada Orthopnoe Lainnya …….……….. Sesak nafas saat inspirasi Saat aktivitas Saat istirahatType Pernafasan Dada Perut Dada dan perut
Kusmaul Cheyne-stokes Biot Lainnya
Irama Pernafasan Teratur Tidak teraturSuara Nafas Vesukuler Bronchovesikuler
Bronchial TrakealSuara Nafas tambahan Wheezing Ronchi kering
Ronchi basah (rales) Lainnya……………Keluhan lainnya : ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
5. CARDIOVASCULER (BLEEDING) Nyeri dada Kram kaki Pucat Pusing/sinkop Clubing finger Sianosis Sakit Kepala Palpitasi Pingsan Capillary refill > 2 detik < 2 detik Oedema : Wajah Ekstrimitas atas
Anasarka Ekstrimitas bawah Asites, lingkar perut ……………………. cm Ictus Cordis Terlihat Tidak melihatVena jugularis Tidak meningkat MeningkatSuara jantung Normal,………………….
Ada kelainan
Keluhan lainnya : ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :......................................................................................................................................................................
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
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6. PERSYARAFAN (BRAIN)Nilai GCS : E : …………………. V : ………………….
M : ………………….Total Nilai GCS : ……………………Kesadaran : Compos Menthis Somnolent Delirium
Apatis Soporus ComaPupil : Isokor Anisokor
Midriasis Meiosis Refleks Cahaya : Kanan Positif Negatif
Kiri Positif Negatif Nyeri, lokasi ……………………………….. Vertigo Gelisah Aphasia Kesemutan Bingung Disarthria Kejang Trernor PeloUji Syaraf Kranial :Nervus Kranial I : .....................................................................................................................Nervus Kranial II : .....................................................................................................................Nervus Kranial III : .....................................................................................................................Nervus Kranial IV : .....................................................................................................................Nervus Kranial V : .....................................................................................................................Nervus Kranial VI : .....................................................................................................................Nervus Kranial VII : .....................................................................................................................Nervus Kranial VIII : .....................................................................................................................Nervus Kranial IX : .....................................................................................................................Nervus Kranial X : .....................................................................................................................Nervus Kranial XI : .....................................................................................................................Nervus Kranial XII : .....................................................................................................................Uji Koordinasi :Ekstrimitas Atas : Jari ke jari Positif Negatif
Jari ke hidung Positif NegatifEkstrimitas Bawah : Tumit ke jempul kaki Positif NegatifUji Kestabilan Tubuh : Positif NegatifRefleks :Bisep : Kanan +/- Kiri +/- Skala…………. Trisep
: Kanan +/- Kiri +/- Skala…………. Brakioradialis : Kanan +/- Kiri +/- Skala…………. Patella
: Kanan +/- Kiri +/- Skala…………. Akhiles: Kanan +/- Kiri +/- Skala…………. Refleks
Babinski Kanan +/- Kiri +/- Refleks lainnya : .....................................................................................................................Uji sensasi : .....................................................................................................................
.....................................................................................................................Keluhan lainnya : ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
7. ELIMINASI URI (BLADDER) :Produksi Urine : ………….ml…………x/hrWarna : Bau : Tidak ada masalah/lancer Menetes Inkotinen Oliguri Nyeri Retensi Poliuri Panas Hematuri Dysuri Nocturi
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
Kateter Cystostomi
Keluhan Lainnya : ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
8. ELIMINASI ALVI (BOWEL) :Mulut dan FaringBibir : ..................................................................................................................................Gigi : ..................................................................................................................................Gusi : ..................................................................................................................................Lidah : ..................................................................................................................................Mukosa : ..................................................................................................................................Tonsil : ..................................................................................................................................Rectum :Haemoroid :BAB : ……….x/hr Warna :..……… . Konsistensi : ……………. Tidak ada masalah Diare Konstipasi Kembung Feaces berdarah Melena Obat pencahar LavementBising usus : ......................................................................................................................Nyeri tekan, lokasi : ......................................................................................................................Benjolan, lokasi : ......................................................................................................................Keluhan lainnya : ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
9. TULANG - OTOT – INTEGUMEN (BONE) : Kemampuan pergerakan sendi Bebas Terbatas Parese, lokasi Paralise, lokasi Hemiparese, lokasi Krepitasi, lokasi Nyeri, lokasi Bengkak, lokasi Kekakuan, lokasi Flasiditas, lokasi Spastisitas, lokasi Ukuran otot Simetris
Atropi Hipertropi Kontraktur Malposisi
Uji kekuatan otot : Ekstrimitas atas……….. Ekstrimitas bawah…….. Deformitas tulang, lokasi............................................................................................................................ Peradangan, lokasi Perlukaan, lokasi Patah tulang, lokasiTulang belakang Normal Skoliosis
Kifosis Lordosis
10. KULIT-KULIT RAMBUTRiwayat alergi Obat......................................................................................................
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
Makanan............................................................................................... Kosametik............................................................................................. Lainnya.................................................................................................
Suhu kulit Hangat Panas DinginWarna kulit Normal Sianosis/ biru Ikterik/kuning
Putih/ pucat Coklat tua/hyperpigmentasiTurgor Baik Cukup KurangTekstur Halus KasarLesi : Macula, lokasi
Pustula, lokasi....................................................................................... Nodula, lokasi....................................................................................... Vesikula, lokasi..................................................................................... Papula, lokasi........................................................................................ Ulcus, lokasi..........................................................................................
Jaringan parut lokasiTekstur rambut ..................................................................................................................................Distribusi rambutBentuk kuku Simetris Irreguler
Clubbing Finger LainnyaMasalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
11. SISTEM PENGINDERAAN :a. Mata/Penglihatan
Fungsi penglihatan : Berkurang Kabur Ganda Buta/gelap
Gerakan bola mata : Bergerak normal Diam Bergerak spontan/nistagmus
Visus : Mata Kanan (VOD) :...........................................................................................Mata kiri (VOS) :............................................................................................
Selera Normal/putih Kuning/ikterus Merah/hifema Konjunctiva Merah muda Pucat/anemic
Kornea Bening KeruhAlat bantu Kacamata Lensa kontak Lainnya…….Nyeri : Keluhan lain :
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b. Telinga / Pendengaran :Fungsi pendengaran : Berkurang Berdengung Tuli
c. Hidung / Penciuman:Bentuk : Simetris Asimetris Lesi Patensi Obstruksi Nyeri tekan sinus TransluminasiCavum Nasal Warna………………….. Integritas……………..Septum nasal Deviasi Perforasi Peradarahan Sekresi, warna ……………………… Polip Kanan Kiri Kanan dan Kiri
Masalah Keperawatan :..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
12. LEHER DAN KELENJAR LIMFE
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
Massa Ya TidakJaringan Parut Ya TidakKelenjar Limfe Teraba Tidak terabaKelenjar Tyroid Teraba Tidak terabaMobilitas leher Bebas Terbatas
13. SISTEM REPRODUKSIa. Reproduksi Pria
Kemerahan, LokasiGatal-gatal, LokasiGland Penis .....................................................................................Maetus Uretra .................................................................................Discharge, warnaSrotum .........................................................................................Hernia .........................................................................................Kelainan ……………………………………………Keluhan lain ………………………………………….
a. Reproduksi WanitaKemerahan, LokasiGatal-gatal, LokasiPerdarahan .....................................................................................Flour Albus .................................................................................Clitoris .............................................................................................Labis .........................................................................................Uretra .........................................................................................Kebersihan : Baik Cukup KurangKehamilan : ……………………………………Tafsiran partus : ……………………………………Keluhan lain.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Payudara : Simetris Asimetris Sear Lesi Pembengkakan Nyeri tekanPuting : Menonjol Datar Lecet Mastitis
Warna areola ..........................................................................................................................................
ASI Lancar Sedikit Tidak keluarKeluhan lainnya.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Masalah Keperawatan : .................................................................................................................................................................
D. POLA FUNGSI KESEHATAN1. Persepsi Terhadap Kesehatan dan Penyakit :
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......................................................................................................................................................................2. Nutrisida Metabolisme
TB : CmBB sekarang : KgBB Sebelum sakit : Kg
Diet : Biasa Cair Saring LunakDiet Khusus : Rendah garam Rendah kalori TKTP Rendah Lemak Rendah Purin Lainnya……….
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
Mual
Muntah…………….kali/hariKesukaran menelan Ya TidakRasa hausKeluhan lainnya....................................................................................................................................................................................................................................
Pola Makan Sehari-hari Sesudah Sakit Sebelum Sakit
Frekuensi/hari
Porsi
Nafsu makan
Jenis Makanan
Jenis Minuman
Jumlah minuman/cc/24 jam
Kebiasaan makan
Keluhan/masalah
Masalah Keperawatan…………………………………………………………………………………………………
3. Pola istirahat dan tidur…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………
4. Kognitif :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………
5. Konsep diri (Gambaran diri, ideal diri, identitas diri, harga diri, peran ) :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………
6. Aktivitas Sehari-hari…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………
7. Koping –Toleransi terhadap Stress…………………………………………………………………………………………………
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………
8. Nilai-Pola Keyakinan………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Masalah Keperawatan…………………………………………………………………………………………………
E. SOSIAL - SPIRITUAL1. Kemampuan berkomunikasi
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2. Bahasa sehari-hari……………………………………………………………………………………………………………………………………………………………………………………………………
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3. Hubungan dengan keluarga :…………………………………………………………………………………………………
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4. Hubungan dengan teman/petugas kesehatan/orang lain :…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
5. Orang berarti/terdekat :………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
6. Kebiasaan menggunakan waktu luang :………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
7. Kegiatan beribadah :……………………………………………………………………………………………………………………………………………………………………………………………………
F. DATA PENUNJANG (RADIOLOGIS, LABORATO RIUM, PENUNJANG LAINNYA)
G. PENATALAKSANAAN MEDIS
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
…. …………..……………..Mahasiswa
( ………………………………)
Lampiran 12 Format Diagnosa Keperawatan
YAYASAN EKA HARAP PALANGKA RAYASEKOLAH TINGGI ILMU KESEHATANPROGRAM STUDI S1 KEPERAWATAN
Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536) 3327707
ANALISIS DATA
DATA SUBYEKTIF DAN DATA OBYEKTIF KEMUNGKINAN PENYEBAB MASALAH
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
Prioritas Masalah
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
Lampiran 13 Format Intervensi Keperawatan
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
YAYASAN EKA HARAP PALANGKA RAYASEKOLAH TINGGI ILMU KESEHATANPROGRAM STUDI S1 KEPERAWATAN
Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536) 3327707
RENCANA KEPERAWATAN
Nama Pasien : ……………………..
Ruang Rawat : ……………………..
Diagnosa Keperawatan Tujuan (Kriteria hasil) Intervensi Rasional
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
Lampiran 14 Format Implementasi Dan Evaluasi Keperawatan
YAYASAN EKA HARAP PALANGKA RAYASEKOLAH TINGGI ILMU KESEHATANPROGRAM STUDI S1 KEPERAWATAN
Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536) 3327707
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
IMPLEMENTASI DAN EVALUASI KEPERAWATAN
Hari/TanggalJam
Implementasi Evaluasi (SOAP)Tanda tangan
danNama Perawat
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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STIKes Eka Harap Palangka Raya
Pedoman Penyususnan & Penulisan Laporan Studi KasusProgram Studi S1 KeperawatanTA. 2012/2013
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