PROGRAM STUDI PENDIDIKAN NERSSTIKES SURYA MITRA HUSADA KEDIRIPROGRAM PENDIDIKAN PROFESI NERSALAMAT : JLN. Manila No. 37 Sumberece Kota Kediri Telp. (0354) 7009713 Fax. (0354) 695130
Nama MahasiswaNIM
: ...:
FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH
Tanggal MRSTanggal Pengkajian
: :
Jam MasukNo. RM
::
Jam PengkajianHari rawat ke
IDENTITAS1. Nama Pasien2. Umur3. Suku/ Bangsa4. Agama5. Pendidikan6. Pekerjaan7. Alamat8. Sumber Biaya
::::::::
::
Diagnosa Masuk :
KELUHAN UTAMA
1.
Keluhan utama:..
RIWAYAT PENYAKIT SEKARANG1. Riwayat Penyakit Sekarang:.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................RIWAYAT PENYAKIT DAHULU
1. Pernah dirawat
: ya
tidak
kapan :
diagnosa :
2. Riwayat penyakit kronik dan menular
ya
tidak
jenis
Riwayat kontrol : .............................Riwayat penggunaan obat :..............3. Riwayat alergi:
ObatMakananLain-lain
4. Riwayat operasi:
yayaya
tidaktidaktidak
jenisjenisjenis
yatidak
-
Kapan
:
-
Jenis operasi :
5. Lain-lain:.............................................................................................................................................................................................................................................................................................................................................................. ...................................................................................................................................................................................................................
STIKes Surya Mitra Husada Kediri
RIWAYAT KESEHATAN KELUARGA
Ya
tidak
-
Jenis
:.....................................................................................................................................
-
Genogram :
PERILAKU YANG MEMPENGARUHI KESEHATANPerilaku sebelum sakit yang mempengaruhi kesehatan:
Masalah Keperawatan :
AlkoholMerokok
yaya
tidaktidak
keterangan.....................
keterangan.........................................................
Obat
ya
tidak
keterangan..............................................................
Olah raga
ya
tidak
keterangan..........................................................
OBSERVASI DAN PEMERIKSAAN FISIK
1.
Tanda tanda vital
S:
N:
T:
RR :
Kesadaran
Compos Mentis
Apatis
Somnolen
Sopor
Koma
2.
Sistem Pernafasan (B1)a. RR:................................
b. Keluhan:Batuk
sesakproduktif
nyeri waktu nafastidak produktif
orthopnea
Sekret:..Warna:..........
Konsistensi :......................Bau :..................................
c. Penggunaan otot bantu nafas:....................................................................................................................................................................................................................................................................................................................................................................
d. PCHe. Irama nafas
yateratur
tidaktidak teratur
f. Pleural Friction rub:.....................................................................................................................
g. Pola nafash. Suara nafasi. Alat bantu napas
DispnoeCraclesya
KusmaulRonkitidak
Cheyne StokesWheezing
Biot
Jenis................................................ Flow..............lpm
j. Penggunaan WSD:
--
Jenis : .................................................................................................................................................................Jumlah cairan : ...................................................................................................................... ............................
--
UndulasiTekanan
:...................................................................................................................................................: ..................................................................................................................................................
k. Tracheostomy:
ya
tidak
....................................................................................................................................................................................................................................................................................................................................................................l. Lain-lain:................................................................................................................................................................................ ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .
STIKes Surya Mitra Husada Kediri
3.
Sistem Kardio vaskuler (B2)
a. TD :b. N :c. HR :
Masalah Keperawatan :
d. Keluhan nyeri dada:
ya
tidak
P :...................................................................Q :...................................................................R :...................................................................S :...................................................................T :...................................................................
e. Irama jantung:
reguler
ireguler
f. Suara jantung:
normal (S1/S2 tunggal)gallop
murmurlain-lain.....
g. Ictus Cordis: .............................................................................................................................................................h. CRT :.............detik
i.
Akral:
hangat
kering
merah
basah
pucat
panas
dingin
j. Sikulasi perifer:
normal
menurun
k. JVPl. CVPm. CTR
:.................................:.................................:.................................
n. ECG & Interpretasinya:.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ ..............................................o. Lain-lain :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
4.
Sistem Persyarafan (B3)
a. GCS : ..................................................b. Refleks fisiologis patella
triceps
biceps
Masalah Keperawatan :
c. Refleks patologis
babinsky
brudzinsky
kernig
Lain-lain
d. Keluhan pusing
ya
tidak
P :...................................................................Q :...................................................................R :...................................................................S :...................................................................T :...................................................................
e. Pemeriksaan saraf kranial:
N1 :N2 :N3 :N4 :N5 :N6 :N7 :N8 :N9 :N10 :N11 :N12 :
normalnormalnormalnormalnormalnormalnormalnormalnormalnormalnormalnormal
tidaktidaktidaktidaktidaktidaktidaktidaktidaktidaktidaktidak
Ket.: ..............................................................Ket.: ..............................................................Ket.: ..............................................................Ket.: ..............................................................Ket.: ..............................................................Ket.: ..............................................................Ket.: ..............................................................Ket.: ..............................................................Ket.: ..............................................................Ket.: ..............................................................Ket.: ..............................................................Ket.: ..............................................................
f. Pupilg. Sclerah. Konjunctiva
anisokoranikterusananemis anemis
isokorikterus
Diameter: /......
STIKes Surya Mitra Husada Kediri
i. Isitrahat/Tidur :................. Jam/Hari
Gangguan tidur : ..............................................................
j. Lain-lain:............................................................................................................................................................................ ..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
5.
Sistem perkemihan (B4)a. Kebersihan genetalia:b. Sekret:c. Ulkus:d. Kebersihan meatus uretra:
BersihAdaAdaBersih
KotorTidakTidak
Kotor
Masalah Keperawatan
e. Keluhan kencing:
Ada
Tidak
Bila ada, jelaskan:............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ ......................................................................................................................................................................................................................................................................................................................................................................................... .....
f. Kemampuan berkemih:
Spontan
Alat bantu, sebutkan: .................................................................................................
Jenis :............................................
UkuranHari ke
:............................................:............................................
g. Produksi urine : ..Warna :............
ml/jam
Bau
:........
h. Kandung kemih :i. Nyeri tekanj. Intake cairan
Membesarya tidakoral : cc/hari
ya tidak
parenteral : cc/hari
k. Balance cairan:....................................................................................................................................................................................................................................................................................................................................... ...............................................................................................................................................................................................................k. Lain-lain:......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
6.
Sistem pencernaan (B5)a. TB :...............b. IMT :................
c. Mulut:d. Membran mukosa:
BBInterpretasi
bersihlembab
:................................:................................
kotor stomatitisberbau kering
Masalah Keperawatan : e Tenggorokansakit menelanpembesaran tonsil
kesulitan menelannyeri tekan
f. Abdomen:g. Nyeri tekan:h. Luka operasi:Tanggal operasiJenis operasiLokasiKeadaan
tegangyaada:................:................:................:................
kembungtidaktidak
ascites
Drain
:
ada
tidak
i.j.
---
JumlahWarnaKondisi area sekitar insersiPeristaltik:.............. x/menitBAB: ......................x/hari
:...................:...................:...................
Terakhir tanggal : ............................................................................
k.
Konsistensi:
keras
lunak
cair
lendir/darah
STIKes Surya Mitra Husada Kediri
l.
Diet:
padat
lunak
cair
m.
Diet Khusus:....................................................................................................................................................................................................................................................................................................................................................................
n.o.
Nafsu makan:Porsi makan:
baikhabis
menuruntidak
Frekuensi:.......x/hariKeterangan:.......................
p.
Lain-lain:................................................................................................................................................................................................................................................................................................................................ ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
7.
Sistem Penglihatana. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD
VisusPalpebraConjunctivaKorneaBMDPupilIrisLensaTIO
OS
b. Keluhan nyeri
ya
tidak
P :...................................................................Q :...................................................................R :...................................................................S :...................................................................T :...................................................................
c. Luka operasi:Tanggal operasiJenis operasiLokasiKeadaan
ada:................:................:................:................
tidak
d. Pemeriksaan penunjang lain : .........................e. Lain-lain :............................................................................................................................................................................. .........................................................................................................................................................................................................................................................................................................................................................................
8. Sistem pendengaran
a.
Pengkajian segmen anterior dan posterior
OD
OS
Masalah Keperawatan :
AurciculaMAEMembranTymphaniRinneWeberSwabach
STIKes Surya Mitra Husada Kediri
b.
Tes Audiometri................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................ ............................................
c. Keluhan nyeri
ya
tidak
P :...................................................................Q :...................................................................R :...................................................................S :...................................................................T :...................................................................
d. Luka operasi:Tanggal operasiJenis operasiLokasiKeadaan
ada:................:................:................:................
tidak
e. Alat bantu dengar: .........................f. Lain-lain :.............................................................................................................................................................................................................................................................................................................................................. ........................................................................................................................................................................................................
8.
Sistem muskuloskeletal (B6)
a. Pergerakan sendi:b. Kekuatan otot:
c. Kelainan ekstremitas:
bebas
ya
tidak
terbatas
Masalah Keperawatan :
d. Kelainan tulang belakang: ya
tidak
Frankel: ................................................................................
e. Fraktur: ya
tidak
-
Jenis
:...................
f. Traksi: ya
tidak
---
JenisBebanLama pemasangan
:...................:...................:...................
g. Penggunaan spalk/gips:
ya
tidak
h. Keluhan nyeri:
ya
tidak
P :...................................................................Q :...................................................................R :...................................................................S :...................................................................T :...................................................................
i.
Sirkulasi perifer: ..............................................
j.
Kompartemen syndrome ya
tidak
k.l.m.
Kulit:TurgorLuka operasi:
ikterikbaikada
sianosiskurangtidak
kemerahanjelek
hiperpigmentasi
Tanggal operasiJenis operasiLokasiKeadaan
:................:................:................:................
Drain
:
ada
tidak
---
JumlahWarnaKondisi area sekitar insersi
:...................:...................:...................
n. ROM
: .................................................
STIKes Surya Mitra Husada Kediri
o. PODp. Cardinal Sign
: ................................................: ................................................
q. Lain-lain:......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
10.
Sistem Integumena. Penilaian resiko decubitus
b.c.
WarnaPitting edema: +/- grade:................
Masalah Keperawatan :
d.e.f.g.h.
Ekskoriasis:Psoriasis:Pruritus:Urtikaria:Lain-lain:
yayayaya
tidaktidaktidaktidak
......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
11. Sistem Endokrina. Pembesaran tyroid:b. Pembesaran kelenjar getah bening:c. Hipoglikemia:d. Hiperglikemia:
yayayaya
tidaktidaktidaktidak
Masalah Keperawatan :
e. Kondisi kaki DM
- Luka gangren
ya
tidak
Jenis ................................................................................................................
- Lama luka- Warna- Luas luka- Kedalaman- Kulit kaki- Kuku kaki- Telapak kaki- Jari kaki
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
- Infeksi- Riwayat luka sebelumyaJika ya:
yaya
tidaktidak
---
TahunJenis LukaLokasi
:::
- Riwayat amputasi sebelumyaJika ya:
ya
tidak
--
TahunLokasi
::
f. ABI : ....................................................g. Lain-lain:....................................................................................................................................... ...............................................................................................................................................................................................................................................................................................................................................................................................................
STIKes Surya Mitra Husada KediriAspek YangDinilaiKriteria PenilaianNilaiAspek YangDinilai1234Persepsi SensoriTerbatasSepenuhnyaSangat TerbatasKeterbatasanRinganTidak AdaGangguanKelembabanTerus MenerusBasahSangat LembabKadang2 BasahJarang BasahAktifitasBedfastChairfastKadang2 JalanLebih SeringjalanMobilisasiImmobileSepenuhnyaSangat TerbatasKeterbatasanRinganTidak AdaKeterbatasanNutrisiSangat BurukKemungkinanTidak AdekuatAdekuatSangat BaikGesekan &PergeseranBermasalahPotensialBermasalahTidakMenimbulkanMasalahNOTE: Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien beresikomengalami dekubisus (pressure ulcers)(15 or 16 = low risk, 13 or 14 = moderate risk, 12 or less = high risk)Total Nilai
PENGKAJIAN PSIKOSOSIALa. Persepsi klien terhadap penyakitnya:.............................................................................................................................................................................................................................................................................................................................................................................................
b. Ekspresi klien terhadap penyakitnya
Masalah keperawatan :
Murung/diamc. Reaksi saat interaksi
gelisahkooperatif
tegangtidak kooperatif
marah/menangiscuriga
d. Gangguan konsep diri:.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................e. Lain-lain:.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
PERSONAL HYGIENE & KEBIASAANJelaskan :
Masalah Keperawatan :
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah- Sebelum sakit
sering
kadang- kadang
tidak pernah
Masalah Keperawatan :
-
Selama sakit
sering
kadang- kadang
tidak pernah
b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)............................................................................................................................................................................................................................................................................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
TERAPI................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
STIKes Surya Mitra Husada Kediri
DATA TAMBAHAN LAIN :................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Kediri, ..20...
()
STIKes Surya Mitra Husada Kediri
PROGRAM STUDI PENDIDIKAN NERSSTIKES SURYA MITRA HUSADA KEDIRI
ANALISIS DATA
STIKes Surya Mitra Husada KediriHari/Tgl/ JamDATAETIOLOGIMASALAH
PROGRAM STUDI PENDIDIKAN NERSSTIKES SURYA MITRA HUSADA KEDIRI
DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN
TANGGAL: .................................1.
2.
3.
4.
5.
6.
STIKes Surya Mitra Husada Kediri
RENCANA INTERVENSI
STIKes Surya Mitra Husada KediriNo.Hari/ Tgl/JamDIAGNOSA KEPERAWATANNOC(Nursing Outcome Classification)NIC(Nursing Intervention Classification)
IMPLEMENTASI DAN EVALUASI KEPERAWATAN
STIKes Surya Mitra Husada KediriHari/Tgl/ShiftNo.DxJamImplementasiParafJamEvaluasi (SOAP)Paraf
STIKes Surya Mitra Husada Kediri
Recommended