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FORMAT PENGKAJIAN ASUHAN KEPERAWATAN MEDIKAL BEDAH
STIKES MUHAMMADIYAH BANJARMASIN
NAMA MAHASISWA :
N P M :
TEMPAT PARAKTIK :
TANGGAL :
1. DATA DEMOGRAFI
A. Identitas Klien
Nama : _________________________________________
Usia : _________________________________________
Jenis kelamin : _________________________________________
Alamat : _________________________________________
Suku/bangsa : _________________________________________
Status pernikahan : _________________________________________
Agama/keyakinan : _________________________________________
Pekerjaan/sumber penghasilan : _________________________________________
Diagnosa medik : _________________________________________
No. medical record : _________________________________________
Tanggal masuk : _________________________________________
Tanggal pengkajian : _________________________________________
B. Penanggung jawab
Nama : _________________________________________
Usia : _________________________________________
Jenis kelamin : _________________________________________
Pekerjaan/sumber penghasilan : _________________________________________
Hubungan dengan klien : _________________________________________
2. KELUHAN UTAMA
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3. RIWAYAT KESEHATAN
A. Riwayat kesehatan sekarang
Waktu timbulnya penyakit, kapan?, Jam?
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Bagaimana awal munculnya? tiba-tiba? berangsur-angsur?
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Keadaan penyakit, apakah sudah membaik, parah atau tetap sama dengan
sebelumnya
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Usaha yang dilakukan untuk mengurangi keluhan
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Kondisi saat dikaji (P Q R S T)
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B. Riwayat kesehatan lalu
Penyakit pada masa anak-anak dan penyakit infeksi yang pernah dialami
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Imunisasi
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Kecelakaan yang pernah dialami
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Prosedur operasi dan perawatan rumah sakit
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Allergi (makanan,obat-obatan, zat/substansi,textil)
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Pengobatan dini (konsumsi obat-obatan bebas)
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C. Riwayat kesehatan keluarga
Identifikasi berbagai penyakit keturunan yang umumnya menyerang
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Anggota keluarga yang terkena alergi, asma, TBC, hipertensi, penyakit jantung,
stroke, anemia, hemopilia, arthritis, migrain, DM, kanker dan gangguan emosional
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Genogram keluarga
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4. RIWAYAT PSIKOSOSIAL
A. Identifikasi klien tentang kehidupan sosialnya
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B. Identifikasi hubungan klien dengan yang lain dan kepuasan diri sendiri
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C. Kaji lingkungan rumah klien, hubungkan dengan kondisi RS
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D. Tanggapan klien tentang beban biaya RS
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E. Tanggapan klien tentang penyakitnya
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5. RIWAYAT SPIRITUAL
A. Kaji ketaatan klien beribadah dan menjalankan kepercayaannya
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B. Support system dalam keluarga
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C. Ritual yang biasa dijalankan
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6. PEMERIKSAAN FISIK
A. Keadaan umum klien
Tanda-tanda dari distress
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Penampilan dihubungkan dengan usia
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Ekspresi wajah, bicara, mood
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Berpakaian dan kebersihan umum
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Tinggi badan, BB, gaya berjalan
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B. Tanda-tanda vital
Suhu : ________________________________________________________
Nadi : ________________________________________________________
Pernafasan : ________________________________________________________
Tekanan darah : ________________________________________________________
C. Sistem pernafasan
Hidung: kesimetrisan, pernafasan cuping hidung, adanya sekret/polip,passase udara
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Leher: Pembesaran kelenjar, tumor
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Dada
- Bentuk dada (normal,barrel,pigeon chest)
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- Perbandingan ukuran anterior-posterior dengan transversi
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- Gerakan dada (kiri dan kanan, apakah ada retraksi)
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- Suara nafas (trakhea, bronchial, bronchovesikular)
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- Apakah ada suara nafas tambahan?
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- Apakah ada clubbing finger
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D. Sistem kardiovaskuler
Conjunctiva (anemia/tidak), bibir (pucat, cyanosis)
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Arteri carotis
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Tekanan vena jugularis
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Ictus cordis/apex
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Suara jantung (mitral,tricuspidalis,S1,S2,bising aorta,murmur,gallop)
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Capillary retilling time
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E. Sistem perncernaan
Sklera (ikterus/tidak)
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Bibir (lembab, kering, pecah-pecah, labio skizis)
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Mulut (stomatitis, apakah ada palatoskizis, jumlah gigi, kemampuan menelan,
gerakan lidah)
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Gaster (kembung, gerakan peristaltik)
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Abdomen
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Anus (kondisi, spinkter ani, koordinasi)
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F. Sistem indra
Mata
- Kelopak mata, bulu mata, alis, lipatan epikantus dengan ujung atas telinga
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- Visus (gunakan snellen card)
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- Lapang pandang
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Hidung
- Penciuman, perih dihidung, trauma, mimisan
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- Sekret yang menghalangi penciuman
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Telinga
- Keadan daun telinga, operasi telinga
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- Kanal auditoris
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- Membrana tympani
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- Fungsi pendengaran
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G. Sistem saraf
Fungsi cerebral
- Status mental (orientasi, daya ingat, perhatian dan perhitungan, bahasa)
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- Kesadaran (eyes, motorik, verbal) dengan GCS)
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- Bicara (ekspresive dan resiptive)
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Fungsi kranial (saraf kranial I s/d XII)
- Olfaktorius (penciuman)
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- Optikus (penglihatan)
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- Okulomotorik (menggerakan kelopak mata dan penggerak mata)
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- Troklearis (menggerakan mata keatas dan kebawah)
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- Trigeminus (sensori wajah dan penggerak rahang/mengunyah)
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- Abdusen (motorik mata, menggerakan mata ke samping)
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- Fasialis (sensori lidah depan dan motorik wajah/ekspresi wajah)
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- Audiotorius (keseimbangan dan sensori suara/pendengaran)
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- Glasofaringus (sensori lidah belakang dan motorik menelan)
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- Vagus (sensori dan motorik organ dalam/lambung)
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- Aksesorius (menggerakan kepala/leher)
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- Hipoglossus (menggerakan lidah)
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Fungsi motorik (massa, tonus dari kekuatan otot)
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Fungsi sensorik (suhu, nyeri, getaran posisi dan diskriminasi)
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Refleks (ekstremitas atas, bawah dan superficial)
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Iritasi meningen (kaku kuduk, lasaque sign, kernig sign, brudzinski sign)
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H. Sistem muskuloskeletal
Kepala (bentuk kepala)
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Vertebrae (bentuk, gerakan, ROM)
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Pelvis (Thomas test, trendelenberg test, ortolani/barlow test, ROM)
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Lutut (Mc Murray Test, Ballotement, ROM)
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Kaki (keutuhan ligamen, ROM)
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Bahu
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Tangan
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I. Sistem integumen
Rambut (distribusi ditiap bagian tubuh, texture, kelembaban, kebersihan)
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Kulit (perubahan warna, temperatur, kelembaban,bulu kulit, erupsi, tahi lalat, ruam,
texture)
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Kuku (warna, permukaan kuku, mudah patah, kebersihan)
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J. Sistem endokrin
Kelenjar tiroid
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Percepatan pertumbuhan
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Gejala kreatinisme atau gigantisme
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Ekskresi urine berlebihan, polydipsi, poliphagi
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Suhu tubuh yang tidak seimbang , keringat berlebihan, leher kaku
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Riwayat bekas air seni dikelilingi semut
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K. Sistem perkemihan
Edema palpebra
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Moon face
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Edema anasarka, ascites
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Keadaan kandung kemih
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Nocturia, dysuria, kencing batu
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Penyakit hubungan sexual
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L. Sistem reproduksi
Wanita
- Payudara (putting, areola mammae, besar, perbandingan kiri dan kanan)
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- Labia mayora dan minora
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- Keadaan hymen
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- Haid pertama
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- Siklus haid
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Laki-laki
- Keadaan gland penis (urethra)
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- Testis (sudah turun/belum)
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- Pertumbuhan rambut (kumis, janggut, ketiak)
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- Pertumbuhan jakun
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- Perubahan suara
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M. Sistem immun
Allergi (cuaca, debu, bulu binatang, zat kimia)Immunisasi
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Penyakit yang berhubungan dengan perubahan cuaca
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Riwayat transfusi dan reaksinya
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7. AKTIVITAS SEHARI-HARI
A. Nutrisi
Selera makan
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Menu makan dalam 24 jam
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Frekuensi makan dalam 24 jam
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Makanan yang disukai dan makanan pantangan
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Pembatasan pola makanan
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Cara makan (bersama keluarga, alat makan yang digunakan)
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Ritual sebelum makan
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B. Cairan
Jenis minuman yang dikonsumsi dalam 24 jam
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Frekuensi minum
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Kebutuhan cairan dalam 24 jam
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C. Eliminasi (BAB & BAK)
Tempat pembuangan
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Frekuensi, Kapan, Teratur
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Konsistensi
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Kesulitan dan cara menanganinya
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Obat-obat untuk memperlancar BAB/BAK
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D. Istirahat Tidur
Apakah cepat tertidur
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Jam tidur (siang/malam)
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Bila tidak dapat tidur apa yang dilakukan
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Apakah tidur secara rutin
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E. Olahraga
Program olahraga tertentu
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Berapa lama melakukan dan jenisnya
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Perasaan setelah melakukan olahraga
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F. Rokok/alkohol dan obat-obatan
Apakah merokok ? jenis ? berapa banyak ? kapan mulai merokok ?
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Apakah minum minuman keras ? berapa minum /hari/minggu ? jenis minuman ?
apakah banyak minum ketika stress ? apakah minuman keras mengganggu prestasi
kerja ?
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Kecanduan kopi, alkohol, tea atau minuman ringan ? berapa banyak /hari?
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Apakah mengkonsumsi obat dari dokter (marihuana, pil tidur, obat bius)
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G. Personal hygiene (frekuensi, cara, alat mandi, kesulitan, mandiri/dibantu)
Mandi
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Cuci rambut
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Gunting kuku
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Gosok gigi
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H. Aktivitas/mobilitas fisik
Kegiatan sehari-hari
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Pengaturan jadwal harian
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Penggunaan alat bantu untuk aktivitas
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Kesulitan pergerakan tubuh
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I. Rekreasi
Bagaimana perasaan anda saat bekerja?
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Berapa banyak waktu luang?
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Apakah puas setelah rekreasi?
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Apakah anda dan keluarga menghabiskan waktu senggang?
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Bagaimana perbedaan hari libur dan hari kerja?
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8. TEST DIAGNOSTIK
A. Laboratorium
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B. Ro foto
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C. CT Scan
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D. MRI, USG, EEG, ECG, dll
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9. THERAPY MEDIS SAAT INI
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