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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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