STIKes Eka Harap

Palangka Raya

YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN
PROGRAM 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. PENGKAJIAN
A. IDENTITAS PASIEN
Nama : ……………………………………………………………..
Umur : ……………………………………………………………..
Jenis Kelamin : ……………………………………………………………..
Suku/Bangsa : ……………………………………………………………..
Agama : ……………………………………………………………..
Pekerjaan : ……………………………………………………………..
Pendidikan : ……………………………………………………………..
Status Perkawinan : ……………………………………………………………..
Alamat : ……………………………………………………………..
Tgl MRS : ……………………………………………………………..
No. Reg : ……………………………………………………………..
Diagnosa Medis : ……………………………………………………………..

B. RIWAYAT KESEHATAN /PERAWATAN

1. Keluhan Utama :
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………

2. Riwayat Penyakit Sekarang:

...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………

3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat operasi)

...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………

4. Riwayat Penyakit Keluarga

...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………

1
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

GENOGRAM KELUARGA:

C. PEMERIKASAAN FISIK
1. Keadaan Umum:
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………
...................................................................................................................................................................... ………

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
k. Insight :  Baik  Mengingkari  Menyalahkan orang lain
m. Mekanisme pertahanan diri :  Adaptif  Maladaptif
n. Keluhan lainnya : ………………….

3. Tanda-tanda Vital :
a. Suhu/T : ……………….0C  Axilla  Rektal  Oral
b. Nadi/HR : ………………x/mt
c. Pernapasan/RR : …..…………..x/tm
d. Tekanan Darah/BP : ……...………..mm Hg

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Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

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 istirahat
Type Pernafasan  Dada  Perut  Dada dan perut
 Kusmaul  Cheyne-stokes  Biot
 Lainnya
Irama Pernafasan  Teratur  Tidak teratur
Suara Nafas  Vesukuler  Bronchovesikuler
 Bronchial  Trakeal
Suara 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 melihat
Vena jugularis  Tidak meningkat  Meningkat
Suara jantung  Normal,………………….
 Ada kelainan
Keluhan lainnya :
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
Masalah Keperawatan :
......................................................................................................................................................................
......................................................................................................................................................................

3
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

6. PERSYARAFAN (BRAIN)
Nilai GCS : E : ………………….
V : ………………….
M : ………………….
Total Nilai GCS : ……………………
Kesadaran :  Compos Menthis  Somnolent  Delirium
 Apatis  Soporus  Coma
Pupil :  Isokor  Anisokor
 Midriasis  Meiosis
Refleks Cahaya :  Kanan  Positif  Negatif
 Kiri  Positif  Negatif
 Nyeri, lokasi ………………………………..
 Vertigo  Gelisah  Aphasia  Kesemutan
 Bingung  Disarthria  Kejang  Trernor
 Pelo
Uji 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  Negatif
Ekstrimitas Bawah : Tumit ke jempul kaki  Positif  Negatif
Uji Kestabilan Tubuh :  Positif  Negatif
Refleks :
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/hr
Warna :
Bau :
 Tidak ada masalah/lancer  Menetes  Inkotinen
 Oliguri  Nyeri  Retensi
 Poliuri  Panas  Hematuri
 Dysuri  Nocturi
 Kateter  Cystostomi

4
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

Keluhan Lainnya :
......................................................................................................................................................................
......................................................................................................................................................................
Masalah Keperawatan :
......................................................................................................................................................................
......................................................................................................................................................................

8. ELIMINASI ALVI (BOWEL) :

Mulut dan Faring
Bibir : ..................................................................................................................................
Gigi : ..................................................................................................................................
Gusi : ..................................................................................................................................
Lidah : ..................................................................................................................................
Mukosa : ..................................................................................................................................
Tonsil : ..................................................................................................................................
Rectum :
Haemoroid :
BAB : ……….x/hr Warna :..……… . Konsistensi : …………….
 Tidak ada masalah  Diare  Konstipasi  Kembung
 Feaces berdarah  Melena  Obat pencahar  Lavement
Bising 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, lokasi
Tulang belakang  Normal  Skoliosis
 Kifosis  Lordosis

5
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

10. KULIT-KULIT RAMBUT

Riwayat alergi  Obat......................................................................................................
 Makanan...............................................................................................
 Kosametik.............................................................................................
 Lainnya.................................................................................................
Suhu kulit  Hangat  Panas  Dingin
Warna kulit  Normal  Sianosis/ biru  Ikterik/kuning
 Putih/ pucat  Coklat tua/hyperpigmentasi
Turgor  Baik  Cukup  Kurang
Tekstur  Halus  Kasar
Lesi :  Macula, lokasi
 Pustula, lokasi.......................................................................................
 Nodula, lokasi.......................................................................................
 Vesikula, lokasi.....................................................................................
 Papula, lokasi........................................................................................
 Ulcus, lokasi..........................................................................................
Jaringan parut lokasi
Tekstur rambut ..................................................................................................................................
Distribusi rambut
Bentuk kuku  Simetris  Irreguler
 Clubbing Finger  Lainnya
Masalah 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  Keruh
Alat bantu  Kacamata  Lensa kontak  Lainnya…….
Nyeri :
Keluhan lain :
…………………………………………………………………
b. Telinga / Pendengaran :
Fungsi pendengaran :  Berkurang  Berdengung  Tuli
c. Hidung / Penciuman:
Bentuk :  Simetris  Asimetris
 Lesi
 Patensi
 Obstruksi
 Nyeri tekan sinus
 Transluminasi
Cavum Nasal Warna………………….. Integritas……………..
Septum nasal  Deviasi  Perforasi  Peradarahan
 Sekresi, warna ………………………
 Polip  Kanan  Kiri  Kanan dan Kiri
Masalah Keperawatan :
......................................................................................................................................................................
......................................................................................................................................................................

6
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

12. LEHER DAN KELENJAR LIMFE

Massa  Ya  Tidak
Jaringan Parut  Ya  Tidak
Kelenjar Limfe  Teraba  Tidak teraba
Kelenjar Tyroid  Teraba  Tidak teraba
Mobilitas leher  Bebas  Terbatas
13. SISTEM REPRODUKSI
a. Reproduksi Pria
Kemerahan, Lokasi
Gatal-gatal, Lokasi
Gland Penis .....................................................................................
Maetus Uretra .................................................................................
Discharge, warna
Srotum .........................................................................................
Hernia .........................................................................................
Kelainan ……………………………………………
Keluhan lain ………………………………………….
a. Reproduksi Wanita
Kemerahan, Lokasi
Gatal-gatal, Lokasi
Perdarahan .....................................................................................
Flour Albus .................................................................................
Clitoris .............................................................................................
Labis .........................................................................................
Uretra .........................................................................................
Kebersihan :  Baik  Cukup  Kurang
Kehamilan : ……………………………………
Tafsiran partus : ……………………………………
Keluhan lain.............................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Payudara :
 Simetris  Asimetris
 Sear  Lesi
 Pembengkakan  Nyeri tekan
Puting :  Menonjol  Datar  Lecet  Mastitis
Warna areola ..........................................................................................................................................
ASI  Lancar  Sedikit  Tidak keluar
Keluhan lainnya.......................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Masalah Keperawatan :
.................................................................................................................................................................

D. POLA FUNGSI KESEHATAN

1. Persepsi Terhadap Kesehatan dan Penyakit :
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
......................................................................................................................................................................
2. Nutrisida Metabolisme
TB : Cm
BB sekarang : Kg
BB Sebelum sakit : Kg
Diet :
 Biasa  Cair  Saring  Lunak
Diet Khusus :
 Rendah garam  Rendah kalori  TKTP
 Rendah Lemak  Rendah Purin  Lainnya……….
 Mual

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Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

 Muntah…………….kali/hari
Kesukaran menelan  Ya  Tidak
Rasa haus
Keluhan 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
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………Masalah Keperawatan
…………………………………………………………………………………………………
8. Nilai-Pola Keyakinan
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
Masalah Keperawatan
…………………………………………………………………………………………………

8
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

E. SOSIAL - SPIRITUAL
1. Kemampuan berkomunikasi
…………………………………………………………………………………………………
…………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………
………………………………………………………………
2. Bahasa sehari-hari
…………………………………………………………………………………………………
…………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………
………………………………………………………………
3. Hubungan dengan keluarga :
…………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………
………………………………………………………………
…………………………………………………………………………………………………
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

Palangka Raya …. …………..……………..

Mahasiswa

( ………………………………)

Lampiran 12 Format Diagnosa Keperawatan

9
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN
PROGRAM STUDI S1 KEPERAWATAN
Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536)
3327707

ANALISIS DATA

DATA SUBYEKTIF DAN DATA

KEMUNGKINAN PENYEBAB MASALAH
OBYEKTIF

Prioritas Masalah
10
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

Lampiran 13 Format Intervensi Keperawatan

11
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN
PROGRAM 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

Lampiran 14 Format Implementasi Dan Evaluasi Keperawatan

12
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013
 STIKes Eka Harap
Palangka Raya

YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN
PROGRAM STUDI S1 KEPERAWATAN
Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536)
3327707

IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Tanda tangan
Hari/Tanggal
Implementasi Evaluasi (SOAP) dan
Jam
Nama Perawat

13
Pedoman Penyususnan & Penulisan Laporan Studi Kasus
Program Studi S1 Keperawatan
TA. 2012/2013