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FORMAT ASUHAN KEPERAWATAN MEDIKAL BEDAH

I. PENGKAJIAN
A. IDENTITAS KLIEN
Nama Klien : ...................................................................................................................
No. RM : ...................................................................................................................
Usia : ...................................................................................................................
Jenis Kelamin : ...................................................................................................................
Tgl. MRS : ...................................................................................................................
Tgl. Pengkajian : ...................................................................................................................
Alamat : ...................................................................................................................
Status Pernikahan : ...................................................................................................................
Agama : ...................................................................................................................
Suku : ...................................................................................................................
Pendidikan Terakhir : ...................................................................................................................
Pekerjaan : ...................................................................................................................
Diagnosa medis : ...................................................................................................................
Dokter yang merawat : ....................................................................................................................

B. KELUHAN UTAMA
Saat MRS : ....................................................................................................................................
.........................................................................................................................................................
Saat Pengkajian : ...........................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................

C. RIWAYAT PENYAKIT
1. Riwayat Penyakit Sekarang
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
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2. Riwayat Penyakit Dahulu

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...............................................................................................................................................
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...............................................................................................................................................

3. Riwayat Penyakit Keluarga

...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
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Genogram :

Keterangan :
: Laki-laki : Garis perkawinan
: Perempuan : Tinggal serumah
/ : Sudah meninggal : Garis keturunan
: Klien

4. Riwayat Sosial
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

D. KEADAAN UMUM
1. Kesadaran : ............................................................................................................
Scale Coma Glosgow : ............................................................................................................
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2. Tanda Vital
a. Tekanan darah : .......................
b. Nadi : .......................
c. Pernapasan : .......................
d. Suhu : .......................

E. PEMERIKSAAN FISIK
1) Kesadaran Umum
a. Kesadaran :
b. GCS :
c. TTV
TD :
Nadi :
Suhu :
Pernapasan :
2) Kepala dan Leher
a. Kepala
Keluhan :
Inspeksi
Bentuk :
Distribusi rambut :
Warna kulit kepala :
Kebersihan kulit kepala :
Palpasi
Massa abnormal :
Krepitasi :
Nyeri Tekan :

b. Mata
Visus :
Inspeksi
Bentuk :
Konjungtiva :
Palpebra :
Pupil :
Tanda Peradangan :
Fungsi Pengelihatan :
Penggunaan alat bantu :
Minus :
Plus :
Silinder :

c. Hidung
Inspeksi
Bentuk :
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Warna :
Pendarahan :
Palpasi
Nyeri Tekan :

d. Mulut dan Tenggorokan

Inspeksi
Warna bibir :
Mukosa bibir :
Mukosa dalam :
Gigi :
Gusi :
Lidah :
Warna lidah :
Pembengkakan tonsil :
Sakit tenggorokan :
Gangguan bicara :

e. Telinga
Inspeksi
Bentuk :
Warna :
Posisi :
Perdarahan :
Massa :
Serumen :
Aroma :

Palpasi
Nyeri :
Gangguan pendengaran :
Tes rinne :

Tes weber :
Tes Scwabach :

f. Leher
Inspeksi/Palpasi
Kekakuan :
JVP :
Deviasi Trakea :
Pembesaran Kel,Tyroid :
Pembesaran Kel.Limfe :
Nyeri :
3) Dada/Thorax
Inspeksi
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Bentuk dada :
Warna kulit dada :
Kondidi kulit dada :
Ekspansi dinding dada :
Tanda peradangan :
Otot bantu napas :
Retraksi Suprasternal :
Palpasi
Massa abnormal :
Krepitasi :
Nyeri tekan :
Letak ictus cordis :
Taktir premitus :

Auskultasi
Jantung
Aortic :
Tricuspidd :
Pulmonal :
Mitral :
BJ Abnormal :
Paru
Suara napas :
Jenis Suara napas :
Perkusi
Jantung :
Batas Jantung :
Paru :

4) Payudara dan Axila

Inspeksi
Ukuran dan Bentuk :
Puting susu :
Kondisi kulit :
Palpasi
Edema :
Massa abnormal :
Nyeri :

5) Abdomen
Inspeksi
Bentuk :
Bayangan vena abnormal :
Kondisi kulit :
Palpasi
Penenggangan dinding abdomen :
Edema :
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Nyeri Tekan :
Massa abnormal :
Auskultasi
Bising usus :
Perkusi :

6) Genetalia

7) Rectum

8) Ekstermitas
Kontraktur :
Eformitas :
Edema :
Nyeri/nyeri tekan :
Kekuatan otot :

Reflek
Bisep :
Trisep :
Pattela :
Achiles :
Plantar (Babinski) :

9) Kulit dan Kuku

Kulit :
Warna :
Jaringan Parut :
Turgor :
Suhu (akral) :
Kuku :
Warna :
Cappilary Refill Time (CRT) :

F. PENGKAJIAN 11 POLA KESEHATAN GORDON

1. Persepsi Terhadap Kesehatan – Manajemen Kesehatan
a. Keadaan Sebelum Sakit
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b. Keadaan Saat Ini

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...........................................................................................................................................
Masalah : .................................................................................................................................

2. Pola Aktivitas dan Latihan

NO AKTIVITAS SKOR
1 Makan/Minum
2 Mandi
3 Berpakaian/Berdandan
4 Toileting
5 Berpindah
6 Berjalan
7 Naik tangga
Keterangan :
0 = mandiri
1 = alat bantu
2 = dibantu orang lain/pengawasan
3 = dibantu orang lain, pengawasan, dan alat bantu
4 = tidak mampu
Alat bantu : tongkat/ splint/ brace/ kursi roda/ pispot/ walker/ kacamata/ dan lain-lain :
Masalah : ............................................................................................................................

3. Pola Istirahat dan Tidur

a. Keadaan Sebelum Sakit
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
...........................................................................................................................................
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...........................................................................................................................................
Masalah : .................................................................................................................................
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4. Pola Nutrisi
a. Keadaan Sebelum Sakit
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...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
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Masalah : .................................................................................................................................

5. Pola Eliminasi
a. Keadaan Sebelum Sakit
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...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
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...........................................................................................................................................
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Masalah : .................................................................................................................................

6. Pola Kognitif – Perceptual

a. Keadaan Sebelum Sakit
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
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Masalah : .................................................................................................................................
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7. Pola Konsep Diri

a. Keadaan Sebelum Sakit
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...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
...........................................................................................................................................
...........................................................................................................................................
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Masalah : .................................................................................................................................

8. Pola Koping
a. Keadaan Sebelum Sakit
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
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...........................................................................................................................................
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Masalah : .................................................................................................................................

9. Pola Seksualitas – Reproduksi

a. Keadaan Sebelum Sakit
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalah : .................................................................................................................................
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10. Pola Peran – Hubungan

a. Keadaan Sebelum Sakit
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
...........................................................................................................................................
...........................................................................................................................................
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Masalah : .................................................................................................................................

11. Pola Nilai dan Kepercayaan

a. Keadaan Sebelum Sakit
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
b. Keadaan Saat Ini
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Masalah : .................................................................................................................................

G. PEMERIKSAAN SARAF
Meningeal sign
Kaku kuduk : ( - / + )
Kernig :(- / + )
Brudzinski I : ( - / + )
Brudzinski II : ( - / + )

Nervus Cranialis
Nervus I, Olfaktorius :
.........................................................................................................................................................
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Nervus II, Optikus :

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.........................................................................................................................................................
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Nervus III, Oculomotorius, Nervus IV, Trokclearis dan Nervus VI, Abdusen :
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Nervus V, Trigeminus :
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Nervus VII, Facialis :

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Nevus VIII, Vestibulokokhlearis :

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Nervus IX, Glosoparingeal :

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Nervus X, Vagus :
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Nervus XI, Accessorius :

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Nervus XII, Hipoglosos :

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Reflek Fisiologis
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Trisep :(- / + )
Bisep :(- / + )
Brakioradialis : ( - / + )
Patella :(- / + )
Acilles :(- / + )

Reflek Patologis
Babinski :(- / + )
Chaddok :(- / + )
Schaeffer :(- / + )
Oppenheim :(- / + )
Gordon :(- / + )
Gonda :(- / + )
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II. PEMERIKSAAN PENUNJANG

Nama : Tanggal :

PEMERIKSAAN HASIL NILAI RUJUKAN SATUAN

HEMATOLOGI
Hemoglobin 14,0 – 18,0 g/dl
Eritrosit 4,0 – 10,5 ribu/µl
Leukosit 4,50 – 6,00 juta/µl
Hematokrit 42.00 – 52.00 vol%
Trombosit 150 – 450 ribu/µl
RDW-CV 11,5- 14,7 %
MCV, MCH, MCHC
MCV 80-97 Fl
MCH 27-32 Pg
MCHC 32-38 %
HITUNG JENIS
Basofil % 0,0-1,0 %
Eusinofil % 1,0-3,0 %
Gran % 50,0-70,0 %
Limfosit % 25,0-40,0 %
Monisit % 3,0-9,0 %
Basofil # <1 ribu/µl
Eusinofil # <3 ribu/µl
Gran # 2,50-7,00 ribu/µl
Limfosit # 1,25-4,0 ribu/µl
MID # 0,30-1.00 ribu/µl
PROTHROMBIN TIME
Hasil PT 9,9-13,5 detik
INR -
Control normal PT -
Hasil APTT 22,2-37,0 detik
Control normal APTT -
KIMIA
GULA DARAH
Gula darah sewaktu < 200 mg/dl
HATI
SGOT 0-46 U/l
SGPT 0-45 U/l
GINJAL
Ureum 10-50 mg/dl
Creatinin 0,7-14 mg/dl
ELEKTROLIT
Natrium 135-146 mmol/l
Kalium 3,4-5,4 mmol/l
Clorida 95-100 mmol/l
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III. DRUG STUDY

Nama Obat, Frekuensi
Pemberian, Dosis, Indikasi Kontraindikasi Efek Samping Cara Kerja Obat Konsiderasi Perawat
Cara Pemberian
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Nama Obat, Frekuensi

Pemberian, Dosis, Indikasi Kontraindikasi Efek Samping Cara Kerja Obat Konsiderasi Perawat
Cara Pemberian
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IV. ANALISA DATA

NO. DATA PROBLEM ETIOLOGI
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NO. DATA PROBLEM ETIOLOGI

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V. PRIORITAS MASALAH KEPERAWATAN

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VI. RENCANA ASUHAN KEPERAWATAN

Diagnosa Keperawatan :
TUJUAN DAN
INTERVENSI RASIONAL IMPLEMENTASI EVALUASI
KRITERIA HASIL
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Diagnosa Keperawatan :
TUJUAN DAN
INTERVENSI RASIONAL IMPLEMENTASI EVALUASI
KRITERIA HASIL
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Diagnosa Keperawatan :
TUJUAN DAN
INTERVENSI RASIONAL IMPLEMENTASI EVALUASI
KRITERIA HASIL
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VII. CATATAN PERKEMBANGAN

HARI/TANGGAL/JAM DX. KEP. CATATAN PERKEMBANGAN (S.O.A.P.I.E) PARAF
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HARI/TANGGAL/JAM DX. KEP. CATATAN PERKEMBANGAN (S.O.A.P.I.E) PARAF

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HARI/TANGGAL/JAM DX. KEP. CATATAN PERKEMBANGAN (S.O.A.P.I.E) PARAF