FORMAT PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH/INTERNA

I. IDENTITAS
A. Biodata Klien
- Nama Ini!ial" #
- $!ia/tan%%al la&i' #
- Jeni! (elamin #
- Alamatlen%(a) den%an no. Tel)" #
- *+(+/,an%!a #
- *tat+! Pe'ni(a&an #
- A%ama/Ke-a(inan #
- Pe(e'.aan/*+m,e' )en%&a!ilan #
- Dia%no!a medi( #
- No. Medi(al Re/o'd #
- Tan%%al ma!+( #
- Tan%%al )en%(a.ian #
- T&e'a)i medi( #
B. Penan%%+an% .a0a,
- Nama #
- $!ia #
- Jeni! (elamin #
- Pe(e'.aan/!+m,e' )en%&a!ilan #
- Alamat
- H+,+n%an den%an (lien #
II. KELUHAN UTAMA
Kel+&an (lien -an% mem,a0a (lien ma!+( (e R+ma& *a(it
Ji(a (lien tida( !ada' ma(a (el+&an +tama di (o!on%(an ata+ tida( da)at
di(a.i
Han-a men/ant+m(an 1 (el+&an -an% di an%%a)(an )alin% men%%an%%+
(lien
III. RIWAYAT KESEHATAN
A. Ri0a-at Ke!e&atan *e(a'an%
Kondi!i !aat di(a.i 2 P3R*T # dit+li! dalam ,ent+( na'a!i 1 Pa'a%'a4"
P 2 Paliati4 5 4a(to' -an% me'in%an(an
Mi! # ,e'i!ti'a&at6 ,e'o,at (e 0a'+n%6 men%i(at (e)ala den%an tali
2 P'o7o(ati4 5 4a(to' -an% mem)e',e'at
Mi! # ,e'a(ti4ita!6 la'i
32 3+alit- 5 Tin%(at (el+&an
Mi! # N-e'i !e)e'ti di t+!+(-t+!+( !(ala n-e'i"
2 3+antit- 5 .+mla& (el+&an
Mi! # !at+ n-e'i (el+&an"
R2 Re%ion 5 a'ea (el+&an
Mi! # n-e'i di'a!a(an )ada a'ea (e)ala
2 Radiation 5 )en-e,a'ann-a
Mi! # n-e'i &in%%a (e len%an dan ,a&+ (i'i
*2 *e7e'- t- 5 dam)a( (el+&an te'&ada) ADL
Mi! # (ondi!i t!, men-e,a,(an (lien tida( ,ia! ,e'a(ti4ita! !e)e'ti ,ia!an-a
T2 Timin% 5 Wa(t+ (el+&an
Mi! # (+'an% le,i& 8 min%%+
D+'a!i # (ala+ n-ei -an% di'a!a(an &ilan% tim,+l6 ,e'a)a lama (el+&an
te'!e,+t di'a!a(an
9onto& #
K+'an% le,i& 8 min%%+ !e,el+m (lien ma!+( R*. Klien men%el+& n-e'i (e)ala
&e,at !e)e'ti dit+!+(-t+!+( ,enda ta.am !e/a'a te'+! mene'+! !(ala :; 1-1<" dan
,e'tam,a& ,e'at (ala+ (lien ,e'a(ti4ita! !e)e'ti men%an%(at ,enda ,e'at a)ala%i
(ala+ (lien ,e'la'i. Ta)i (ondi!i te'!e,+t ,e'(+'an% a)a,ila (lien ,e'i!ti'a&at.
Men%i(at (e)ala den%an tali dan memin+m o,at da'i 0a'+n%. N-e'i -an%
di'a!a(an (lien !e'in% te'a!a &in%%a (e ,a&+ dan len%an (i'i. Hal te'!e,+t
men-e,a,(an (lien tida( ,i!a ,e'a(ti7ita! !e)e'ti ,ia!an-a )e'%i (e(anto'".
Ka'ena &in%%a !e(a'an% tida( ada )e'+,a&an -an% ,e'a'ti ma(a (lien )+t+!(an
+nt+( ,e'o,at (e R* La(i)adada Tato'.
B. Ri0a-at Ke!e&atan Lal+
- Pen-a(it )ada ma!a ana(-ana( dan )en-a(it in4e(!i -an% )e'na dialami
- Im+ni!a!i
- Ke/ela(aan -an% )e'na dialami
- P'o!ed+' o)e'a!i dan )e'a0atan R*
- Ale'%i ma(anan6 o,t-o,atan6 =at/!+,!tan!i6 te>til"
- Pen%o,atan dini (om!+m!i o,at-o,atan ,e,a!"
9. Ri0a-at Ke!e&atan Kel+a'%a
- Identi4i(a!i ,e',a%ai )en-a(it (et+'+nan -an% +m+mn-a men-e'an%
- An%%ota (el+a'%a -an% te'(ena ale'%i6 a!ma6 TB96 &i)e'ten!i6 )en-a(it
.ant+n%
- B+at ,a%an den%an %eno%'am minimal ? %ene'a!i6 (lien ,e'da )ada %ene'a!i
(e ?
- Men/ant+m(an (ete'an%an +nt+( ma!in%-ma!in% an%%ota te'ma!+( +!ia"
- Kete'an%an
La(i-la(i #
Pe'em)+an #
*a(it #
Menin%%al #
I,+ Hamil #
B+te(i #
B+ta Wa'na #
9e'ai #
Tin%%al dalam !at+ '+ma& # -------------------
IV. RIWAYAT PSIKOSOSIAL
- Identita! (lien tentan% (e&id+)an !o!ialn-a #
- Identita! &+,+n%an (lien den%an -an% lain dan (e)+a!an di'i !endi'i #
- Ka.i lin%(+n%an '+ma& (lien6 &+,+n%an den%an (ondi!i R* #
- Tan%%a)an (lien tentan% ,e,an ,ia-a R* #
- Tan%a)an (lien tentan% )en-a(itn-a #
V. RIWAYAT SPIRITUAL
- Ka.i (etaatan (lien ,e'i,ada& dan men.alan(an (e)e'/a-aann-a #
- *+))o't !-!tem dalam (el+a'%a #
- Rit+al -an% ,ia!a di.alan(an #
VI. PEMERIKSAAN FISIK PENDEKATAN HEAD TO TOE
A. Keadaan $m+m
- Ke!ada'an )eme'i(!aaan G9*" #
- Ba+ Badan ata+ ,a+ na)a! #
- Po!t+' t+,+& #
- K+lit #
Wa'na #
No'mal !a0o matan%6 &itam6 )+ti&"
Fl+!&in%/(eme'a&an
Jo+ndi/e/i(te'i(/(e(+nin%an
9-ano!i!/(e,i'+an
Palo'/)+/at
- Oedema #
B. Tanda @ital
- *+&+ #
- Nadi #
- Pe'na4a!an #
- Te(anan da'a& #
- TB A BB #
9. Dae'a& Ke)ala dan Le&e'
- Ke)ala
In!)e(!i # ,ent+( me!o/e)&al6 mi('o/e)&al6 ma('o/e)&al"
- Ram,+t
In!)e(!i # 0a'na6 di!t'i,+!i6 te(!t+'6 ada tida(n-a dand'+4 A (+t+
Pal)a!i # ,e'min-a(6 )e'len%(etan
- K+lit (e)ala
In!)e(!i # (elem,a,an6 dand'+46 le!i6 te(!t+'
Pal)a!i # ada tida(n-a ma!!a
- Wa.a&
In!)e(!i # 0a'na6 )i%menta!i6 a(ne6 t'emo'6 !(a'6 (e!imet'i!an %e'a(an
Pal)a!i # (e(+atan otot ma!ete' dan tem)o'ali!6 !en!a!i !ent+&an/'a,aan
- Mata
In!)e(!i # 0a'na !/le'a6 )to!i!6 0a'na (on.+n%ti7a6 )+)il
+(+'an6 'ea(!i te'&ada) /a&a-a; mio!i! o' mid'ia!i!"6 4+n%!i
)en%li&atan (eta.aman )en%li&atan6 la)an% )andan%6
)e'%e'a(an ,ola mata6 te!t (o'nea"6 )en%%+naan (a/a mata-
(onta( le!-)'o!te!i!6 di)lo)ia6 )&oto)o,ia.
Pal)a!i # n-e'i te(an
- Telin%a
In!)e(!i # (e!imet'i!an6 a+'i(+la6 !+m,atan MAE6 !e/'et da'i mMAE6
(e,e'!i&an6 te!t 4+n%!i )enden%a'an 'inne6 0e,e'6 !0a,a/&"
Pal)a!i # n-e'i )ada a+'i(+la
- Hid+n%
In!)e(!i # ,ent+( &id+n%6 )e'%e'a(an /+)in% &id+n%6 adan-a )oli/ma!!a6
!e/'et6 di!t'i,+!i 'am,+t &id+n%6 0a'na m+(o!a6 4+n%!i
)en!i+man6 leta( !e)t+m.
Pal)a!i # n-e'i te(an )ada !in+! 4'ontali! A Ma>ila'i!
- M+l+t
In!)e(!i #
o Bi,i' # ,ent+(6 0a'na6 le!i6 (elem,a,an !a'ia0an6 la,io=(-!i!
o Gi%i # (elen%(a)an .+mla& %i%i6 (eadan %i%i
,e'l+,an%/tida("6
%i%i )al!+ o'otea!e"
o G+!i # 0a'na6 )e'da'a&an6 !a'ia0an
o M+(o!a # 0a'na6 (elem,a,an6 le!i
o Lida& # 0a'na6 (elem,a,an6 ,e'/a(-,e'/a(
o Palat+m # ada tida(n-a )alato=(-!i!
o Ton!il # 0a'na6 )em,e!a'an
o $7+la # leta(
o Ten%%o'o(an # 'e4le(! menelan dan GAG 'e4le(!6 n-e'i menelan
o *+a'a # !e'a(6 a4onia
- Le&e'
In!)e(!i #
o Kelen.a' Ti'oid # )em,e!a'an
o Te(anan @ena J+%+la'i! # )enin%(atan te(anan
o Rentan% %e'a( # 'ota!i6 4le(!i6 e(!ten!i6 d!t
Pal)a!i #
o Kelen.a' ti'oid # (on!i!ten!i6 )em,e!a'an
o Kelen.a' Geta& ,enin% # )em,e!a'an
o De7ia!i t'a(ea
o Te(anan 7ena J+%+la'i! # te'.adi )enin%(atan te(anan +(+'an"
o Ke(+atan otot !teno(leidoma!toide+!
D. Dae'a& Dada T&o'a(!"
In!)e(!i # +(+'an ante'io'6 )o!te'io'"6 ,ent+(6 (e!imet'i!an6
n-e'i
o K+lit # di!t'i,+!i 'am,+t6 0a'na
o Pa-+da'a # (e!imet'i!an6 0a'na
o Ae'ola # 0a'na6 )en%el+a'an
Pal)a!i #
o K+lit # !+&+
o Pa-+da'a # ma!!a /ata lo(a!i6 +(+'an A ,ent+("6 n-e'i
o A(!ila # (elen.a' %eta& ,enin% )em,e!a'an6 (on!i!ten!i"
- Pa'+ B)a'+
In!)e(!i # )ola )e'na)a!an 'e!)i'a!i 'ate6
(ete'at+'an6 )en%+naan otot tam,a&an )e'na)a!an6 'a!io in!)i'a!i B
e(!)i'a!i6 'et'a(!i inte'(o!ta"
Pe'(+!i # ,+n-i la)an% )a'+ 'e!onan/e6
4latne!!6 t-m)ani6 d+llne!!"
Pal)a!i # 4o(al 4'emit+! A
)en%em,an%an dada
A+!(+lta!i # ,+n-i na)a! ,'on/&ial6
,'on/&o7e!i(+le' A 7e!i(+le'" !+a'a na)a! tam,a&an 'on/&i6
'ale!/'a/(le!6 0&ee=in%"
- Jant+n%
In!)e(!i A )al)a!i
Leta( .ant+n%6 ada/tida(n-a n-e'i dada
Pe'(+!i
La)an% .ant+n% D+lne!!"
A+!(+lta!i
Pola .ant+n% ta'e6 'itme6 PMI"
B+n-i .ant+n% #
*I 5 te'leta( di I9* C A : (i'i a'ea t'i(+!)idali!/7enti(+la' di
de!('i)!i(an
den%an ,+n-i DL+,D
*8 5 te'leta( di I9* 1 A8 (i'i )+lmonal" (ana ao'ta"
*? 5 te'leta( di 7ent'i(el (anan A a'ea a)e(!
*C 5 te'leta( di !etia) (at+) .ant+n% mit'al t'i(+!)idali!6 ao'ta E
)+lmonal"
E. Dae'a& A,domen
In!)e(!i
Bent+(6 !t'iae6 )ele,a'an )em,+l+& da'a&6 /a)+t mend+!a6 (elainan +m,ili/al6
lin%(a' )e'+t
Pe'(+!i
Pem,e!a'an &e)a'6 ,ata!-,ata! &e)a'6 di!ten!i 7e!i(a +'ina'-6 lam,+n%
Pal)a!i
N-e'i te(an/le)a!6 ada tida(n-a di!ten!i a,domen6 a!ite!
A+!(+lta!i
Pe'i!tlti( 4'e(+en!i6 (ete'at+'an"
F. Gin.al
In!)e(!i
Pen%el+a'an +'ine .+mla&6 0a'na6 ,a+6 !edimen"6 4'e(+en!i +'%en/-6
d'i,,lin%6 )e'a!aan te',a(a'/)ana!6 in(ontinen6 &emat+'i6 no(t+'ia dan
olo%+'ia
Pal)a!i
Kont+'6 +(+'an dan n-e'i te(an 'enal
Pe'(+!i
Ada tida(n-a n-e'i te(an )ada %in.al
A+!(+lta!i
A'ea e)i%a!t'i(6 a'ea (+ad'an (i'i dan (anan ata! +nt+( menden%a' !+a'a
de!i'an ao'ta dan a'te'i 'enali!
G. E(!te'mita!
- E(!te'mita! ata!
In!)e(!i A Pal)a!i
$dema de'a.at"
T+'%o' (+lit
Otot ma!!a6 ton+! A (e(+atan"6 !)a!me6 t'emo'6 (e!imet'i!an
Pe'!endian ROM6 n-e'i 6 (e(a(+an"
Pem,+l+& da'a& (e(+atan nadi6 )le,iti!"
Re4le(! ,i!e)6 t'i!e)"
Lin%(a' LLA
K+(+ ,ent+(6 0a'na6 (eadaan6 9RT"
- E(!te'mita! ,a0a&
In!)e(!i A Pal)a!i
$dema de'a.at"
T+'%o' (+lit
Otot ma!!a6 ton+! A (e(+atan"
Pe'!endian ROM6 n-e'i 6 (e(a(+an"
Pem,+l+& da'a& (e(+atan nadi6 )le,iti!"
Re4le(! )atela6 a/&ile!6 ,a,in!(i"
K+(+ ,ent+(6 0a'na6 (eadaan"
H. Dae'a& Genitalia
In!)e(!i
Bent+( !e(!+al6 leta( +'et'a6 di!t'i,+!i 'am,+t6 4+n%!i6 (e,e'!i&an.
Pema(aian (atete'
I. Re/t+m
In!)e(!i
A)a(a& ada &emo'oid6 ma!!a6 %atal6 4+n%!i !)'in%te' anal
J. P+n%%+n%
In!)e(!i A Pal)a!i
Po!t+' t+,+&6 a,no'malita! t+lan% ,ela(an% !/olia!i!6 lo'do!i!6 (o4o!i!"
N-e'i6 (elen%(a)an t+lan% ,ela(an%
VII. AKTIVITAS SEHARI HARI
NO ADL DI R$MAH DI R$MAH *AKIT
1. NUTRISI :
Ma(anan #
- Jeni!
- Po'!i/ .+mla& (alo'i
- Ma(anan (e!+(aan
- Ma(anan )antan%an
- Na4!+ ma(an
- 9a'a ma(an !endi'i/di,ant+"
Min+m #
- Jeni!
- F'e(+en!i
- J+mla&/in)+t 99"
9a'a min+m !endi'i/di,ant+"
Masalah :
2. Eliminasi :
BAB
- F'e(+en!i
- Pen%%+naan )en/a&a'
- Wa(t+
- Ba+6 da'a& A lendi'
- Kon!i!ten!i
- Ke!+litan
- Kolo!tomi
- O,!ti)a!i
- Dia'e
- 9a'a/)'o!e! men%el+a'(an
!endi'i/di,ant+"
BAK #
- F'e(+en!i
- J+mla& +'ine o+t )+t dalam //"
- Wa'na
- Ba+6 da'a&
- Ke!+litan
- In(ontinen!ia
- Hemat+'ia
- Pen%%+naan (atete'
9a'a/)'o!e! men%el+a'(an
!endi'i/di,ant+"
Masalah :
?. ISTIRAHAT DAN TIDUR :
- Wa(t+ tid+'
Malam6 )+(+l #
*ian%6 )+(+l #
- Laman-a
- Ke,ia!aan )en%anta' tid+'
- Ma!ala& tid+'
- Ke%iatan -an% dila(+(an !aat i!ti'a&at
Masalah :
C. KEBER*IHAN DIRI #
- Pemeli&a'aan ,adan mandi"
- Pemeli&a'aan m+l+t/%i%i
- Pemeli&a'aan (+(+
- Pemeli&a'aan 'am,+t
- 9a'a mela(+(an !endi'i/di,ant+"
Masalah :
:. AKTIVITASLATIHAN :
- Ola& 'a%a
Jeni!
F'e(+en!i
- Ke%iatan di 0a(t+ l+an%
- 9a'a mela(+(an !endi'i/di,ant+"
Masalah :
VIII. TEST DIA!NOSTIK
- La,o'ato'i+m t+li! nilai no'maln-a" #
- Ro 4oto #
- 9T */an #
MRI6 $*G6 EEG6 EKG6 dll #
IF. THERAPI SAAT INI T+li! den%an 'in/i"
DATA FOK$*
9P. 1 A "
DATA SU"#EKTIF DATA O"#EKTIF
ANALISA DATA
$ %P.& " '
NO DATA ETIOLO!I MASALAH
DIA!NOSA KEPERAWATAN
$ %P.2 '
NAMA PA*IEN # GGGGGGGGGG. NAMA MAHA*I*WA # GGGGGG.
NO.REKAM MEDIK # GGGGGGGGGG. N I M # GGGGGG.
R$ANG RAWAT # GGGGGGGGGG.
NO MASALAHDIA!NOSA T!L.DITEMUKAN T!L.TERATASI
REN%ANA KEPERAWATAN
$ %P.( '
T!L TU#UAN REN%ANA RASIONAL
ND). DAN DATA
PENUN#AN! TINDAKAN
IMPLEMENTASI
$ %P. * '
T!L KODE ND) #AM TINDAKAN KEPERAWATAN
%ATATAN PERKEM"AN!AN
$ %P.+ '
NAMA PA*IEN # GGGGGGGGGG. NAMA MAHA*I*WA # GGGGGG.
NO.REKAM MEDIK # GGGGGGGGGG. N I M # GGGGGG.
R$ANG RAWAT # GGGGGGGGGG.
T!L KODE ND, # A M EVALUASI SOAP
* #
RESUME KEPERAWATAN
$ %P.- '
N A M A # NO. REKAM MEDIK #
$ M $ R # R$ANG RAWAT #
J.KELAMIN # TGL. MA*$K R* #
A G A M A # TGL. KEL$AR R* #
ALAMAT #
1. Ma!ala& (e)e'a0atan )ada !aat )a!ien di'a0at #
8. Tinda(an (e)e'a0atan !elama di'a0at #
?. E 7 a l + a ! I #
C. Na!e&at )ada 0a(t+ )a!ien )+lan% #
NAMA MH* # GGGGGGGGGGGG GGGGGGGGGG"
N IM # GGGGGGGGGGGG
FORMAT PEN!ISIAN "UKU .OVERAN.
PRAKTEK KLINIK KDM AKADEMI KEPERAWATAN RANTEPAO
NO NAMA KLIEN D,. M/0is %a1a1an P/23/m4an5an Kli/n K/1
Keadaan $m+m #
Tanda-tana @ital #
D>. Ke)e'a0atan -an%
ditem+(an #
1.
8.
Tinda(an Ke)e'a0atn -an%
!+da& dila(+a(n / &a!il A 'e!)on
(lien
1.
8
Ren/ana tinda( Lan.+t #
1.
8.
Pa'a4 Ma&a!i!0a
.........................."
FORMAT ADL
MAHASISWA AKADEMI KEPERAWATAN RANTEPAO
N6 Ha2iTan55al #am Nama #/nis P26s/072
Pa2a8
%I %I
Pasi/n Tin0a3an
Lahan Ins1i17si
DAFTAR KONSULTASI MATERI SEMINAR
MAHASISWA TIN!KAT I AKADEMI KEPERAWATAN RANTEPAO
Nama Mahasis9a :
NIM :
Tin53a1 :
Kas7s :
RS R7an5an :
NO Ha2i Tan55al Ma1/2i 36ns7l1asi TTD
P/m4im4in5
TTD
Mahasis9a
M/n5/1ah7i:
Di2/3172 A3;/2 Ran1/;a6
$ Al4/21hin K: SKM: M.K/s'