Post on 28-Jan-2016
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PENGKAJIAN KEPERAWATAN
KEPERAWATAN MEDIKAL BEDAH
PROGRAM STUDI PROFESI NERS
Nama mahasiswa yang mengkaji : Sulfiana NIM : 15.04.044
Ruangan : Lontara 3 atas belakang Tanggal Pengkajian : 11 – 11 - 2011
Kamar : Waktu Pengkajian : 14.30
Tanggal masuk RS : 10 – 11 – 2015 Auto Anamnese
Allo Anamnese
I. IDENTITAS
A. Klien
Nama Initial : Tn. K
Tempat/Tanggal Lahir (Umur) : Belawa, 1 - 7 - 1963
Jenis Kelamin : Laki-laki Perempuan
Status Perkawinan : Kawin/Tidak Janda / Duda
Jumlah Anak : -
Agama/Suku : Islam, bugis
Warga Negara : Indonesia Asing
Bahasa yang digunakan : Indonesia Daerah Asing
Pendidikan : SD SMP SMA S-1 S-2
Tidak/Belum Sekolah Lainnya
Pekerjaan : Swasta Pegawai Negeri Lainnya,
petani
Alamat : Jl. Belawa, Sidrap
B. Penanggung Jawab
Nama : Tn. B
Alamat : Perdos, tamalanrea
II. DATA MEDIK
A. Dikirim Oleh : UGD Dokter Praktek
B. Diagnosa Medik :
Saat Masuk : Os. Ulkus Kornea
Saat Pengkajian : Os. Ulkus Kornea
III. KEADAAN UMUM
A. Keadaan Sakit : Klien tampak sakit ringan/ sedang/ berat/ tidak tampak
sakit/ tidak bereaksi/ baring lemah/ duduk/ aktif/ pucat/ sianosis/ sesak nafas.
Penggunaan alat medik : ............................................................................................
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Keluhan Utama : ............................................................................................
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B. Tanda-tanda Vital
1. Kesadaran :
Kualitatif : Compos Mentis Somnolens Koma
Apatis Soporcoma
Kuantitatif :
Skala Coma Glasgow : 15 Respon Motorik : 6
Respon Bicara : 5
Respon Membuka Mata : 4
Kesimpulan : Kesadaran penuh
Tremor : Positif Negatif
2. Tekanan Darah :120/80 mmHg
Kesimpulan : Normal
3. Suhu : 36,5 ºC Oral Axilla Rectal
4. Nadi : 80 x/ menit
5. Pernapasan : 20 x/ menit
Irama : Teratur Kusmaul Cheyne-Stokes
Jenis : Dada Perut
C. Pengukuran
1. Lingkar lengan atas : ................. cm Tinggi Badan : 165 cm
2. Lipat kulit triceps : ................. cm Berat Badan : 58 kg
Indeks Massa Tubuh (IMT) : 21,3 Kg/ m2
Kesimpulan : ...........................................................................
Catatan : ...........................................................................
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D. Genogram
IV. PENGKAJIAN POLA KESEHATAN
A. Kajian Persepsi Kesehatan – Pemeliharaan Kesehatan
Riwayat penyakit yang pernah dialami : sakit berat/ dirawat/ kecelakaan, operasi,
gangguan kehamilan/ persalinan/ abortus/ transfusi/ reaksi alergi.
Kapan : .........................................................
Catatan :........................................................
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Kapan : .........................................................
Catatan : ........................................................
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Tn. K
Riwayat Kesehatan Sekarang :
Klien mengeluh nyeri pada mata sebelah kiri naik ke kepala.
1. Data Subyektif :
a. Keadaan sebelum sakit :
Klien mampu beraktivitas penuh tanpa bantuan
b. Keadaan sejak sakit/ sakit saat ini :
Klien mengeluh penglihatan kabur
Klien mengeluh nyeri pada mata kiri disertai sakit kepala
2. Data Obyektif
Observasi :
Kebersihan rambut : bersih
Kulit Kepala : bersih
Kebersihan Mulut : bersih
B. Kajian Nutrisi Metabolik
1. Data Subyektif
a. Keadaan sebelum sakit :
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b. Keadaan sejak sakit/ sakit saat ini :
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2. Data Obyektif
a. Observasi :
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b. Pemeriksaan Fisik
Keadaan Rambut : ..........................................................................................
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Hidrasi Kulit : ..........................................................................................
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Conjungtiva : ..........................................................................................
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Hidung : ..........................................................................................
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Rongga Mulut : ..........................................................................................
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Gusi : ..........................................................................................
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Kemampuan mengunyah keras : ...................................................................
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Lidah : ..........................................................................................
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Pharing : ..........................................................................................
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Kelenjar getah bening :..................................................................................
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Kelenjar tyroid : ..........................................................................................
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Abdomen
Inspeksi Bentuk : ..........................................................................................
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Bayangan Vena Benjolan Massa
Auscultasi : Peristaltik : ................ x/ menit
Palpasi : Tanda nyeri umum : ...............................................................
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Massa : ...............................................................
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Hidrasi Kulit : ...............................................................
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Perkusi :
Ascites Negatif Positif
Lingkar Perut : ............. cm
Kelenjar Lympe Inguinale :
Kulit :
Oedema Negatif Positif
Ichterik Negatif Positif
Tanda Radang...........................................................................................
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Lesi ............................................................................................................
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Lain-lain .....................................................................................................
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Kesimpulan .....................................................................................................
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c. Pemeriksaan Diagnostik
Laboratorium
WBC : 14.2 mm3
HGB : 9.5 g/dL
MCHC : 22.2 g/dL
Lain-
lain ..............................................................................................................................
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d. Terapi
Infus RL 16tts/menit
c.LFx EDMD 1 tetes/4jam/OS
c.Tobro 1 tetes/4jam/OS
c.Reepitel EDMD 1 tetes/4jam/OS
Nevanac ED 1tetes/8jam/OS
c. Tropin 1% ED 1tetes/12jam/OS
C. Kajian Pola Eliminasi
1. Data Subyektif
a. Keadaan sebelum sakit :
b. Keadaan sejak sakit/ sakit saat ini :
.
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2. Data Obyektif
a. Observasi ....................................................................................................................
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b. Pemeriksaan Fisik
Peristaltik usus .......... x/ menit
Palpasi supra pubic : Kandung kemih Penuh Kosong
Nyeri ketuk ginjal : Kiri Negatif Positif
Kanan Negatif Positif
Anus :
Peradangan Negatif Positif
Fissura Negatif Positif
Hemorhoid Negatif Positif
Prolapsus Recti Negatif Positif
Fistula Ani Negatif Positif
Massa Tumor Negatif Positif
Kesimpulan :
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D. Kajian Pola Aktivitas dan Latihan
1. Data Subyektif
a. Keadaan sebelum sakit :
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b. Keadaan sejak sakit/ sakit saat ini :
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2. Data Objektif
a. Observasi
Aktivitas harian
Makan : Mandiri
Mandi :
Berpakaian : ...............................................................
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Kerapian : ...............................................................
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BAB : ...............................................................
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BAK : ...............................................................
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Mobilisasi ditempat tidur : dibantu sebagian
Ambulasi : Mandiri
Postur tubuh : ...............................................................
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Anggota gerak yang cacat : ..................................................
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Fixasi : ...............................................................
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Kesimpulan :
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Perfusi pembuluh perifer kuku :
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Thorax dan Pernapasan
Inspeksi Bentuk Thoraks : .................................................................
Stridor Negatif Positif
Dyspnea d’effort Negatif Positif
Syanosis Negatif Positif
Palpasi Vocal Fremitus : ...................................................................
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Perkusi Sonor Redup Pekak
Batas Paru Hepar : ................................................................
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Auskultasi
Suara Napas : ........................................................................
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Suara Ucapan : .....................................................................
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Suara Tambahan : .................................................................
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Jantung
Inspeksi : Ictus Cordis :......................................................................
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Klien menggunakan alat pacu jantung : Negatif
Positif
Palpasi : Ictus Cordis : .....................................................................
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Perkusi
Batas Atas Jantung : ............................................................
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Batas Kanan Jantung : .........................................................
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Batas Bawah Jantung : ........................................................
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Batas Kiri Jantung : .............................................................
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Auskultasi
Bunyi Jantung II A : ............................................................
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Bunyi Jantung II P : ............................................................
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Bunyi Jantung I T : ..............................................................
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Bunyi Jantung I M : .............................................................
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Bunyi Jantung III Irama Gallop :
Negatif Positif
Mur-mur Negatif Positif
Tempat : ..............
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Grade : ................
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HR : .......... x/ menit
Bruit Aorta Negatif Positif
A. Renalis Negatif Positif
A. Femoralis Negatif Positif
Lengan dan Tungkai
Atrofi Otot Negatif Positif
Rentang Gerak : ...................................................................
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Mati Sendi : .......................................................
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Kaku Sendi : .....................................................
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Refleks Fisiologi : ................................................................
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E. Kajian Pola Tidur dan Istirahat
1. Data Subyektif
a. Keadaan Sebelum Sakit ..................................................................................
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b. Keadaan Sejak Sakit ......................................................................................
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2. Data Obyektif
a. Observasi :
Ekspresi wajah mengantuk Negatif Positif
Banyak menguap Negatif Positif
Palpabrae inferior berwarna gelap Negatif Positif
b. Terapi :
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F. Kajian Pola Persepsi Kognitif
1. Data Subyektif
a. Keadaan Sebelum Sakit
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b. Keadaan Sejak Sakit
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2. Data Obyektif
a. Observasi
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b. Pemeriksaan Fisik
Penglihatan
Cornea : ................................................................................
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Visus :..................................................................................
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Pupil : ...................................................................................
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Lensa Mata : ........................................................................
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Tekanan Intra Okuler : ........................................................
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Pendengaran
Pina : ....................................................................................
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Canalis : ..............................................................................
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Membran Timpani : ............................................................
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Test Pendengaran : .............................................................
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G. Kajian Pola Persepsi dan Konsep Diri
1. Data Subyektif
a. Keadaan Sebelum Sakit
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b. Keadaan Sejak Sakit
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2. Data Obyektif
a. Observasi
Kontak Mata :
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Rentang Penglihatan :
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Suara dan Tata bicara :
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Postur Tubuh :
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b. Pemeriksaan Fisik
Abdomen :
Bentuk :..........................................................................
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Bayangan Vena : ...........................................................
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Bayangan Massa : ...........................................................
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Kulit :
Lesi Kulit : ......................................................................
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H. Kajian Pola Peran dan Hubungan Dengan Sesama
1. Data Subyektif
a. Sebelum keadaan sakit
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b. Keadaan sejak sakit
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2. Data Obyektif
Observasi
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I. Kajian Pola Reproduksi-Seksualitas
1. Data Subyektif
a. Keadaan sebelum sakit :
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b. Keadaan sejak sakit :
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2. Data Obyektif
a. Observasi
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b. Pemeriksaan Fisik
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c. Pemeriksaan Diagnostik
Laboratorium
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Lain-lain
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d. Terapi
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J. Kajian Mekanisme Koping dan Toleransi Terhadap Stress
1. Data Subyektif
a. Keadaan sebelum sakit
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b. Keadaan sejak sakit
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2. Data Obyektif
a. Observasi
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b. Pemeriksaan Fisik
Tekanan Darah : Berbaring : mmHg
Duduk : mmHg
Berdiri : mmHg
Kesimpulan Hipotensi Ortostatik : Negatif Positif
HR : x/menit
Kulit : Keringat Dingin Basah
c. Terapi
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K. Kajian Pola Sistem Nilai Kepercayaan
1. Data Subyektif
a. Keadaan sebelum sakit
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b. Keadaan sejak sakit
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2. Data Obyektif
Observasi
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Yang Mengkaji
PENGELOMPOKAN DATA
DATA OBYEKTIF DATA SUBYEKTIF
Klien mengeluh nyeri pada
daerah matanya
P : Mata merah
Q : Nyeri Tajam
R : Mata Kiri
S : 4
T : Intermiten
Klien mengeluh sakit kepala
Klien mengeluh tidak dapat
beraktivitas seperti biasanya
karena gangguan penglihatan
Klien mengeluh penglihatannya
kabur
Klien mengeluh penglihatan silau
Ekspresi wajah nampak meringis
Nampak memegang area mata
Penurunan ketajaman mata,
penurunan visus
Hasil :
VOD : 20/40
VOS : 1/300
Nampak mengecilkan mata bila
ada respon cahaya
Mata nampak merah
DIAGNOSA KEPERAWATAN
Nama / Umur : Tn. K / 52 tahun
Ruang / Kamar : Lontara 3 Atas Belakang / K5 bed 6
NO. DIAGNOSA KEPERAWATAN NAMA JELAS
1.
2.
Nyeri berhubungan dengan agens penyebab cedera fisik ;
tertusuk kulit buah coklat.
Gangguan Persepsi Sensori (Penglihatan) berhubungan dengan
perubahan dan atau penurunan integrasi sensori.
Nyeri
Gangguan
persepsi sensori
RENCANA ASUHAN KEPERAWATAN
Nama/ Umur : Tn. K / 52 tahun
Ruang / Kamar : Lontara 3 Atas Belakang
TGL DIAGNOSA
KEPERAWATAN
TUJUAN/ HASIL YANG
DIHARAPKAN
RENCANA TINDAKAN RASIONAL TINDAKAN TTD/
NAMA
11 Nov
2015
Nyeri berhubungan dengan
agens penyebab cedera
fisik ; tertusuk kulit buah
coklat.
Setelah dilakukan tindakan
keperawatan selama 1 x 24 jam
pasien mengatakan nyeri
berkuranang deng dengan kriteria
hasil:
Mampu mengontrol nyeri (tahu
penyebab nyeri, mampu
menggunakan tehnik non
farmakologi untuk mengurangi
nyeri)
Melaporkan bahwa nyeri
berkurang dengan menggunakan
manajemen nyeri
Tanda vital dalam rentang normal
1. Kaji skala nyeri dengan
menggunakan PQRST
2. Observasi Tanda – tanda
vital
3. Kontrol lingkungan yang
dapat mempengaruhi nyeri
seperti suhu ruangan,
pencahayaan dan
kebisingan
4. Ajarkan tentang teknik non
farmakologi: napas dalam.
5. Berikan analgetik untuk
mengurangi nyeri.
1. Mengetahui derajat nyeri
yang dirasakan klien
sehingga memudahkan
dalam menentukan
tindakan selanjutnya.
2. Suplay okesigen ke
jaringan barkurang maka
akan menyebabkan nyeri
3. lingkungan yang nyaman
dapat mengurangi nyeri.
4. Untuk mengurangi rasa
nyeri.
TGL DIAGNOSA
KEPERAWATAN
TUJUAN/ HASIL YANG
DIHARAPKAN
RENCANA TINDAKAN RASIONAL TINDAKAN TTD/
NAMA
11 Nov
2015
Gangguan Persepsi
Sensori (Penglihatan)
berhubungan dengan
perubahan dan atau
penurunan integrasi
sensori.
Setelah dilakukan tindakan
keperawatan selama 1 x 24
jam pasien mampu mengenal
gangguan sensori dan
berkompensasi terhadap
perubahan.
1. Tentukan ketajaman
penglihatan, catat apakah
satu atau kedua mata terlibat.
2. Orientasi pasien terhadap
lingkungan.
3. Observasi tanda dan gejala
disorientasi : pertahankan
pagar tempat tidur.
4. Berikan pendidikan
kesehatan tentang pemberian
obat mata (Jika ada).
1. Kebutuhan individu dan
pilihan intervensi
bervariasi sebab
kehilangan penglihatab
terjadi lambat dan
progresif.
2. Memberikan peningkatan
kenyamanan.
3. Menurunkan resiko jatuh
bila pasien bingung.
4. Untuk mencegah
kemungkinan terjadinya
kesalahan dalam
pemberian obat.
PELAKSANAAN ASUHAN KEPERAWATAN
Nama / Umur : Tn. K / 52 tahun
Ruang / Kamar : Lontara 3 Atas Belakang
NO. NO. DP TANGGAL PELAKSANAAN KEPERAWATAN NAMA JELAS
1 1 14 nov 2015 1. Mengkaji skala nyeri dengan
menggunakan PQRST
2. Mengobservasi tanda – tanda vital
3. Mengontrol lingkungan yang dapat
mempengaruhi nyeri seperti suhu
ruangan, pencahayaan dan kebisingan
4. Mengajarkan tentang teknik non
farmakologi: napas dalam.
5. Memberikan analgetik untuk
mengurangi nyeri
NO. NO. DP WAKTU PELAKSANAAN KEPERAWATAN NAMA JELAS
2 2 14 nov 2015 1. Menentukan ketajaman penglihatan,
catat apakah satu atau kedua mata
terlibat.
2. Mengorientasi pasien terhadap
lingkungan.
3. Mengobservasi tanda dan gejala
disorientasi : pertahankan pagar tempat
tidur.
4. Memberikan pendidikan kesehatan
tentang pemberian obat mata (Jika ada).
EVALUASI ASUHAN KEPERAWATAN
Nama / Umur : Tn. K / 52 tahun
Ruang / Kamar : Lontara 3 Atas Belakang / K5 bed 6
NO DP TANGGAL EVALUASI KEPERAWATAN NAMA
JELAS
1
2
Nyeri
Gangguan
persepsi
sensori
S : Klien mengatakan nyeri mata kiri
berkurang
O : Keadaan umum baik
Kesadaran Compos mentis
Skala nyeri 2
A : Masalah belum teratasi
P : Lanjutkan intervensi 1,2,4,5
S : Klien mengatakan penglihatannya kabur
O : Klien Nampak memegang area mata
VOD : 20/40
VOS : 1/300
A : Masalah belum teratasi
P : Lanjutkan intervensi 2, 3, 4
NO DP TANGGAL EVALUASI KEPERAWATAN NAMA
JELAS