ASUHAN KEPERAWATAN KEPERAWATAN MEDIKAL BEDAH Nama Mahasiswa:NIM:Ruang:INFORMASI UMUM Nama:Usia:Tanggal Lahir:Jenis Kelamin:Suku Bangsa:Tanggal masuk:Sumber Informasi:

ISTIRAHAT Pekerjaan: Perasaan bosan: Keterbatasan karena kondisi :Tidur Jam: Tidur siang: .Kebiasaan tidur ..Lain-lain: Massa/ tonus otot : Deformitas : Masalah lainnya:

SIRKULASI Riwayat tentang : Hipertensi : Masalah jantung : Demam rematik : Edema mata kaki/ kaki: Flebitis:Ekstremitas : Kesemutan : Kebas : Batuk/ hemoptisis : Perubahan frekuensi/ jumlah urine :TD :mmHg. Tekanan nadi: Frekuensi Nadi:.x/menitBunyi jantung:Ekstremitas : Suhu: Abnormalitas kuku Penyebaran/ kualitas rambut :

Warna : Membran mukosa: Bibir: Punggung kuku : Konjungiva : Sklera : Diaforesis : Masalah lainnya :

INTEGRITAS EGO Agama: Gaya hidup:Keputusasaan: Ketidak berdayaan :Masalah lainnya

Status emosional (beri tanda cek untuk yang sesuai) : Tenang Cemas Marah Menarik diri Takut Mudah tersinggung Tidak sabar Respons-respons fisiologis yang terobservasi Masalah lainnya

ELIMINASI POLA BAB: Penggunaan laksatif Karakter fases BAB terakhir Riwayat perdarahan Hemoroid Konstipasi Diare POLA BAK: Karakter urine Nyeri/ rasa terbakar/ kesulitan BAK Riwayat penyakit ginjal/ kandung kemih Penggunaan diuretik Abdomen : Nyeri tekan Lunak Keras Bising usus :..............x/menitMasalah lainnya :. ......................MAKANAN/ CAIRAN Diit biasa (tipe) : Jumlah makanan per hari Makan terakhir/ masukan Pola diit Kehilangan selera makan Mual/ muntah Nyeri ulu hati Yang berhubungan dengan Alergi/ intoleransi makanan Masalah-masalah mengunyah/ menelan Berat badan biasa Perubahan berat badan Berat badan sekarang Tinggi badan Bentuk tubuh Turgor kulit : Kelembaban/ kering membran mukosa :Kondisi gigi/ gusi : Penampilan lidah :Masalah lainnya :

HIGIENE Aktivitas sehari-hari (Tergantung/ Mandiri) Mobilitas : Makan : Hegiene Berpakaian : Toileting : Bantuan diberikan oleh:Penampilan umum :Waktu mandi yang diinginkan:Cara berpakaian : Kebiasaan pribadi : Bau badan: Kondisi kulit kepala :Adanya kutu :Masalah lainnya :

NEUROSENSORI Rasa ingin pingsan/ pusing: Sakit kepala : Lokasi nyeri :Frekuensi :Kesemutan/ kebas/ kelemahan (lokasi) : Stroke (gejala sisa) : Mata : Kehilangan penglihatan: Pemeriksaan terakhir : Glaukoma : Katarak: Telinga: Kehilangan pendengaran : Pemeriksaan terakhir : Epistaksis:Status mental :Terorientasi/ disorientasi : Waktu : Tempat : Orang :Kesadaran : Mengantuk Letargi Stupor Koma Kooperatif Menyerang Delusi Halusinasi Afek (gambarkan)Kaca mata :Kontak lensa :Alat bantu dengar :Rekasi pupil : Ka/ Ki Genggaman tangan/ lepas : Ka/ Ki:Postur Masalah lainnya

NYERI/ KETIDAKNYAMANAN Faktor-faktor pencetus KualitasLokasi intensitas (1-10)Frekuensi Durasi Penjalaran: Cara menghilangkan: Mengkerutkan muka Menjaga area yang sakit Respons emosional Masalah lainnya :PERNAPASAN Dispnea yang berhubungan dengan batuk/ sputum : Riwayat bronkitis: Asma :Tuberkulosis : Emifisema :Pneumonia kambuhan :Pemanjanan terhadap udara berbahaya :Merokok :..................................... Banyak:.hari Lama: .......................tahunPenggunaan alat bantu pernapasan: Frekuensi :x/menit Kedalaman:Simetris : .......................................... Penggunaan otot-otot asesori Masalah lainnya :KEAMANAN Alergi/ sensitivitas :Reaksi : Perubahan sistem imun sebelumnya :Penyebab : Tranfusi darah/ jumlah :Kapan : Gambaran reaksi :Riwayat cedera kecelakaan :Fraktur/ dislokasi :Artritis/ sendi tak stabil :Masalah punggung : Kerusakan penglihatan, pendengaran :Suhu tubuh :Diaforesis : Integritas kulit :Jaringan parut :Kemerahan : Laserasi:Ulserasi :Ekimosis :Lepuh : Luka bakar : (derajat/ persen):Drainase: Tandai lokasi pada diagram di bawah ini : Kekuatan Umum :Tonus otot:Cara berjalan :ROM :Parestesia/ paralisis : Masalah lainnya :INTERAKSI SOSIAL Status perkawinan :Hidup dengan : Masalah-masalah/ stres :Orang pendukung lain :Masalah-masalah yang berhubungan dengan penyakit/ kondisi : Bicara : Jelas Tak Jelas Tidak Dapat Dimengerti Afasia .Masalah lainnya :PENYULUHAN/ PEMBELAJARAN Bahasa dominan (khusus) :Melek huruf : Tingkat pendidikan :Keterbatasan kognitif : Masalah lainnya :Obat yang diresepkan :

ANALISA DATANoData SenjangEtiologiMasalah

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RENCANA ASUHAN KEPERAWATAN NoDiagnosa KeperawatanTujuan / sasaranIntervensiParaf

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TINDAKAN KEPERAWATANWaktuNo. DxCatatan tindakan dan evaluasi hasil tindakanParaf

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CATATAN PERKEMBANGAN TanggalNo. DxS O A PParaf

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CI/Kepala Ruangan..Mahasiswa

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