Kasus 1

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


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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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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



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2. Data Obyektif

a. Observasi ....................................................................................................................

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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


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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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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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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


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b. Keadaan sejak sakit :

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2. Data Obyektif

a. Observasi

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c. Pemeriksaan Diagnostik

Laboratorium

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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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2. Data Obyektif

a. Observasi

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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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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


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


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

Kasus 1

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