PROGRAM STUDI PENDIDIKAN NERS

STIKES SURYA MITRA HUSADA KEDIRI

PROGRAM PENDIDIKAN PROFESI NERS
ALAMAT : JLN. Manila No. 37 Sumberece Kota Kediri Telp. (0354) 7009713 Fax. (0354) 695130

Nama Mahasiswa : ………………………………………………...

NIM : …………………………………………………

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH

Tanggal MRS : Jam Masuk :
Tanggal Pengkajian : No. RM :
Jam Pengkajian : Diagnosa Masuk :
Hari rawat ke :

IDENTITAS
1. Nama Pasien :
2. Umur:
3. Suku/ Bangsa :
4. Agama :
5. Pendidikan :
6. Pekerjaan :
7. Alamat :
8. Sumber Biaya :

KELUHAN UTAMA
1. Keluhan utama: Klien masuk rumah sakit dengan keluhan napasnya sesak sewaktu bangun pagi dan
semakin meningkat ketika beraktivitas, serta batuk berdahak.

9. Riwayat Penyakit Dahulu

10. Klien mengatakan mempunyai riwayat asma sejak kelas 6 SD
11.  Riwayat penyakit Sekarang
12. Klien mengeluh sesak, batuk berdahak dengan dahak berwarna putih.
13.  Riwayat Penyakit Keluarga
14. Klien mengatakan bahwa ada salah satu anggota keluarganya yang memiliki riwayat asma,
yaitu ibunya.

RIWAYAT PENYAKIT SEKARANG

1. Riwayat Penyakit Sekarang:
………………………………………………………………………………...................................................................
…………………………………………………………………………………………………………….......................
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…………………………………………………………………………………………………………….......................
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RIWAYAT PENYAKIT DAHULU
1. Pernah dirawat : ya tidak kapan :…… diagnosa :…………
2. Riwayat penyakit kronik dan menular ya tidak jenis……………………
Riwayat kontrol : .............................
Riwayat penggunaan obat :..............
3. Riwayat alergi:
Obat ya tidak jenis……………………
Makanan ya tidak jenis……………………
Lain-lain ya tidak jenis……………………

4. Riwayat operasi: ya tidak

STIKes Surya Mitra Husada Kediri

 - Kapan : ……………………
- Jenis operasi : ……………………

5. Lain-lain:
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
RIWAYAT KESEHATAN KELUARGA
Ya tidak
- Jenis :………………….....................................................................................................................................
- Genogram :

PERILAKU YANG MEMPENGARUHI KESEHATAN

Perilaku sebelum sakit yang mempengaruhi kesehatan:
Alkohol ya tidak keterangan……….....................
Merokok ya tidak
keterangan…………………….........................................................
Obat ya tidak
keterangan…..............................................................………………
Olah raga ya tidak
keterangan…..........................................................…………………

OBSERVASI DAN PEMERIKSAAN FISIK

1. Tanda tanda vital
S: N: T: RR :
Kesadaran Compos Mentis Apatis Somnolen Sopor Koma

2. Sistem Pernafasan (B1)

a. RR:................................
b. Keluhan: sesak nyeri waktu nafas orthopnea
Batuk produktif tidak produktif
Sekret:…….. Konsistensi :......................
Warna:.......... Bau :.................................. Masalah Keperawatan :
c. Penggunaan otot bantu nafas:
..................................................................................................................................................................................
..................................................................................................................................................................................
d. PCH ya tidak
e. Irama nafas teratur tidak teratur
f. Pleural Friction rub:.....................................................................................................................
g. Pola nafas Dispnoe Kusmaul Cheyne Stokes Biot
h. Suara nafas Cracles Ronki Wheezing
i. Alat bantu napas ya tidak

Jenis................................................ Flow..............lpm

j. Penggunaan WSD:
- Jenis : .................................................................................................................................................................
- Jumlah cairan : ..................................................................................................................................................
- Undulasi :...................................................................................................................................................
- Tekanan : ..................................................................................................................................................

STIKes Surya Mitra Husada Kediri

 k. Tracheostomy: ya tidak
..................................................................................................................................................................................
..................................................................................................................................................................................
l. Lain-lain:
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
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3. Sistem Kardio vaskuler (B2)

a. TDKeperawatan
:
Masalah :
b. N :
c. Keluhan nyeri dada: ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
d. Irama jantung: reguler ireguler
e. Suara jantung: normal (S1/S2 tunggal) murmur
gallop lain-lain.....
f. Ictus Cordis: .............................................................................................................................................................
g. CRT :.............detik
h. Akral: hangat kering merah basah pucat
panas dingin
i. Sikulasi perifer: normal menurun
j. JVP :.................................
k. CVP :.................................
l. CTR :.................................
m. ECG & Interpretasinya:
..................................................................................................................................................................................
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n. Lain-lain :
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4. Sistem Persyarafan (B3)

a. GCS : .................................................. Masalah Keperawatan :
b. Refleks fisiologis patella triceps biceps
c. Refleks patologis babinsky brudzinsky kernig
Lain-lain
d. Keluhan pusing ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................

e. Pemeriksaan saraf kranial:

N1 : normal tidak Ket.: ……..............................................................
N2 : normal tidak Ket.: ……..............................................................
N3 : normal tidak Ket.: ……..............................................................
N4 : normal tidak Ket.: ……..............................................................
N5 : normal tidak Ket.: ……..............................................................
N6 : normal tidak Ket.: ……..............................................................
N7 : normal tidak Ket.: ……..............................................................
N8 : normal tidak Ket.: ……..............................................................
N9 : normal tidak Ket.: ……..............................................................
N10 : normal tidak Ket.: ……..............................................................

STIKes Surya Mitra Husada Kediri

 N11 : normal tidak Ket.: ……..............................................................
N12 : normal tidak Ket.: ……..............................................................

f. Pupil anisokor isokor Diameter: ……/......

g. Sclera anikterus ikterus
h. Konjunctiva ananemis anemis
i. Isitrahat/Tidur :................. Jam/Hari Gangguan tidur : ..............................................................
j. Lain-lain:
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
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5. Sistem perkemihan (B4)

Masalah Keperawatan
a. Kebersihan genetalia: Bersih Kotor
b. Sekret: Ada Tidak
c. Ulkus: Ada Tidak
d. Kebersihan meatus uretra: Bersih Kotor
e. Keluhan kencing: Ada Tidak
Bila ada, jelaskan:
..................................................................................................................................................................................
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f. Kemampuan berkemih:
Spontan Alat bantu, sebutkan: .................................................................................................
Jenis :............................................
Ukuran :............................................
Hari ke :............................................
g. Produksi urine : ………….. ml/jam
Warna :............……
Bau :......………..
h. Kandung kemih : Membesar ya tidak
i. Nyeri tekan ya tidak
j. Intake cairan oral : ……… cc/hari parenteral : ……… cc/hari
k. Balance cairan:
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................
k. Lain-lain:
..................................................................................................................................................................................
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6. Sistem pencernaan (B5)
a. TB :............... BB :................................ Masalah Keperawatan :
b. IMT :............... Interpretasi :................................

c. Mulut: bersih kotor berbau

d. Membran mukosa: lembab kering stomatitis
e. Tenggorokan:
sakit menelan kesulitan menelan
pembesaran tonsil nyeri tekan
f. Abdomen: tegang kembung ascites
g. Nyeri tekan: ya tidak
h. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
i. Peristaltik:.............. x/menit

STIKes Surya Mitra Husada Kediri

 j. BAB: ......................x/hari Terakhir tanggal : ............................................................................
k. Konsistensi: keras lunak cair lendir/darah
l. Diet: padat lunak cair
m. Diet Khusus:
..................................................................................................................................................................................
..................................................................................................................................................................................
n. Nafsu makan: baik menurun Frekuensi:.......x/hari
o. Porsi makan: habis tidak Keterangan:.......................
p. Lain-lain:
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7. Sistem Penglihatan
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Visus
Palpebra
Conjunctiva
Kornea
BMD
Pupil
Iris
Lensa
TIO

b. Keluhan nyeri ya tidak

P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................

c. Luka operasi: ada tidak

Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
d. Pemeriksaan penunjang lain : .........................
e. Lain-lain :
..................................................................................................................................................................................
..................................................................................................................................................................................
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8. Sistem pendengaran
a. Pengkajian segmen anterior dan posterior
Masalah Keperawatan :
OD OS
Aurcicula
MAE
Membran
Tymphani
Rinne
Weber
Swabach

b. Tes Audiometri
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STIKes Surya Mitra Husada Kediri

 ..................................................................................................................................................................................
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c. Keluhan nyeri ya tidak

P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
d. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
e. Alat bantu dengar: .........................
f. Lain-lain :
..................................................................................................................................................................................
..................................................................................................................................................................................
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8. Sistem muskuloskeletal (B6)
a. Pergerakan sendi: bebas terbatas
b. Kekuatan otot:
Masalah Keperawatan :

c. Kelainan ekstremitas: ya tidak

d. Kelainan tulang belakang: ya tidak
Frankel: ................................................................................
e. Fraktur: ya tidak
- Jenis :...................
f. Traksi: ya tidak
- Jenis :...................
- Beban :...................
- Lama pemasangan :...................
g. Penggunaan spalk/gips: ya tidak
h. Keluhan nyeri: ya tidak
P :...................................................................
Q :...................................................................
R :...................................................................
S :...................................................................
T :...................................................................
i. Sirkulasi perifer: ..............................................
j. Kompartemen syndrome ya tidak
k. Kulit: ikterik sianosis kemerahan hiperpigmentasi
l. Turgor baik kurang jelek
m. Luka operasi: ada tidak
Tanggal operasi :................
Jenis operasi :................
Lokasi :................
Keadaan :................
Drain : ada tidak
- Jumlah :...................
- Warna :...................
- Kondisi area sekitar insersi :...................
n. ROM : .................................................

o. Cardinal Sign : ................................................

p. Lain-lain:
..................................................................................................................................................................................
..................................................................................................................................................................................
..................................................................................................................................................................................

10. Sistem Integumen

a. Penilaian resiko decubitus
Kriteria Penilaian Nilai

STIKes Surya Mitra Husada Kediri

 Aspek Yang 1 2 3 4
Dinilai
Persepsi Sensori Terbatas Sangat Terbatas Keterbatasan Tidak Ada
Sepenuhnya Ringan Gangguan
Kelembaban Terus Menerus Sangat Lembab Kadang2 Basah Jarang Basah
Basah
Aktifitas Bedfast Chairfast Kadang2 Jalan Lebih Sering
jalan
Mobilisasi Immobile Sangat Terbatas Keterbatasan Tidak Ada
Sepenuhnya Ringan Keterbatasan
Nutrisi Sangat Buruk Kemungkinan Adekuat Sangat Baik
Tidak Adekuat
Gesekan & Bermasalah Potensial Tidak
Pergeseran Bermasalah Menimbulkan
Masalah
NOTE: Pasien dengan nilai total < 16 maka dapat dikatakan bahwa pasien beresiko Total Nilai
mengalami dekubisus (pressure ulcers)
(15 or 16 = low risk, 13 or 14 = moderate risk, 12 or less = high risk)

b. Warna Masalah Keperawatan :

c. Pitting edema: +/- grade:................
d. Ekskoriasis: ya tidak
e. Psoriasis: ya tidak
f. Pruritus: ya tidak
g. Urtikaria: ya tidak
h. Lain-lain:
..................................................................................................................................................................................
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11. Sistem Endokrin

a. Pembesaran tyroid: ya tidak Masalah Keperawatan :
b. Pembesaran kelenjar getah bening: ya tidak
c. Hipoglikemia: ya tidak
d. Hiperglikemia: ya tidak
e. Kondisi kaki DM
- Luka gangren ya tidak
Jenis ................................................................................................................
- Lama luka ...............................................................................................
- Warna ...............................................................................................
- Luas luka ...............................................................................................
- Kedalaman ...............................................................................................
- Kulit kaki ...............................................................................................
- Kuku kaki ...............................................................................................
- Telapak kaki ...............................................................................................
- Jari kaki ...............................................................................................
- Infeksi ya tidak
- Riwayat luka sebelumya ya tidak
Jika ya:
- Tahun :
- Jenis Luka :
- Lokasi :
- Riwayat amputasi sebelumya ya tidak
Jika ya:
- Tahun :
- Lokasi :
f. ABI : ....................................................
g. Lain-lain:
..................................................................................................................................................................................
..................................................................................................................................................................................
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PENGKAJIAN PSIKOSOSIAL Masalah keperawatan :

a. Persepsi klien terhadap penyakitnya:
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................

b. Ekspresi klien terhadap penyakitnya

Murung/diam gelisah tegang marah/menangis
c. Reaksi saat interaksi kooperatif tidak kooperatif curiga

STIKes Surya Mitra Husada Kediri

d. Gangguan konsep diri:
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
e. Lain-lain:
...........................................................................................................................................................................................
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PERSONAL HYGIENE & KEBIASAAN
Masalah Keperawatan :
Jelaskan :
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................
.............................................................................................................................................................................................

PENGKAJIAN SPIRITUAL
a. Kebiasaan beribadah Masalah Keperawatan :
- Sebelum sakit sering kadang- kadang tidak pernah
- Selama sakit sering kadang- kadang tidak pernah

b. Bantuan yang diperlukan klien untuk memenuhi kebutuhan beribadah:

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

PEMERIKSAAN PENUNJANG (Laboratorium,Radiologi, EKG, USG , dll)

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TERAPI
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DATA TAMBAHAN LAIN :

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Kediri, ……………..20...

STIKes Surya Mitra Husada Kediri

 (……………………………)

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STIKES SURYA MITRA HUSADA KEDIRI

ANALISIS DATA

Hari/
DATA
Tgl/ Jam
S : Px mengatakan Sesak
nafas(+),batuk (+), Nyeri
dada, wajah Gelisa terlihat
adanya bercak kehitaman,
Konjungtiva Pucat.
DO :
- Px nampak sesak nafas,
memegang dadanya,
penggunaan otot batuk
penapasaan, ekspresi wajah
gelisah, terlihat adanya
bercak kehitaman,
Konjungtiva Pucat
ETIOLOGI MASALAH
Pencetus serangan Ketidak Efektifan
(alergen) Bersihan Jalan Nafas
↓
Reaksi antigen & antibodi
↓
Dikeluarkannya substansi
vasoaktif (histamin,
bradikinin, & anafilaksin)
↓
↑ permeabilitas kapiler
↓
Kontraksi otot polos
Edema mukosa

STIKes Surya Mitra Husada Kediri

 - Px tampak berkeringat. Hipersekresi
- Px batuk-batuk pada ↓
auskultasi terdengar bunyi Obstruksi jalan nafas
tambahan (wheezing). ↓
TTV : Tidak efektifnya bersihan
TD : 120/80mmHg jalan nafas
RR: 26x/mnt
N: 88x/mnt
S: 36 C
BB : 48 kg

DS : Px merasa sesak (+), Pencetus serangan Pola Nafas Tidak

Batuk(+) , Nyeri dada, (alergen) Efektif
wajah Gelisa terlihat adanya ↓
bercak kehitaman, Reaksi antigen & antibodi
Konjungtiva Pucat. ↓
Dikeluarkannya substansi
O : Px tampak sesak nafas vasoaktif (histamin,
disertai batuk, berwarna putih bradikinin, & anafilaksin)
agak kental, Suara napas px ↓
terdengar wheezing. Kontraksi otot polos
Tanda-tanda vital: ↓
TD : 120/80mmHg Bronkospasme
RR: 26 x/menit ↓
N: 88x/mnt Suplai O2 menurun
S: 37oC ↓
Merangsang kemoreseptor
sentral (spons dan medulla
oblongata)
↓
Hiperventilasi
↓
Sesak
↓
Pola nafas tidak efektif

S : Px mengatakan
Sasak nafas Gangguan
Nyeri dada Pertukaran Gas
Gelisah
Keringat
Batuk
Nafas tambahan
Wajah terlihat adanya bercak
kehitaman
O : Px memegang dadanya,
penggunaan otot batuk
penapasaan, ekspresi wajah
gelisah, terlihat adanya bercak
kehitaman, Konjungtiva Pucat
Px tampak berkeringat. Px
batuk-batuk pada auskultasi
terdengar bunyi tambahan
wheezing +
TTV :
TD : 120/80mmHg
RR: 26x/mnt
N: 88x/mnt

STIKes Surya Mitra Husada Kediri

 S: 36 C
BB : 48 kg
Hb: 10g/dl
PCO2 : 62mmHg.
HCO3 : 23 mEq/L
BE : + 1
RR : 26x/ mnt

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DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

TANGGAL: .................................
1.

2.

3.

4.

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5.

6.

STIKes Surya Mitra Husada Kediri

 RENCANA INTERVENSI

Hari/ Tgl/ NOC NIC

No. DIAGNOSA KEPERAWATAN
Jam (Nursing Outcome Classification)
Dalam waktu 3x24 jam setelah diberikan
Ketidakefektifan bersihan tindakan bersihan jalan napas kembali
jalan napas efektif
Kriteria hasil :
- Dapat mendemonstrasikan batuk
efektif
- Dapat menyatakan strategi untuk
menurunkan kekentalan sekresi
- Tidak ada suara napas tambahan dan
wheezing (-)
- Pernapasan klien normal (16-20x/m)
tanpa ada penggunaan otot bantu
napas.
(Nursing Intervention Classification)
Observasi :
Kaji warna dan kekentalan sputum
Atur posisi semi fowler
Mandiri :
1. Ajarkan pasien pernapasan dalam.
2. Tinggikan kepala dan bantu mengubah posisi.
Berikan posisi semi fowler.
Ajarkan cara batuk efektif
Bantu klien napas dalam
Pertahankan intake cairan sedikitnya 2500 ml/hari kecuali tidak
diindikasikan
Kolaborasi dengan melakukan fisioterapi dada dengan tehnik postural
drainase, perkusi dan fibrasi dada.

Kolaborasi pemberian obat :

Bronkodilator golongan B2
Nebuler (via inhalasi) dengan golongan terbutaline 0.25 mg, fenoterol
HBr 0.1% solution, orciprenaline sulfur 0.75 mg.
Intravena dengan golongan theophyline ethilenediamine (Aminofilin)
bolus IV 5-6 mg/kgBB.

STIKes Surya Mitra Husada Kediri

 Agen mukolitik dan ekspektoran
kortikosteroid
Mandiri
1. Ajarkan pasien pernapasan dalam.
2. Tinggikan kepala dan bantu mengubah posisi. Berikan posisi semi
fowler.

1. Membuka jalan nafas, dengan teknik mengangkat dagu dan mendorong

rahang, jika diperlukan

2. Posisikan pasien untuk memaksimalkan potensi ventilasi

3. Identifikasi pasien yang membutuhkan masukan jalan nafas

aktual/potensial

4. Memasukan jalan nafas oral atao nasofaring, jika diperlukan

5. Menghilangkan sekresi dengan mendorong batuk atau pengisapan

6. Auskultasi bunyi nafas, mencatat area ventilasi menurun atau tidak ada
dan adanya suara adventif

7. Lakukan pengisapan endotrakeal atau nasotrakeal, jika diperlukan

Pola nafas tidak efektif
8.Mengelola bronkodilator, jika diperlukan
berhubungan dengan
9. Ajarkan pasien bagaimana menggunakan inhaler, jika diperlukan
gangguan suplai oksigen
(bronkospasme) 10. Kelola perawatan aerosol, jika diperlukan

11. Kelola perawatan ultrasonik nebulizer, jika diperlukan

12. Mengelola kelembaban udara atau oksigen, jika diperlukan

STIKes Surya Mitra Husada Kediri
 13.Mengatur asupan cairan untuk mengoptimalkan keseimbangan cairan

14. Posisikan untuk mengurangi dispnea

15. Monitor status pernafasan dan oksigenasi, jika diperlukan

Perbaikan pola nafas dengan kriteria hasil Kolaborasi

sebagai berikut: 3. Berikan oksigen tambahan.
1. Mempertahankan ventilasi adekuat
dengan menunjukan RR:16-20 x/menit
dan irama napas teratur.
2. Tidak mengalami sianosis atau
tanda hipoksia lain. Mandiri
3. Pasien dapat melakukan pernafasan 1. Ajarkan pasien pernapasan dalam.
dalam. 2. Tinggikan kepala dan bantu mengubah posisi. Berikan posisi semi
fowler.
Gangguan pertukaran gas Kolaborasi
berhubungan dengan 3. Berikan oksigen tambahan.

gangguan suplai oksigen

(bronkuspasme)

Perbaikan pertukaran gas dengan kriteria

STIKes Surya Mitra Husada Kediri
hasil sebagai berikut:
1. Perbaikan ventilasi.
2. Perbaikan oksigen jaringan adekuat.

Mandiri
1. Kaji/awasi secara rutin kulit dan membrane mukosa.
2. Palpasi fremitus.
3. Awasi tanda-tanda vital dan irama jantung.
Kolaborasi
4. Berikan oksigen tambahan sesuai dengan indikasi hasil AGDA dan
toleransi pasien.

STIKes Surya Mitra Husada Kediri

 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/
No.
Tgl/ Jam Implementasi Paraf Jam Evaluasi (SOAP) Paraf
Dx
Shift
 Mengatur posisi yang nyaman bagi pasien S : klien mengatakan sesaknya sudah berkurang
 menganjurkan teknik nafas dalam O : sesak nafas klien tampak sedikit berkurang
Membarikan terpi oksegen 3 lt/menit A : sesak nafas teratasi sebagian
P : Intervensi dihentikan, pasien pulang

STIKes Surya Mitra Husada Kediri

STIKes Surya Mitra Husada Kediri