PENGKAJIAN

KEPERAWATAN MEDIKAL BEDAH

DISUSUN OLEH :

KELOMPOK 2:

NAMA :
1. AFREDO G. S SIAHAYA (12114201190006)
2.GLORIA.M.TANIKWELE (12114201180047)
3. MARINA.M.PERULU (12114201190163)
4. SENDY F. VAN BERGEN (12114201190234)

KELAS/ SEMESTER : C/ANTARA

TUGAS : BAHASA INGGRIS
DOSEN : Ns. Syulce luselya Tubalawony. M, kep

UNIVERSITAS KRISTEN INDONESIA MALUKU

FAKULTAS KESEHATAN
PROGRAM STUDI KEPERAWATAN
 2020

NURSING CARE IN ...... WITH DISORDERS

SYSTEM ....... : .............. IN SPACE ......

RS .............

A. ASSESMENT
1. The identity of the patient
Name :
Age :
Religion :
Gender :
Status :
Education :
Occupation :
Tribal Nation :
Address :
Date of entry :
Date of assesment :
No. Register :
Diagnose medical :

2. The identity of the person in charge of

Name :
Age :
Relationship with patient :
Work :
Address :

3. Health Status
a. Current health Status :
b. The main complaint (when the MRS. and Current) :
 c. Reason for hospital admission and the current trip :
d. The efforts made to overcome it :

4. The health Status of the past

a. The disease has ever experienced :
b. Never treated :
c. Allergies :
d. Habits (smoking/coffee/alcohol etc)

1. Family medical history :

2. Genogram :

3. Diagnosis and medical therapy :

4. The pattern of the Basic Needs (bio-psycho-socio-cultural-spiritual) :

5. Pattern perception and health management :

6. Pattern nutritional metabolic

- Before a sick :
- When sick :

7. The pattern of elimination

CHAPTER
- Before a sick :
- When sick :
WHIRLPOOL
- Before a sick :
- When sick :

8. The pattern of activity and exercise

Aktivity
Save care ability 0 1 2 3 4
Eat and drink
Bath
Toileting
Dress
Move
0: Self, 1: tool, 2: assited other people, 3: assited other people and tool, 4:
thee pending on the total
Exercise :
- Before a sick :
- When sick

9. The pattren of cognitive and perception :

10. Pattren perception-self concept :

11. Pattrens of sleep and rest :

- Before a sick :
- Wheen sick :

12. Pattren role-relarionship :

13. Pattrens of sexual-reproductive

- Before a sick :
- When sick :

14. The pattren of toleransce to stress-coping

15. Pattren value-belief :

16. Assesment of phsical :

a. He general state of the :
Level of consciousness :
GCS : eyes : verbal : psychomotor :
b. Vital signs :
Pulse = 98×/min
Temperature = 36°C
 TD = 110/70 mmhg
RR = 18×/min
c. The state of the physical ( Inspection, Palpation, Percussion and
Aukultasi)
Head and neck :
- Head : head Shape normal head Shape : Mesosefal
Scalp : Clean, Hair : black, straight and not easily removed
Eyes : Palpebral : No oedema, the Conjunctiva :Not anemis, Sclera :
white, not icteric, Pupils : Isokor, pupil Diameter left/right : 2mm,
Reflexes to light : Reflexes normal, No use of visual aids
Nose : nose Shape is symmetrical, clean, no polyps, no breath lobe
additional, the Mouth : a full set of Teeth, lip dry, stomatitis does not
exist.
The ear : auditory Function normal, symmetrical shape, clean, no
cerumen, no ear pain
- Neck : No visible lumps and enlargement of the thyroid gland.
 
Chest :
- Lungs
Inspection : Symmetrical, the development of the right chest and left
the same
Palpation : Vocal premitus left right same
Percussion : Sonor
Auscultation : Sound vesiculer
- Heart
Inspection : Ictus cordic does not seem
Palpation : No tenderness
Percussion : Dim
Auscultation : BJ I, BJ II Lup Dup
 
Breast and axilla :
The left breast daan right the same and there are no lumps in the
breast and armpit
 
Abdomen :
- Inspection : skin Color the same, no injury, symmetric
- Auscultation : Peristalsis is increased 40x/minute
 - Percussion : Hypertimpani, flatulence
- Palpation : skin Turgor is not a direct return in 1 seconds
 
Genetalia :
Female gender, no odema, no abnormalities, and do not use the hose
of the catheter
 
Integument : the color of the skin sawo matang , decreased skin
turgor.
 
Extremities :
- Above : Complete, the patient can move the hand left and right,
there is no oedema, no visible atrophy, infusion of RL 30tpm macro
conditions bandage is clean, no visible signs of infection.
- Down : Full, left and right legs can be moved and no disruption.
There is no oedema. The leg muscles do not atrophy.
 
Neurological :
- Mental Status and emotions : Depression and anxiety
- Assessment of the nerve cranial : sensing better
- The examination of reflexes : reflex motoric better
 
17. Investigations

- Laboratory Data that relates :

 
- Radiological examination :

- The results of the consultation :

- Examination of the supporting diagnostic other :