JURUSAN KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Tempat Praktik :
NIM : Tgl. Praktik :

A. Identitas Klien
Nama : Nn. A No. RM :.........................................
Usia : 14 tahun Tgl. Masuk :.........................................
Jenis kelamin : Perempuan Tgl. Pengkajian :.........................................
Alamat :.......................................... Sumber informasi :.........................................
No. telepon :.......................................... Nama klg. dekat yg bisa dihubungi:................
Status pernikahan : Belum menikah.................
Agama :.......................................... Status :.........................................
Suku :.......................................... Alamat :.........................................
Pendidikan :.......................................... No. telepon :.........................................
Pekerjaan :.......................................... Pendidikan :.........................................
Lama berkerja :.......................................... Pekerjaan :.........................................

B. Status kesehatan Saat Ini

1. Keluhan utama : Nyeri pada tungkai kanan dan tidak dapat di gerakkan
2. Lama keluhan : 3 jam post kecelakaan lalu lintas
3. Kualitas keluhan : .................................................................................................................
4. Faktor pencetus : kecelakaan lalu lintas dan mengalami fraktur tertutup
5. Faktor pemberat : .................................................................................................................
6. Upaya yg. telah dilakukan :
7. Diagnosa medis : Fraktur komplit femur dextra 1/3 tengah

C. Riwayat Kesehatan Saat Ini

Klien mengalami kecelakaan lalu lintas 3 jam yang lalu,di tabrak oleh motor dari arah sebelah kanan,
saat kejadian klien lansung terjatuh dan pingsan selama 5 menit.saat sadar klien sudah tidak dapat
lagi menggerakkan tungkai kanannya. Tungkai kiri dan tungkai atas tidak ada keluhan.pasien
lansung di bawa ke puskesmas dan di lakukan pemasangan spalk lalu di rujuk ke rumah sakit.
Hasil pemeriksaan rontgen di dapatkan fraktur komplit pada femur dextra 1/3 tengah dengan
aligment dan apoisi buruk. Oleh dokter pasien di terapi asam mefenamat 500 mg 3x1 tablet dan
amoxicillin 500 mg3x1 tablet pemasangan spalk ulang dan direncanakan untuk pemasangan internal
fiksasi.
D. Riwayat Kesehatan Terdahulu
1. Penyakit yg pernah dialami:
a. Kecelakaan (jenis & waktu) : tidak pernah....................................................................
b. Operasi (jenis & waktu) : tidak pernah....................................................................
c. Penyakit:
Kronis : tidak ada ..............................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
Akut :tidak ada................................................................................................
d. Terakhir masuki RS : belum pernah MRS sebelumnya.....................................
2. Alergi (obat, makanan, plester, dll):
Tipe Reaksi Tindakan
.................................................... .............................................. .................................................
.................................................... .............................................. .................................................
3. Imunisasi:
( ) BCG ( ) Hepatitis
( ) Polio ( ) Campak
( ) DPT ( ) .................
4. Kebiasaan:
Jenis Frekuensi Jumlah Lamanya
Merokok .................................. ........................................ ........................................
Kopi .................................. ........................................ ........................................
Alkohol .................................. ........................................ ........................................

5. Obat-obatan yg digunakan:
Jenis Lamanya Dosis
.................................................... .............................................. .................................................
.................................................... .............................................. .................................................

E. Riwayat Keluarga
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
GENOGRAM
F. Riwayat Lingkungan
Jenis Rumah Pekerjaan
Kebersihan ....................................................... .......................................................
Bahaya kecelakaan ....................................................... .......................................................
Polusi ....................................................... .......................................................
Ventilasi ....................................................... .......................................................
Pencahayaan ....................................................... .......................................................
............................... .................................................... ..........................................................

G. Pola Aktifitas-Latihan
Rumah Rumah Sakit
Makan/minum .................................................... ....................................................
Mandi .................................................... ....................................................
Berpakaian/berdandan .................................................... ....................................................
Toileting .................................................... ....................................................
Mobilitas di tempat tidur ....................................................
Berpindah .................................................... ....................................................
Berjalan .................................................... ....................................................
Naik tangga .................................................... ....................................................
Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang lain, 4 = tidak mampu

H. Pola Nutrisi Metabolik

Rumah Rumah Sakit
Jenis diit/makanan .............................................. .................................................
Frekuensi/pola .............................................. .................................................
Porsi yg dihabiskan .............................................. .................................................
Komposisi menu .............................................. .................................................
Pantangan .............................................. .................................................
Napsu makan .............................................. .................................................
Fluktuasi BB 6 bln. terakhir .............................................. .................................................
Jenis minuman .............................................. .................................................
Frekuensi/pola minum .............................................. .................................................
Gelas yg dihabiskan .............................................. .................................................
Sukar menelan (padat/cair) .............................................. .................................................
Pemakaian gigi palsu (area) .............................................. .................................................
Riw. masalah penyembuhan luka .............................................. .................................................
I. Pola Eliminasi
Rumah Rumah Sakit
BAB:
- Frekuensi/pola .................................................... .................................................
- Konsistensi .................................................... .................................................
- Warna & bau .................................................... .................................................
- Kesulitan .................................................... .................................................
- Upaya mengatasi .................................................... .................................................
BAK:
- Frekuensi/pola .................................................... .................................................
- Konsistensi .................................................... .................................................
- Warna & bau .................................................... .................................................
- Kesulitan .................................................... .................................................
- Upaya mengatasi .................................................... .................................................

J. Pola Tidur-Istirahat
Rumah Rumah Sakit
Tidur siang:Lamanya .............................................. ....................................................
- Jam s/d ............................................. ..................................................
- Kenyamanan stlh. tidur ............................................. ..................................................
Tidur malam: Lamanya .............................................. ....................................................
- Jam s/d ............................................. ..................................................
- Kenyamanan stlh. tidur ............................................. ..................................................
- Kebiasaan sblm. tidur ............................................. ..................................................
- Kesulitan ............................................. ..................................................
- Upaya mengatasi ............................................. ..................................................

K. Pola Kebersihan Diri

Mandi:Frekuensi
- Penggunaan sabun
Keramas: Frekuensi
- Penggunaan shampoo
Gososok gigi: Frekuensi
- Penggunaan odol
Ganti baju:Frekuensi
Rumah Rumah Sakit
................................................. .................................................
................................................ ................................................
................................................. .................................................
................................................ ................................................
................................................. .................................................
................................................ ................................................
................................................. .................................................
 Memotong kuku: Frekuensi ................................................. .................................................
Kesulitan ................................................. .................................................
Upaya yg dilakukan ................................................. .................................................

L. Pola Toleransi-Koping Stres

1. Pengambilan keputusan: ( ) sendiri ( ) dibantu orang lain, sebutkan,.......................................
2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri, dll):...............

3. Yang biasa dilakukan apabila stress/mengalami masalah:.................................................................

4. Harapan setelah menjalani perawatan:..............................................................................................
5. Perubahan yang dirasa setelah sakit:.................................................................................................

M. Konsep Diri
1. Gambaran diri:....................................................................................................................................
2. Ideal diri:.............................................................................................................................................
3. Harga diri:...........................................................................................................................................
4. Peran:.................................................................................................................................................
5. Identitas diri........................................................................................................................................

N. Pola Peran & Hubungan

1. Peran dalam keluarga........................................................................................................................
2. Sistem pendukung:suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain, sebutkan:...............

3. Kesulitan dalam keluarga: ( ) Hub. dengan orang tua ( ) Hub.dengan pasangan

( ) Hub. dengan sanak saudara ( ) Hub.dengan anak
( ) Lain-lain sebutkan,.................................................................
4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS:..................................
......................................................................................................................................................... ..
5. Upaya yg dilakukan untuk mengatasi:................................................................................................
O. Pola Komunikasi
1. Bicara: ( ) Normal ( )Bahasa utama:.....................................
( ) Tidak jelas ( ) Bahasa daerah:..................................
( ) Bicara berputar-putar ( ) Rentang perhatian:............................
( ) Mampu mengerti pembicaraan orang lain( ) Afek:..................................................
2. Tempat tinggal: ( ) Sendiri
( ) Kos/asrama
( ) Bersama orang lain, yaitu:.................................................................................
3. Kehidupan keluarga
a. Adat istiadat yg dianut:................................................................................................................
 b. Pantangan & agama yg dianut:...................................................................................................
c. Penghasilan keluarga: ( ) < Rp. 250.000 ( ) Rp. 1 juta 1.5 juta
( ) Rp. 250.000 500.000 ( ) Rp. 1.5 juta 2 juta
( ) Rp. 500.000 1 juta ( ) > 2 juta

P. Pola Seksualitas
1. Masalah dalam hubungan seksual selama sakit: ( ) tidak ada ( ) ada
2. Upaya yang dilakukan pasangan:
( ) perhatian ( ) sentuhan ( ) lain-lain, seperti, ............................................................

Q. Pola Nilai & Kepercayaan

1. Apakah Tuhan, agama, kepercayaan penting untuk Anda, Ya/Tidak
2. Kegiatan agama/kepercayaan yg dilakukan dirumah (jenis & frekuensi):.........................................
....................................................................................................................................................
3. Kegiatan agama/kepercayaan tidak dapat dilakukan di RS:...............................................................
4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya:.....................................................
R. Pemeriksaan Fisik
1. Keadaan Umum: sakit sedang..........................................................................................................
......................................................................................................................................................
Kesadaran:Compos mentis............................................................................................................
Tanda-tanda vital: - Tekanan darah :130/70 mmHg - Suhu :36,7oC
- Nadi :88... x/meni - RR : x/menit
Tinggi badan: ....................................cm Berat Badan:........................kg
2. Kepala & Leher
a. Kepala:
Dalam batas normal.......................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
b. Mata:
Dalam batas normal.......................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
c. Hidung:
Dalam batas normal.......................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
d. Mulut & tenggorokan:
......................................................................................................................................
 ......................................................................................................................................
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......................................................................................................................................

e. Telinga:
......................................................................................................................................
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......................................................................................................................................
......................................................................................................................................
f. Leher:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
3. Thorak & Dada:

Jantung
- Inspeksi:..................................................................................................................................
................................................................................................................................................
- Palpasi:...................................................................................................................................
................................................................................................................................................
- Perkusi:...................................................................................................................................
................................................................................................................................................
- Auskultasi:..............................................................................................................................
................................................................................................................................................
Paru
- Inspeksi:..................................................................................................................................
................................................................................................................................................
- Palpasi:...................................................................................................................................
................................................................................................................................................
- Perkusi:...................................................................................................................................
................................................................................................................................................
- Auskultasi:.................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................

4. Payudara & Ketiak

..................................................................................................................................................
5. Punggung & Tulang Belakang
..................................................................................................................................................
6. Abdomen
Inspeksi:Perut terlihat kaku............................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
Palpasi:Tersdapat rebound tandernes, abdomen kaku .................................................................
....................................................................................................................................................
Perkusi:..........................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Auskultasi: Bising usus 2x/ menit..................................................................................................
......................................................................................................................................................
7. Genetalia & Anus
Inspeksi:........................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Palpasi:.......................................................................................................................................
8. Ekstermitas
Atas:tidak ada keluhan................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Bawah:di dapatkan pemendekan,bengkak, deformitas,angulasi ke lateral, kulit utuh(tidak
terdapat luka) pada pemeriksaan movement di dapatkan nyeri aktif, nyeri gerak pasif,ROM sulit
di nilai, krepitasi tidak di lakukan. Pemeriksaan NVD di dapatkan dorsalis pedis teraba, CRT
kurang dari 2 detik. Sensibilitas normal.......................................................................................
...........................................................................................................................................
...........................................................................................................................................
9. Sistem Neorologi
Pemeriksaan Neuro Vaskular Distal (NVD) di dapatkan A dorsalis pedis teraba..........................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
10. Kulit & Kuku
 Kulit:

Kuku:

S. Hasil Pemeriksaan Penunjang : foto rontgen regio femur dextra AP lateral di dapatkan fraktur
komplit pada femur dextra 1/3 tengah dengan aligment dan aposisi buruk.
TERLAMPIR

T. Terapi
.............................................................................................................................................................
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.............................................................................................................................................................
.............................................................................................................................................................

U. Persepsi Klien Terhadap Penyakitnya

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V. Kesimpulan
.............................................................................................................................................................
.............................................................................................................................................................
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.............................................................................................................................................................

W. Perencanaan Pulang
Tujuan pulang:....................................................................................................................................
Transportasi pulang:...........................................................................................................................
Dukungan keluarga:...........................................................................................................................
 Antisipasi bantuan biaya setelah pulang:...........................................................................................
Antisipasi masalah perawatan diri setalah pulang:.............................................................................
Pengobatan:.......................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Rawat jalan ke:...................................................................................................................................
....................................................................................................................................................
Hal-hal yang perlu diperhatikan di rumah:........................................................................................
....................................................................................................................................................
.........................................................................................................................................................
Keterangan lain:.................................................................................................................................
ANALISA DATA
 Data Etiologi Masalah
DS : Trauma Nyeri akut
Mengeluh nyeri pada tungkai kanan
dan tidak dapat digerakan 3 jam
pasca kecelakaan

Fraktur
DO : Cedere cel (tulang)
Pemeriksaan lokalis pada regio
crusis dextra
(look):didapatkan pemendekan,
bengkak, deformitas, angulasi
kelateral, kulit utuh (tidak Degranulasi sel mast
terdapat luka robek)
Feel : didapatka nyeri tekan,
pulsasi distal teraba, sesibilitas
normal.
Movement : didapatkan nyeri Pelepasa mediator
gerak aktiv, nyeri gerak pasif, kimia
ROM sulit dinilai, krepitasi tidak
dilakukan
Foto rontagen : fraktur compled
Rangsangan
femur 1/3 tengah dengan aligment
dan aposisi buruk
diterukan ke korteks
serebri

Nyeri akut

DS : Trauma Ketidak efektifan perfusi

Mengeluh nyeri pada tungkai kanan jaringan
dan tidak dapat digerakan 3 jam
pasca kecelakaan Gangguan
hemodinamik
DO :
 RENCANA ASUHAN KEPERAWATAN

Nama klien : Tgl Pengkajian :

No. Reg : Diagnosa Medis :

No Tgl Diagnosa Keperawatan Tujuan & Kriteria hasil Intervensi

1. Nyeri akut b/d fraktur NOC I : NIC
Manajemen Nyeri (1400)
Kontrol Nyeri Aktivitas -aktivitas
Kriteria Hasil : 1. Lakukan pengkajian nyeri komprehensif yang
meliputi lokasi, karakteristik, onset,
1. Mengetahui faktor penyebab nyeri
frekuwensi, kualitas, intensitas dan faktor
2. Mengenali kapan nyeri terjadi.
pencetus
3. Menggunakan tindakan pengurangan 2. Berikan informasi mengenai nyeri, seperti
nyeri tanpa analgesik penyebab nyeri, berapa lama nyeri akan
4. Melaporkan nyeri yang terkontol dirasakan dan antisipasi dari

NOC II ketidaknyamanan akibat prosedur

3. Kendalikan faktor lingkungan yang dapat
Tingkat Nyeri
mempengaruhi respon pasien terhadap
Kriteria Hasil :
ketidaknyamanan
1. Melaporkan nyeri berkurang atau hilang 4. Kurangi atau eliminasi faktor yang dapat

2. Panjang episode nyeri berkurang. mencetuskan atau meningkatkan nyeri

5. Ajarkan penggunaan teknik nonfarmakologi
3. Ekspresi wajah saat nyeri
Pemberian analgesik (247)
6. evaluasi adanya riwayat alergi obat
7. monitor tanda vital sebelum dan setelah
 pemberian analgesik
8. berikan analgesik sesuai dengan waktu
peruhnya, terutama pada nyeri yang berat
9. evaluasi keefektifan analgesik dengan
interval yang teratur pada setiap setelah
pemberian.
10. observasi juga efeksamping yang muncul
 2 Ketidakefektifan jaringan NOC NIC
perifer berhubungan Perfusi Jaringan Perifer Monitor tanda tanda vital
1. Monitor tekanan darah, nadi, suhu, dan status
dengan trauma Kriteria Hasil:
pernafasan denan cepat
tekanan darah dan denyut nadi dalam 2. monitor sianosis sentral dan perifer
batas normal 3. identifikasi kemungkinan penyebab perubahan
tanda tanda vital
pengisisan kapiler jari tidak ada deviasi
Manajemen sensasi perifer
dari kisaran normal 1. Monitor adanya parasthesia degan tepat
2. diskusikan atau identifikasikan penyebab
Edema perifer berkurang sensasi abnormal atau perubahan sensasi yang
terjadi
mati rasa tidak ada 3. instruksikan pasien dan keluarga untuk
memeriksa adanya kerusakan kulit setiap
harinya

IMPLEMENTASI KEPERAWATAN
N Hari/tg Diagnosa keperawatan Implmentasi Evaluasi
O l
1 Nyeri akut b/d fraktur 11. Melakukan pengkajian nyeri komprehensif S :
 yang meliputi lokasi, karakteristik, onset, Klien mengatakan masih merasa
nyeri pada area yang fraktur
frekuwensi, kualitas, intensitas dan faktor Klien mengatakan memahami
pencetus informasi tentang nyeri yang
12. memberikan informasi mengenai nyeri, dijelaskan dan metode relaksasi
yang diajarkan
seperti penyebab nyeri, berapa lama nyeri O :
Klien tampak tidak meringis
akan dirasakan dan antisipasi dari Pemeriksaan lokalis pada regio
ketidaknyamanan akibat prosedur crusis dextra
13. Mengajarkan klien teknik relaksasi, distraksi (look):didapatkan
dan imagenery. pemendekan, bengkak,
14. Melakukan evaluasi adanya riwayat alergi obat deformitas, angulasi kelateral,
15. Mengobservasi tanda-tanda vital sebelum dan
kulit utuh (tidak terdapat luka
setelah pemberian analgesik
robek)
16. Memberikan analgesik sesuai dengan waktu
Feel : didapatka nyeri tekan,
peruhnya, terutama pada nyeri yang berat
pulsasi distal teraba, sesibilitas
normal.
Movement : didapatkan nyeri
gerak aktiv, nyeri gerak pasif,
ROM sulit dinilai, krepitasi
tidak dilakukan
TTV ; TD : 130/70mmHg, N:
88x/m, P : 24x/m,S : 36,7 .
A : Masalah nyeri akut belum terarasi
P : lanjutakan intervensi nomor
8,9,10
2 Ketidakefektifan jaringan perifer 4. Memonitor tekanan darah, nadi, suhu, dan status S : -
berhubungan dengan trauma pernafasan denan cepat O:
5. Memonitor sianosis sentral dan perifer TTV ; TD : 130/70mmHg, N:
6. Mengidentifikasi kemungkinan penyebab
88x/m, P : 24x/m,S : 36,7
perubahan tanda tanda vital
7. Memonitor adanya parasthesia degan tepat
pengisisan kapiler jari tidak
8. Mendiskusikan atau identifikasikan penyebab
ada deviasi dari kisaran normal ;
sensasi abnormal atau perubahan sensasi yang
CRT : 3
terjadi
9. Menginstruksikan pasien dan keluarga untuk
Edema perifer berkurang
memeriksa adanya kerusakan kulit setiap harinya

parasthesia tidak ada

A : Masalah Teratasi Sebagian

P : Lanjutkan intervensi nomor 1, 3, 6