PENGKAJIAN KEPERAWATAN

A. Identitas Klien.
Nama

: Tn. X

Jenis Kelamin

: Laki-laki

Umur

: 61 tahun.

Agama

: Islam

Suku/Bangsa

:Betawi Indonesia

Pendidikan

: SR

Pekerjaan

: Pengembala

Tgl. Masuk RS

:27/03/2014

No. Register

:-

Diagnosa Medis

: Penurunan Kesadaran,

Tanggal Pengkajian

: 28/03/2014

B. Riwayat Kesehatan.
1. Keluhan Utama :
Pasien Terlihat Tak Berdaya
2. Riwayat Kesehatan Sekarang :
Keluarga Pasien Mengatakan sebelum masuk RSUD Karawang. Pasien dirawat inap di
RS Proklamasi selama 5 hari dengan kondisi tak sadarkan diri.
3. Riwayat Kesehatan Masa Lalu :

Keluarga / anak pasien mengatakan tidak mengetahui dikarenakan tidak tinggal 1

rumah.

C. Pola Kebiasaan (ADL)

Aktivitas
Pola Nutrisi

Di Rumah
Pola Makan:

Di Rumah Sakit
Pola Makan:

Waktu

:.........X.......@.........Porsi

Makanan

Waktu
:.........X.......@.........Porsi

Makanan

Pokok :........................

Pokok :........................

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

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

...

..

Lauk

Lauk

Pauk :...................................

Pauk :...................................

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

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

...

..

Sayuran :................................

Sayuran :.................................

........

.......

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

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

...

..

Buah-

Buah-

buahan :.............................

buahan :.............................

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

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

...

..

Tambahan :

Tidak ada data u/ pola maka-

Tambahan :
Pasien dipasang NGT

n dirumah
Pola Minum :

Waktu

Pola Minum :

:..................X........................

Takaran :.................................

:..................X........................

..ml

Tambahan :

Waktu

Takaran :.................................
..ml

Tambahan :

Tidak ada data u/ pola minu-

Keluarga pasien mengatakan

M dirumah

Pasien hanya menggunakan

Cairan infus u/ memenuhi
Kebutuhan cairannya.

Pola Eliminasi

BAK :

BAK :
Frekwensi

:..................X......................

Takaran :.................................

:.................X......................

..cc

Warna :....................................
Bau :........................................

Volume :.................................

Tambahan :

Bau :........................................
................

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

Warna :....................................
...............

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

Takaran :.................................
..cc

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

Frekwensi

Volume :..................................
.........

Tidak ada data BAK dirumah

Tambahan :
Pasien menggunakan kateter
u/ BAK dan baru terisi
7000cc

BAB :

BAB :

Frekwensi
:...............X....................

:...............X....................

Warna :....................................
...........

Bau :........................................

Bau :........................................
............

Tekstur :..................................
..........

Warna :....................................
...........

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

Frekwensi

Tekstur :..................................
.........

Tambahan :
Tidak ada data BAB dirumah

Tambahan :
Pasien menggunakan popok
Dan feses yang di popok berWarna kuning dengan

Pola Istirahat & Tidur

tekstur encer
Malam : Jam..........s/d.........(...........Jam)Malam : Jam..........s/d.........(...........Jam)
Siang : Jam..........s/d.........(............Jam)Siang : Jam..........s/d.........(............Jam)
Lainnya : Tidak ada data

Personal Hygiene

Mandi

Lainnya : Bed rest total

:........................................
Mandi

...

:........................................

...

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

......

Sikat

Sikat

Gigi

:........................................... Gigi

:...........................................

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

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

Cuci

Cuci

Rambut :............................................ Rambut :............................................

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

......

Gunting

Gunting

Kuku

Kuku

:.........................................

:.........................................

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

......

Ganti

Ganti

Baju

:........................................... Baju

:...........................................

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

.......

Tambahan :

Tambahan :

Tidak ada data personal gygine

Keluarga pasien mengatakan sejak

dirumah

Dirawat di RS proklamasi pasien beLum mandi, sikat gigi, kramas, gunTing kuku, dan ganti baju

D.

Riwayat Kesehatan Keluarga : Tidak ada data

E.

Riwayat Tumbuh Kembang,

1. Neonatus (lahir-28 hari)
2. Bayi (1 Bln-1 Thn)
3. Todler (1-3 Thn)
4. Pre Sekolah (3-6 Thn)
5. Usia Sekolah (6-12 Thn)
6. Remaja (12-18/20 Thn)
7. Dewasa Muda (20-40 Thn)
8. Dewasa Menengah (40-65 Thn)
9. Dewasa Tua :

F.

Young-Old ( 65-74 Thn )

Middle-Old ( 75 84 Thn )

Old-Old ( > 85 )

Riwayat Psikososial Spiritual :

G.

Psiko

: tidak ada data

Social

: tidak ada data

Spiritual

: tidak ada data

Riwayat Seksualitas :
Keluarga ( anak ) pasien mengatakan dari sejak di rawat di RS Proklamasi ibu
tirinya baru menjenguk 1 kali.

H.

Pemeriksaan Fisik.
1. Keadaan Umum :

Kesadaran : Semi Koma

Penampilan

: Pasien Nampak kucel, bau, kotor, kusam.

TTV

TD : 100/70 mmHg (Normal 90-120/60-80 mmHg)

S : 36,9 ( Normal 36,6C - 37,2 C )

N : 81 /menit

RR : 32/menit

Berat Badan

: tidak ada data

Tinggi Badan

: tidak ada data

2. Integument

Inspeksi :
-

Kebersihan

: Kotor

Warna

: Coklat

Pigmentasi

: Kehitaman

Lesi

: ada dikulit kaki

Ruam

: Tidak ada ruam

Kondisi Kuku

:clubbing finger kuku kaki KIKA

Bau

: asem

Sianosi

: ada pada bagian jari kaki KIKA

Ikterik

: Tidak ada

Lainnya
:........................................................................................
.........................................................................
...............

Palpasi :
-

Tekstur

: Kasar

Kelembaban

: Kering

Suhu

: Hangat

Turgor

: Derajat 3

Edema

: Tidak ada

Lainnya

:.................................................................

.......................
.........................................................................
...............
3. Kepala

Inspeksi

: Simetris, tidak ada lesi, kotor, rambut kering dan

kusam

Palpasi

: Tidak ada benjolan, dan tidak ada nyeri tekan pada

sinus frontal dan sinus maxilary,

Lainnya

Inspeksi

: Mata KIKA simetris, Konjungtiva anemis, Sclerea

4. Mata

ikterik

Palpasi

: Tidak terdapat benjolan

Lainnya

: tidak dilakukan test ketajaman mata karena pasien

tidak sadarkan diri.

5. Hidung.

Inspeksi

:Simetris, warna sama dengan kulit lain, tidak ada lesi,

bulu hidung lebat, tidak ada perdarahan.

Palpasi

: tidak ada benjolan pada sinus ethmoid

Lainnya

Inspeksi

: Warna mukosa mulut dan bibir pucat dan kering, gigi

6. Mulut

kurang lengkap, dan kotor.

Palpasi

: Tidak ada data

Lainnya

7. Telinga

Inspeksi

: Simetris, tidak da lesi, Nampak kotor,

Palpasi

: Tidak ada benjolan

Lainnya

8. Leher

Inspeksi

: Nampak kotor, simetris,

Palpasi

: Tidak ada pembesaran kelenjar tiroid

Inspeksi

: Simetris, kotor, Distres pernapasan

Palpasi

: Tidak ada data.

Perkusi

: tidak ada data

Auskultasi : Bunyi nafas wheezing

Lainnya

9. Thorax

10. Abdomen

Inspeksi

Palpasi

:Tidak ada lesi, kotor, tidak ada kelainan umbilicus.

:.....................................................................................................
.................
....................................................................................................................
....................................................................................................................
.................................................

Perkusi
:.....................................................................................................
.................
....................................................................................................................
....................................................................................................................
..................................................

Auskultasi : bising usus 14/menit

11. Ekstremitas

Ekstremitas Atas : PASIEN TAK BERDAYA

-

Inspeksi
:.........................................................................................
..............
..................................................................................
....................

Palpasi
:.........................................................................................
..............
..................................................................................
....................

Motorik

:.............................................................................

..........................
..................................................................................
....................
-

Refleks
:.........................................................................................
..............
..................................................................................
....................

Sensorik
:.........................................................................................
..............
..................................................................................
....................

Lainnya

:.............................................................................

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

Ekstremitas Bawah : PASIEN TAK BERDAYA

-

Inspeksi
:.........................................................................................
..............
..........................................................................
............................

Palpasi
:.........................................................................................
..............
..................................................................................
....................

Motorik

:.............................................................................

..........................
..................................................................................
....................
-

Refleks
:.........................................................................................
..............
..................................................................................
....................

Sensorik
:.........................................................................................
..............
..................................................................................
....................

Lainnya : ................................................................................
..........................

12. Genital & Anus

Genital :
-

Inspeksi

: Tidak ada data

Palpasi

: Tidak ada data

Inspeksi

: Tidak ada data

Palpasi

: Tidak ada data

Anus

I. Pemeriksaan Penunjang

Uji lab

: Hb 15 g/dl, LEU = 7,6 103/l , Tromb = 125 103/l,

Hemtok = 41,8 %

Tambahan :.........................................................................................
............................
.............................................................................................
........................

J. Riwayat Pengobatan

Nama Obat dan dosis X waktu :

Tidak ada data

Tambahan :

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

ANALISA DATA
Nama Pasien

: Tn. X

No.RM

:............................................................
Umur

: 61 Thn

Dx.Medis

: Penurunan Kesadaran

No
1.

Tanggal/Waktu Data
28/03/2014
Ds :

Masalah
Gangguan Personal

Keluarga pasien
mengatakan sejak
Dirawat di RS proklamasi
pasien belum mandi, sikat
gigi, kramas, gunting kuku,
dan ganti baju.
Do :
1. Pasien Nampak
kucel, bau, kotor, lengket, kusam.
2. Inspeksi :
Integumen :
Nampak kotor
Kepala :
Kotor dan rambut
Kusam.
Telinga :
Nampak Kotor
Mulut :
Gigi Kotor
Leher :
Kulit Kotor
Thorax :
Kulit Kotor
Abdomen :
Kulit kotor

Hygine

Penyebab
Ketidak berdayaan.

Dx. Keperawatan
1. Gangguan Kebutuhan Personal Hygine B/D Ketidak Berdayaan
2. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
3. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
4. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
5. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
6. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
7. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
8. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
9. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
10. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
11. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
12. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
13. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................

14. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
15. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
16. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................
17. ...........................................................................................................................................
...........................................................................................................................................
...............................................................................