PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Tempat Praktik :

NIM : Tanggal Praktik :

A. Identitas Klien
Nama : ............................... Tgl. Masuk : .........................................
Usia : ................................ Tgl. Pengkajian : .........................................
Jenis Kelamin : ................................ Sumber Informasi : ........................................
Alamat : .......................................... Nama Klg. Dekat yg bias dihubungi..............
No. Telepon : ........................................
Satus Pernikahan Status : .........................................
Sumber Informasi : ....................................... Alamat : .........................................
Suku : ........................................ No. telepon :..........................................
Pendidikan : ........................................ Pendidikan : .........................................
Pekerjaan : ......................................... Pekerjaan : .........................................
Lama Bekerja : .........................................

No. RM : .........................................
B. Status Kesehatan Saat Ini
1. Keluhan Utama
a. Saat MRS : ..................................................................................................
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b. Saat Pengkajian : ..................................................................................................
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c. Diagnosa Medis ...................................................................................................
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2. Riwayat Kesehatan Saat Ini
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C. Riwayat Kesehtan Terdahulu
1. Penyakit Yang Pernah Dialami
a. Kecelakaan (Jenis & Waktu) : .............................................................................
b. Operasi (Jenis & waktu) : .............................................................................
c. Penyakit
Kronis :...........................................................................................................
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Akut : ..........................................................................................................
d. Terakhir Masuk Rs :.............................................................................................
2. Alergi (Obat, makanan, plester, dll)
Tipe Reaksi Tindakan

3. Kebiasaan :
Jenis Frekuensi Jumlah Lamanya

4. Obat-obatan yang digunakan :

Jenis Lamanya Dosis

D. Riwayat Keluarga
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GENOGRAM
E. Riwayat Lingkungan
Rumah Pekerjaan
Jenis

Kebersihan

Bahaya Kecelakaan
Polusi
Ventilasi
Pencahayaan

F. Pola Aktifitas Lain

Jenis Rumah Rumah Sakit

MAkan/Minum

Mandi

Berpakaian/berdandan

Toileting


Mobilitis 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

G. Pola Nutrisi

Rumah Rumah Sakit

Jenis makanan

Frekuensi/pola


Porsi yang dihabiskan


Komposisi menu

Pantangan

Napsu makan

Jenis minuman

Frekuensi/pola



Gelas yang dihabiskan


Sukar menelan


Pemakaian gigi palsu

Riw. Penyembuhan luka

H. Pola Eliminasi

BAB
-frekuensi/pola Rumah Rumah Sakit

-Konsistensi

-warna/bau

-kesulitan

-upaya mengatasi

BAK
-frekuensi/pola
-Konsistensi
-warna/bau
-kesulitan

-upaya mengatasi

I. Pola Istirahat Tidur

Rumah Rumah Sakit

Tidur siang: lamanya
Mandi: frekuensi
-jams/d
-penggunaan sabun
-kenyamanan stlh.tidur
Keramas : frekuensi
-pengguaan
Tidur malam: lamanya
sampo

Gosok gigi: frekuensi
-jam..s/d..
-penggunaan
Kenyamanan odolstlh tidur
Ganti baju: frekuensi
-kesulitan
Memotong kuku: ......
-upaya mengatasi
frekuensi ......
Kesulitan upaya yang
dilakukan
J. Pola Kebersihan Diri
Rumah Rumah Sakit

Mandi : Frekuensi

Penggunaan sabun

Keramas : Frekuensi

Penggunaan Shampo
Gosok Gigi : Frekuensi
Penggunaan odol

Ganti baju : Frekuensi

 Memotong kuku : Frekuensi
Kesulitan
Upaya yang dilakukan

K. Pola Toleransi-Koping Stress

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

L. Pola Peran & Hubungan

1. Peran dalam keluarga ................................................................................................
2. System 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/huubngan dengan keluarga selama perawatan di RS: ..........
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5. Upaya yang dilakukan untuk mengatasi : ..................................................................

M. Pola Komunikasi
1. Bicara : ( ) Normal ( ) bahasa utama ..............................
( )Tidak jelas ( ) Bahasa daerah: ............................
( ) Bicara Berputar-putar ( ) rentang perhatian : ......................
( ) mampu mengerti pembicaran orang lain ( )Afek :..............................
2. Tempat tinggal
( ) sendiri
( ) kos / asrama
( ) bersama orang lain, sebutkan : .............................................................................
3. Kehidupan keluarga
a. Adat istiadat yang dianut : ...................................................................................
b. Pantangan & agama yang 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 ( ) > Rp. 2 juta

N. Pola nilai & Kepercayaan

1. Apakah tuhan, agama, kepercayaan penting untuk anda: Ya / Tidak
2. Kegiatan agama / kepercayaan yang dilakukan di rumah (Jenis & frekuensi) : ........
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3. Kegiatan agama/ kepercayaan tidak dapat dilakukan di RS : ....................................
4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya : ...........................

O. Pemeriksaan Fisik
1. Keadaan Umum : .......................................................................................................
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Kesadaran :...........................................................................................................
Tanda tanda vital : - Tekanan darah : mmHg -Suhu : c
Nadi : x/m - RR : x/m
Tinggi badan : cm Berat badan : cm

2. Kepala dan leher

a. Kepala : ................................................................................................................
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b. Mata : ...................................................................................................................
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c. Hidung : ...............................................................................................................
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 d. tenggorokan : .......................................................................................................
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e. Telinga : ...............................................................................................................
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f. Leher : ..................................................................................................................
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3. Thorak & Dada
Jantung
- Inspeksi : ........................................................................................................

- Palpasi : ..........................................................................................................
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- Perkusi............................................................................................................

- Auskultasi ......................................................................................................

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Paru
- Inspeksi : ........................................................................................................
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- Palpasi : ..........................................................................................................

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- Perkusi : .........................................................................................................

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- Auskultasi : ....................................................................................................

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4. Payudara & Ketiak

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5. Punggung & Tulang Punggung

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6. Abdomen :
Inspeksi : ..............................................................................................................
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Palpasi : ................................................................................................................

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

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Auskultasi : ..........................................................................................................

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7. Genetalia & Anus :
Inspeksi : ..............................................................................................................
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Palapasi : ..............................................................................................................

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8. Ekstremitas
Atas ......................................................................................................................
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Bawah ..................................................................................................................

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9. Sistem Neurologi
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10. Kulit & Kuku
Kulit
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Kuku
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P. Hasil Pemeriksaan Penunjang

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Q. Terapi

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R. Persepsi Klien Terhadap Penyakitnya

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S. Perencanaan Pulang
Tujuan pulang .................................................................................................................
Transportasi puang ..........................................................................................................
Dukungan keluarga .........................................................................................................
Antisipasi bantuan biaya setelah pulang .........................................................................
Antisipasi masalah perawatan diri setelah pulang ..........................................................
Pengobatan ......................................................................................................................
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Rawat jalan ke .................................................................................................................
Hal- hal yang perlu diperhatikan di rumah .....................................................................
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Keterangan lain ...............................................................................................................
PEMERIKSAAN RADIOLOGI
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TINDAKAN DAN TERAPI
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 ANALISA DATA

Nama: No. RM:

Diagnosa Medis :
Data penunjang Penyebab Masalah

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 DIAGNOSA KEPERAWATAN
Nama : No. RM:
Dx Medis :
No. Tgl. Muncul Diagnosa Keperawatan Tgl. Teratasi
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 RENCANA TINDAKAN KEPERAWATAN

Nama : No.RM : ..
Diagnosa Medis :
Tgl Diagnosa Keperawatan NOC NIC
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 IMPLEMENTASI

Nama Klien : Tanggal Pengkajian :

Diagnosa Medis :

Tanggal No. Dx Jam Tindakan Keperawatan Respon Klien TTD & Nama
Keperawatan Terang
Tanggal No. Dx Jam Tindakan Keperawatan Respon Klien TTD & Nama
Keperawatan Terang
 IMPLEMENTASI DAN EVALUASI
Nama :
Dx Medis :
Tgl / No Implementasi
jam Dx
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No. RM:
evaluasi Tanda
Tangan
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 CATATAN PERKEMBANGAN

Nama Klien : Tanggal :

Dx Medis : Ruang :

S O A P I E