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JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN
Nama Mahasiswa

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Tempat Praktik

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NIM

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Tgl. Praktik

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A. Identitas Klien
Nama

:.......................................... No. RM

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Usia

:............. tahun

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Jenis kelamin

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Alamat

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No. telepon

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Status pernikahan

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Agama

:.......................................... Status

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Suku

:.......................................... Alamat

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Pendidikan

:.......................................... No. telepon

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Pekerjaan

:.......................................... Pendidikan

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Lama berkerja

:.......................................... Pekerjaan

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Tgl. Masuk

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B. Status kesehatan Saat Ini
1. Keluhan utama

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2. Lama keluhan

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3. Kualitas keluhan

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4. Faktor pencetus

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5. Faktor pemberat

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6. Upaya yg. telah dilakukan
7. Diagnosa medis

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a.

.................................................................................... Tanggal.......................................

b.

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c.

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C. Riwayat Kesehatan Saat Ini
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....................................................................................................................... ...................... ......... dll): Tipe Reaksi Tindakan ..................................... .2 D................................................. b................................................ ................................................................................................. ............ Alkohol ............................................. ....... ............................................... .............................. ...................................................................... Obat-obatan yg digunakan: Jenis Lamanya Dosis . ............................ .............. Penyakit yg pernah dialami: a.................. Riwayat Kesehatan Terdahulu 1............................................................................................................................................................................................... ...................................................................................................................................................................................................................................................................................................................................... .................................................................................... ..................................................... Operasi (jenis & waktu) :....................................................... .. Frekuensi Jumlah Lamanya ................................................................................................ makanan........................................ .......................... Terakhir masuki RS :......................................................................................................... Kebiasaan: Jenis Merokok ( ) Hepatitis ( ) Campak ( ) ............ Penyakit: • Kronis :.................... • Akut :.................................................................................. Alergi (obat............. .................................................... plester...................... 2...................................................................... Kopi ............. ... .... E........... .................................................................................................................................. 3............................. c............................................... Imunisasi: ( ) BCG ( ) Polio ( ) DPT 4.................................... Kecelakaan (jenis & waktu) :............................................................................... ................. 5................. GENOGRAM ............................................................. Riwayat Keluarga ................................ d..................... .........................................................

... ......... ...................................... 1 = alat bantu............................................ . terakhir ......................... • Sukar menelan (padat/cair) ................................................................................................................ ............ ...................... ..................... ..... • Komposisi menu .......................................................................... G................................................................................................................................................................................................................................................... Riwayat Lingkungan Jenis • Kebersihan Rumah Pekerjaan ............ • Pantangan .......................................................................................................................................................................................................... Pemberian Skor: 0 = mandiri......................................................................................... ... • Berjalan .......................................................... • Riw.. masalah penyembuhan luka ................................................................................................... • Frekuensi/pola ......................................................... .............. • Pencahayaan .......................................... ..................................................................................... • Jenis minuman .... • Toileting .................................... ............. • Napsu makan ...........Pola Nutrisi Metabolik • Jenis diit/makanan Rumah Rumah Sakit .......................................................................... • Ventilasi ........................ ..................................... ...................................................... 2 = dibantu orang lain................... ...... ................ .. • Porsi yg dihabiskan ................................ ................. 4 = tidak mampu H................ .......................................................... • Berpakaian/berdandan .................................................................. • Bahaya kecelakaan ............ ................................................................................. • Mandi .................... .... Pola Aktifitas-Latihan • Makan/minum Rumah Rumah Sakit .... ................. • Mobilitas di tempat tidur ............................................................. • Fluktuasi BB 6 bln................. • Berpindah .................. • Gelas yg dihabiskan ........................................................... • Frekuensi/pola minum ..................................................... • Naik tangga ......... ................................. ......... .............................................................................................. ........................................................................................ ................................................................................................................................................3 F.............. • Pemakaian gigi palsu (area) .......................... 3 = dibantu orang lain.................... ............................ ............................... .................................... • Polusi .................................................................................

.................. .......................................... ................ - Kenyamanan stlh...................................................... tidur .............................. ................ ........ ................................................... - Kenyamanan stlh................ ........ - Kesulitan ............................ - Konsistensi .................................................... ................................................................................................................................................................ - Konsistensi .......................................................................... J..................... .......... ........................................................... ......................................... ........................................................................... - Jam …s/d… ................. tidur ............................ .......... ...................... - Warna & bau ................................ .............................................. .......... • Tidur malam: Lamanya ................ ................................................................................................................................................................................................................................................................................. .... ... ............. • BAK: - Frekuensi/pola ........ - Jam …s/d… ........................................................................................................................... ............................................................................................................. ........................................................................ Pola Kebersihan Diri • • - Mandi:Frekuensi Penggunaan sabun Keramas: Frekuensi Penggunaan shampoo Rumah Rumah Sakit .... .................. • Memotong kuku: Frekuensi .... .................... .... - Upaya mengatasi ................................................ - Kesulitan ..................................... ..................................................................................... tidur ..................................................................... - Kesulitan ........... .. K................................................................................................................ ...................... ..... .............................................................................. • Gososok gigi: Frekuensi - Penggunaan odol • Ganti baju:Frekuensi ................................................ - Kebiasaan sblm.......... • Kesulitan .................................................... Pola Eliminasi Rumah • Rumah Sakit BAB: - Frekuensi/pola .... - Upaya mengatasi ............................................................................................................................. - Upaya mengatasi ........................................................................... ................................................................................................4 I. - Warna & bau ........ .............................................. ... ..................................................................................................... Pola Tidur-Istirahat • Tidur siang:Lamanya Rumah Rumah Sakit ............................................................................................ .........

.......................... Pantangan & agama yg dianut:...............................................................................dengan pasangan ( ) Hub............................................................................................ dll):... 2.................. 3.................................... Sistem pendukung:suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain.... sebutkan...................... Pola Toleransi-Koping Stres 1. Perubahan yang dirasa setelah sakit:.................................................................................................dengan anak ( ) Lain-lain sebutkan. Peran dalam keluarga... Kehidupan keluarga a....... Harga diri:........................................................................................................................... Bicara: ( ) Normal ( )Bahasa utama:........................................................................... ( ) Mampu mengerti pembicaraan orang lain( ) Afek:.... M........................... dengan sanak saudara ( ) Hub.... 2.................... 5....... 4................. Yang biasa dilakukan apabila stress/mengalami masalah:........................................................... sebutkan:........................................................................ Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS:............ Gambaran diri:......... Adat istiadat yg dianut:......................................... 3........................................................................ Identitas diri............................................................................................................................................................ ( ) Tidak jelas ( ) Bahasa daerah:................................ 2............. L.................... 4...... dengan orang tua ( ) Hub................ 3......Pola Peran & Hubungan 1........................................................................ O.......... Pengambilan keputusan: ( ) sendiri ( ) dibantu orang lain................................................. 2.......... 3.............. perawatan diri.................................................................................................................................................................. Harapan setelah menjalani perawatan:..... .......................................................................................5 • Upaya yg dilakukan ...............................................Pola Komunikasi 1........................................... Konsep Diri 1....................... .................................. 5.......... Masalah utama terkait dengan perawatan di RS atau penyakit (biaya........................................................ N........... 4............ Tempat tinggal: ( ) Sendiri ( ) Kos/asrama ( ) Bersama orang lain................................. Peran:..... Upaya yg dilakukan untuk mengatasi:........................................ 5................ ....................................... Ideal diri:.......... yaitu:.. Kesulitan dalam keluarga: ( ) Hub.. ( ) Bicara berputar-putar ( ) Rentang perhatian:........................................................ b......

................................................................... Keadaan Umum:..............Nadi :…….................................................................................... . • Kesadaran:............................. agama................ ... .................................................... Kepala & Leher a...................................................................... ..... Upaya yang dilakukan pasangan: ( ) perhatian ( ) sentuhan ( ) lain-lain...................................................................................................................... Q.........................000 ( ) Rp........................................................................000 – 1 juta ( ) Rp................................................................... ..... Penghasilan keluarga: ( ) < Rp..............Tekanan darah :……… mmHg ........5 juta ( ) Rp.................................................................................................................................................................... Kegiatan agama/kepercayaan yg dilakukan dirumah (jenis & frekuensi):............................................................. c........................ x/meni • Tinggi badan: ......................................................................................................................................Suhu :………oC ...............................Pola Nilai & Kepercayaan 1................................ Pola Seksualitas 1............................................................. ........... 500.............................................6 c..................................................................... Hidung: .....RR :……… x/menit Berat Badan:........ ................................... kepercayaan penting untuk Anda. Apakah Tuhan......................... 250...................................5 juta – 2 juta ( ) > 2 juta P............................................................ Pemeriksaan Fisik 1........ seperti...........................................cm ........................ Kepala: .......... Harapan klien terhadap perawat untuk melaksanakan ibadahnya:........................................................................................................................................................................ 1........................................................................ Mata: ............................................................. .......................................... b............................................. Mulut & tenggorokan: ..................................................000 – 500. Ya/Tidak 2..................................... d................... ........................................ ..................................................................................................... 1 juta – 1....................................................kg 2...................... 250........... R.......................................... ........ Kegiatan agama/kepercayaan tidak dapat dilakukan di RS:............................................................................................000 ( ) Rp..................................................................................... • Tanda-tanda vital: ............... .. Masalah dalam hubungan seksual selama sakit: ( ) tidak ada ( ) ada 2............................ 4.................................... 3.............................................

..................... ................................................................................................................................................ ..............................................................................................................................................Auskultasi:................................ ..................................................................................................................................................................................... Leher: ................ Telinga: ........................................................................................... Thorak & Dada: • Jantung ............................................................................................................Inspeksi:........................................................................................................Inspeksi:...............Palpasi:........................................ .............................. ..... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................ ................................................................. .............................................................................................................................Perkusi:......................................................................................................................................... Punggung & Tulang Belakang .......................................................................................................................................................................Palpasi:.............................................................................................................. ................................................................... f..........Auskultasi:...................................................... 4........................................................... ................................................ .......................................... .................................................. ...................................................................................................................................................Perkusi:......................................... e.................. Payudara & Ketiak ....... ........................................................................................................................ • Paru .......................................... ............................................................................................................................................................................................ ............................. .................................................................................. ............................................................ .......................................... ................................................................................................................................................................................................................................................7 ................................................... .................................................................................................... ........................................................................................................ 3......................................................................................... ........................................................... .................................................................................................................................................................................................................................................................................................................... 5.............................................................................

.....................................8 6....... Kulit & Kuku • Kulit: • Kuku: .................................................... ....................................................................... • Auskultasi:........................... ............................................................................ Abdomen • Inspeksi:......................................................... ......................................................................................................................................................................... ................................. Genetalia & Anus • Inspeksi:.................................................................................................................................................................... Sistem Neorologi .......................................................................................................... ........................................................................................................................................................................................................................................................................................................ 7............................................................................................................................................................... ............................... ............................................................. 10........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ .................................................................................................................................................................................. Ekstermitas • Atas:.................................................................. ....................................................... .................................................................................................................................................................................................................................... • Bawah:............................................................................................................................................................... ................... .................................................................................................................................................................... ...................................... ....... 8................................................................................................................. .................................................................................................................................................................................................................................................... 9..................................................................................................................................................... .................................................................................................................................... .................................................................................................................................................... • Palpasi:............................................................... • Palpasi:.............................................................. • Perkusi:.................................................................................... ......

................................................................................................................................................................................................................................................................................................................................. • Hal-hal yang perlu diperhatikan di rumah:............................................................................. .................................................................. .................................. ............................................................................................................................................................................................................ Terapi ................................. .......... .................. ........................................................................................................................................................................................................................................... Persepsi Klien Terhadap Penyakitnya ...................................................... ................................................................................................................................................................................... ...................................................... .............................................................................................................................................................................................................................................................................................................................................................................. V............... • Antisipasi bantuan biaya setelah pulang:......................................................................................................................................................................................................................................................................................... • Rawat jalan ke:.................................................................................................................... W......................................................................................................................................................................................................................................................... Perencanaan Pulang • Tujuan pulang:........................................................................................ .................................................................. Hasil Pemeriksaan Penunjang TERLAMPIR T.................................................................. ....................................................................................... U..........................................................................................9 S............................................................ ........................... • Pengobatan:.......................................................................... • Dukungan keluarga:................... • Transportasi pulang:.............................................................................................................................................................................. • Antisipasi masalah perawatan diri setalah pulang:........................................................................................... ................................................................................. ........................................................................................................................ Kesimpulan .........................

..... ........................................................................................................................................................................................................................... .........................................................................1 ................................................................................................ • Keterangan lain:.....................................

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