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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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Tgl. Praktik

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A. Identitas Klien
Nama

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Usia

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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

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Suku

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Pendidikan

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Pekerjaan

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Lama berkerja

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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.

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b.

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c.

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

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

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

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

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

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

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

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

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

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