1

JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN
Nama Mahasiswa

:

Tempat Praktik

:

NIM

:

Tgl. Praktik

:

A. Identitas Klien
Nama

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

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

Usia

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

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

Jenis kelamin

:.......................................... Tgl. Pengkajian

Alamat

:.......................................... Sumber informasi :.........................................

No. telepon

:.......................................... Nama klg. dekat yg bisa dihubungi:................

Status pernikahan

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

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

Agama

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

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

Suku

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

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

Pendidikan

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

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

Pekerjaan

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

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

Lama berkerja

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

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

Tgl. Masuk

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

B. Status kesehatan Saat Ini
1. Keluhan utama

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

2. Lama keluhan

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

3. Kualitas keluhan

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

4. Faktor pencetus

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

5. Faktor pemberat

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

6. Upaya yg. telah dilakukan
7. Diagnosa medis

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

:

a.

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

b.

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

c.

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

C. Riwayat Kesehatan Saat Ini
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

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

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

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

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

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

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

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

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

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