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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

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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

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

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

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

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

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

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

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

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

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

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