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Pengkajian keperawatan

Pengkajian keperawatan

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Pengkajian keperawatan
Pengkajian keperawatan

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Published by: Andien de Shieta on Dec 31, 2012
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JURUSAN KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA
PENGKAJIAN DASAR KEPERAWATAN
Nama Mahasiswa : Tempat Praktik :
NIM : Tgl. Praktik :
A. Identitas Klien
Nama :.......................................... No. RM :.........................................
Usia :............. tahun Tgl. Masuk :.........................................
Jenis kelamin :.......................................... Tgl. Pengkajian :.........................................
Alamat :.......................................... Sumber inormasi :.........................................
No. telepon :.......................................... Nama klg. !ekat "g bisa !ihubungi:................
Status pernikahan :.......................................... ..........................................
Agama :.......................................... Status :.........................................
Suku :.......................................... Alamat :.........................................
Pen!i!ikan :.......................................... No. telepon :.........................................
Pekerjaan :.......................................... Pen!i!ikan :.........................................
#ama berkerja :.......................................... Pekerjaan :.........................................
B. Status kesehatan Saat Ini
$. %eluhan utama : .................................................................................................................
&. #ama keluhan : .................................................................................................................
'. %ualitas keluhan : .................................................................................................................
(. )aktor pen*etus : .................................................................................................................
+. )aktor pemberat : .................................................................................................................
,. Upa"a "g. telah !ilakukan : ..................................................................................................
-. .iagnosa me!is :
a. .................................................................................... Tanggal.......................................
b. .................................................................................... Tanggal.......................................
*. .................................................................................... Tanggal.......................................
C. Riwayat Kesehatan Saat Ini
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
1
D.Riwayat Kesehatan Terdahulu
$. Pen"akit "g pernah !ialami:
a. %e*elakaan /jenis 0 waktu1 :.........................................................................................
b. 2perasi /jenis 0 waktu1 :.........................................................................................
*. Pen"akit:
• %ronis :...............................................................................................................
................................................................................................................
................................................................................................................
• Akut :...............................................................................................................
!. Terakhir masuki RS :.........................................................................................
&. Alergi /obat3 makanan3 plester3 !ll1:
Tipe Reaksi Tin!akan
.................................................... .............................................. .................................................
.................................................... .............................................. .................................................
'. Imunisasi:
/ 1 456 / 1 7epatitis
/ 1 Polio / 1 5ampak
/ 1 .PT / 1 .................
(. %ebiasaan:
Jenis )rekuensi Jumlah #aman"a
Merokok .................................. ........................................ ........................................
%opi .................................. ........................................ ........................................
Alkohol .................................. ........................................ ........................................
+. 2bat8obatan "g !igunakan:
Jenis #aman"a .osis
.................................................... .............................................. .................................................
.................................................... .............................................. .................................................
E. Riwayat Keluarga
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
69N26RAM
2
F. Riwayat Lingkungan
Jenis Rumah Pekerjaan
• %ebersihan ....................................................... .......................................................
• 4aha"a ke*elakaan ....................................................... .......................................................
• Polusi ....................................................... .......................................................
• :entilasi ....................................................... .......................................................
• Pen*aha"aan ....................................................... .......................................................
............................... .................................................... ..........................................................
G. Pola Aktiitas!Latihan
Rumah Rumah Sakit
• Makan;minum .................................................... ....................................................
• Man!i .................................................... ....................................................
• 4erpakaian;ber!an!an .................................................... ....................................................
• Toileting .................................................... ....................................................
• Mobilitas !i tempat ti!ur ....................................................
• 4erpin!ah .................................................... ....................................................
• 4erjalan .................................................... ....................................................
• Naik tangga .................................................... ....................................................
Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang lain, 4 = tidak mampu
H.Pola Nutrisi "eta#olik
Rumah Rumah Sakit
• Jenis !iit;makanan .............................................. .................................................
• )rekuensi;pola .............................................. .................................................
• Porsi "g !ihabiskan .............................................. .................................................
• %omposisi menu .............................................. .................................................
• Pantangan .............................................. .................................................
• Napsu makan .............................................. .................................................
• )luktuasi 44 , bln. terakhir .............................................. .................................................
• Jenis minuman .............................................. .................................................
• )rekuensi;pola minum .............................................. .................................................
• 6elas "g !ihabiskan .............................................. .................................................
• Sukar menelan /pa!at;*air1 .............................................. .................................................
• Pemakaian gigi palsu /area1 .............................................. .................................................
• Riw. masalah pen"embuhan luka .............................................. .................................................
3
I. Pola Eli$inasi
Rumah Rumah Sakit
• 4A4:
- )rekuensi;pola .................................................... .................................................
- %onsistensi .................................................... .................................................
- <arna 0 bau .................................................... .................................................
- %esulitan .................................................... .................................................
- Upa"a mengatasi .................................................... .................................................
• 4A%:
- )rekuensi;pola .................................................... .................................................
- %onsistensi .................................................... .................................................
- <arna 0 bau .................................................... .................................................
- %esulitan .................................................... .................................................
- Upa"a mengatasi .................................................... .................................................
J. Pola Tidur!Istirahat
Rumah Rumah Sakit
• Ti!ur siang:#aman"a .............................................. ....................................................
- Jam =s;!= ............................................. ..................................................
- %en"amanan stlh. ti!ur ............................................. ..................................................
• Ti!ur malam: #aman"a .............................................. ....................................................
- Jam =s;!= ............................................. ..................................................
- %en"amanan stlh. ti!ur ............................................. ..................................................
- %ebiasaan sblm. ti!ur ............................................. ..................................................
- %esulitan ............................................. ..................................................
- Upa"a mengatasi ............................................. ..................................................
K. Pola Ke#ersihan Diri
Rumah Rumah Sakit
• Man!i:)rekuensi ................................................. .................................................
- Penggunaan sabun ................................................ ................................................
• %eramas: )rekuensi ................................................. .................................................
- Penggunaan shampoo ................................................ ................................................
• 6ososok gigi: )rekuensi ................................................. .................................................
- Penggunaan o!ol ................................................ ................................................
• 6anti baju:)rekuensi ................................................. .................................................
• Memotong kuku: )rekuensi ................................................. .................................................
• %esulitan ................................................. .................................................
4
• Upa"a "g !ilakukan ................................................. .................................................
L. Pola Toleransi!Ko%ing Stres
1. Pengambilan keputusan: / 1 sen!iri / 1 !ibantu orang lain3 sebutkan3......................................
2. Masalah utama terkait !engan perawatan !i RS atau pen"akit /bia"a3 perawatan !iri3 !ll1:..............
3. >ang biasa !ilakukan apabila stress;mengalami masalah:...............................................................
4. 7arapan setelah menjalani perawatan:.............................................................................................
5. Perubahan "ang !irasa setelah sakit:...............................................................................................
M. Konse% Diri
$. 6ambaran !iri:..................................................................................................................................
&. I!eal !iri:...........................................................................................................................................
'. 7arga !iri:.........................................................................................................................................
(. Peran:...............................................................................................................................................
+. I!entitas !iri......................................................................................................................................
N.Pola Peran & 'u#ungan
$. Peran !alam keluarga.......................................................................................................................
&. Sistem pen!ukung:suami;istri;anak;tetangga;teman;sau!ara;ti!ak a!a;lain8lain3 sebutkan:.............
'. %esulitan !alam keluarga: / 1 7ub. !engan orang tua / 1 7ub.!engan pasangan
/ 1 7ub. !engan sanak sau!ara / 1 7ub.!engan anak
/ 1 #ain8lain sebutkan3................................................................
(. Masalah tentang peran;hubungan !engan keluarga selama perawatan !i RS:................................
.........................................................................................................................................................
+. Upa"a "g !ilakukan untuk mengatasi:...............................................................................................
O.Pola Ko$unikasi
1. 4i*ara: / 1 Normal / 14ahasa utama:....................................
/ 1 Ti!ak jelas / 1 4ahasa !aerah:..................................
/ 1 4i*ara berputar8putar / 1 Rentang perhatian:............................
/ 1 Mampu mengerti pembi*araan orang lain/ 1 Aek:..................................................
2. Tempat tinggal: / 1 Sen!iri
/ 1 %os;asrama
/ 1 4ersama orang lain3 "aitu:...............................................................................
3. %ehi!upan keluarga
a. A!at istia!at "g !ianut:................................................................................................................
b. Pantangan 0 agama "g !ianut:...................................................................................................
5
c. Penghasilan keluarga: / 1 ? Rp. &+@.@@@ / 1 Rp. $ juta A $.+ juta
/ 1 Rp. &+@.@@@ A +@@.@@@ / 1 Rp. $.+ juta A & juta
/ 1 Rp. +@@.@@@ A $ juta / 1 B & juta
P. Pola Seksualitas
1. Masalah !alam hubungan seksual selama sakit: / 1 ti!ak a!a / 1 a!a
2. Upa"a "ang !ilakukan pasangan:
/ 1 perhatian / 1 sentuhan / 1 lain8lain3 seperti3 ............................................................
Q.Pola Nilai & Ke%er(ayaan
$. Apakah Tuhan3 agama3 keper*a"aan penting untuk An!a3 >a;Ti!ak
&. %egiatan agama;keper*a"aan "g !ilakukan !irumah /jenis 0 rekuensi1:.........................................
....................................................................................................................................................
'. %egiatan agama;keper*a"aan ti!ak !apat !ilakukan !i RS:.............................................................
(. 7arapan klien terha!ap perawat untuk melaksanakan iba!ahn"a:...................................................
R. Pe$eriksaan )isik
1. %ea!aan Umum:...............................................................................................................................
.....................................................................................................................................................
• %esa!aran:...................................................................................................................................
• Tan!a8tan!a Cital: 8 Tekanan !arah :=== mm7g 8 Suhu :===
o
5
8 Na!i :==... D;meni 8 RR :=== D;menit
• Tinggi ba!an: ....................................*m 4erat 4a!an:........................kg
2. %epala 0 #eher
a. %epala:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
b. Mata:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
*. 7i!ung:
......................................................................................................................................
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......................................................................................................................................
......................................................................................................................................
!. Mulut 0 tenggorokan:
......................................................................................................................................
6
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
e. Telinga:
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......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
. #eher:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
3. Thorak 0 .a!a:
• Jantung
- Inspeksi:..................................................................................................................................
................................................................................................................................................
- Palpasi:...................................................................................................................................
................................................................................................................................................
- Perkusi:...................................................................................................................................
................................................................................................................................................
- Auskultasi:..............................................................................................................................
................................................................................................................................................
• Paru
- Inspeksi:..................................................................................................................................
................................................................................................................................................
- Palpasi:...................................................................................................................................
................................................................................................................................................
- Perkusi:...................................................................................................................................
................................................................................................................................................
- Auskultasi:...............................................................................................................................
................................................................................................................................................
................................................................................................................................................
4. Pa"u!ara 0 %etiak
.................................................................................................................................................
5. Punggung 0 Tulang 4elakang
.................................................................................................................................................
7
6. Ab!omen
• Inspeksi:.......................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
• Palpasi:........................................................................................................................................
....................................................................................................................................................
• Perkusi:........................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
• Auskultasi:....................................................................................................................................
.....................................................................................................................................................
7. 6enetalia 0 Anus
• Inspeksi:.......................................................................................................................................
............................................................................................................................................
............................................................................................................................................
• Palpasi:.......................................................................................................................................
8. 9kstermitas
• Atas:............................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
• 4awah:........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
9. Sistem Neorologi
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
$@. %ulit 0 %uku
•%ulit:
•%uku:
8
S. 'asil Pe$eriksaan Penun*ang
TERLA"PIR
T. Tera%i
.............................................................................................................................................................
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U. Perse%si Klien Terhada% Penyakitnya
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V. Kesi$%ulan
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
W. Peren(anaan Pulang
• Tujuan pulang:..................................................................................................................................
• Transportasi pulang:.........................................................................................................................
• .ukungan keluarga:..........................................................................................................................
• Antisipasi bantuan bia"a setelah pulang:..........................................................................................
• Antisipasi masalah perawatan !iri setalah pulang:............................................................................
• Pengobatan:.....................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
• Rawat jalan ke:.................................................................................................................................
....................................................................................................................................................
• 7al8hal "ang perlu !iperhatikan !i rumah:........................................................................................
9
....................................................................................................................................................
.........................................................................................................................................................
• %eterangan lain:................................................................................................................................
1

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

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