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JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN
Nama Mahasiswa

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A. Identitas Klien
Nama

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Usia

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Jenis kelamin

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Alamat

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No. telepon

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Agama

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Suku

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Pendidikan

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Pekerjaan

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B. Status kesehatan Saat Ini
1. Keluhan utama

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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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b.

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

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

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

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

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

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

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

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

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