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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

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

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

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

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

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

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

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

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

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

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