JURUSAN KEPERAWATANFAKULTAS KEDOKTERANUNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa: NIM : Tempat Praktik: Tgl. Praktek :

A. Identitas KlienNama:.........................................No.RM:.......................................Usia:.........................................Tgl. Masuk:.......................................Jenis Kelamin:.........................................Tgl. Pengkajian:.......................................Alamat:.........................................Sumber Informasi:.......................................No. Telepon:.........................................Nama klg. Dekat yng bisa dihubungi:................Status Pernikahan:....................................................................................................................Agama:.........................................Status:.......................................Suku:..........................................Alamat:.......................................Pendidikan:.........................................No. Telepon:.......................................Pekerjaan:.........................................Pendidikan:.......................................Lama Bekerja:.........................................Pekerjaan:.......................................

B. Status Kesehatan Saat Ini1. Keluhan utama:.............................................................................................................2. Diagnosa Medis:a. ..................................................................... Tanggal .........................................................

Riwayat Kesehatan Saat IniSaat MRS:............................................................................................................................................................................................................................................................................................................................................................................ ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ...........Keluhan Saat pengkajian : ............................................................................................................................................................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................C. Riwayat Kesehatan Terdahulu1. Penyakit yang pernah dialami:a. Kecelakaan (jenis & waktu):.................................................................................................b. Operasi (jenis & waktu): .................................................................................................c. Penyakit: Akut: ........................................................................................................................ Kronis: ........................................................................................................................2. Alergi (obat, makanan, plester, dll):TipeReaksiLamanya............................................................................................. ....................................................................................................................................... ..........................................3. Imunisasi( ) BCG( ) Hepatitis( ) Polio( ) Campak( ) DPT( ) ....................4. KebiasaanJenisFrekuensiJumlahLamanyaMerokok............................................................................... ...................................Kopi............................................................................... ...................................Alkohol............................................................................... ................................................................................................................................ ...................................5. Obat-obatan yang digunakanJenisLamanyaDosis............................................................................................. ....................................................................................................................................... ..........................................

D. Riwayat Keluarga...................................................................................................................................................................................................................................... .......................................................................GENOGRAM

E. Riwayat LingkunganJenisRumahPekerjaan Kebersihan....................................................................................................... Bahaya kecelakaan...................................................................................................... Polusi...................................................................................................... Ventilasi...................................................................................................... Pencahayaan...................................................................................................... ................................................................................................................................

F. Pola Aktivitas-LatihanJenisRumahRumah Sakit Makan/Minum........................................................................................................................ Mandi...................................................................................................................... Berpakaian..................................................................................................................... Toiletting...................................................................................................................... Mobilitas..................................................................................................................... Berpindah...................................................................................................................... Berjalan...................................................................................................................... Naik tangga.......................................................................................................................Pemberian Skor: 0=mandiri, 1=alat bantu, 2=dibantu orang lain (1 orang), 3=dibantu orang lain (>1 orang), 4=tidak mampu

G. Pola NutrisiJenisRumahRumah Sakit Makan Jenis diit/makanan....................................................................................................... Frekuensi/pola...................................................................................................... Porsi yang dihabiskan...................................................................................................... Komposisi menu...................................................................................................... Pantangan...................................................................................................... Nafsu makan...................................................................................................... Fluktuasi BB 6 bl trhr......................................................................................................Minum Jenis minuman...................................................................................................... Frekuensi/pola minum...................................................................................................... Gelas yang dihabiskan...................................................................................................... Sukar menelan...................................................................................................... Pemakaian gigi palsu...................................................................................................... Riw.masalah penyembuhan luka......................................................................................................

H. Pola EliminasiJenisRumahRumah SakitBAB Frekuensi/pola....................................................................................................... Konsistensi....................................................................................................... Warna & bau....................................................................................................... Kesulitan ....................................................................................................... Upaya mengetasi.......................................................................................................BAK Frekuensi/pola....................................................................................................... Konsistensi....................................................................................................... Warna & bau....................................................................................................... Kesulitan ....................................................................................................... Upaya mengetasi.......................................................................................................

I. Pola Tidur-IstirahatRumahRumah Sakit Tidur siang: Lamanya.............................................................................................- Jam .....s/d....................................................................................................- Kenyamanan stl tidur.............................................................................................. Tidur malam: Lamanya..............................................................................................- Jam .....s/d....................................................................................................- Kenyamanan stl tidur..............................................................................................- Kebiasaan sbl tidur..............................................................................................- Kesulitan..............................................................................................- Upaya mengatasi..............................................................................................

J. Pola Kebersihan DiriRumahRumah Sakit Mandi: Frekuensi............................................................................................. Penggunaan sabun.............................................................................................. Keramas: Frekuensi..............................................................................................- Penggunaan Shampo.............................................................................................. Gosok gigi: Frekuensi..............................................................................................- Penggunaan odol.............................................................................................. Ganti baju: Frekuensi.............................................................................................. Memotong kuku: Frekuensi......................................................................................... Kesulitan.............................................................................................. Upaya yang dilakuan..............................................................................................

K. Pola Toleransi Koping Stress1. Pengembilan keputusan: ( ) sendiri, ( ) dibantu orang lain, ........................................................2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri, dll)...........................................................................................................................................................3. Yang biasa dilakukan apabila stres/mengalami masalah ..........................................................4. Harapan setelah menjalani perawatan.......................................................................................5. Perubahan yang dirasa setelah sakit.........................................................................................

L. Pola peran & Hubungan1. Peran dalam keluarga................................................................................................................2. Sistem pendukung: suami/istri/tetangga/teman/keluarga/tidak ada, sebutkan ..........................3. Kesulitan dalam keluarga( ) Hub. dgn orang tua( ) Hub.dgn pasangan( ) Hub. dgn sanak saudara( ) Hub. dgn anak ( ) Lain-lain sebutkan4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS .............................................................................................................................................................................5. Upaya yang dilakukan untuk mengatasi.....................................................................................

M. Pola Komunikasi1. Bicara:( ) Normal( ) Bahasa utama: jawa( ) Tidak Jelas( ) Bahasa daerah( ) Bicara berputar-putar ( ) Rentang perhatian( ) Mampu mengerti pembicaraan orang lain ( ) Afek........................................2. Tempat tinggal:( ) Sendiri( ) Kos/asrama( ) Bersama orang lain, yaitu: ...............................................................3. Kehidupan Keluargaa. Adat istiadat yag dianut: ......................................................................................................b. Pantangan adat dan agama yang dianut: ...........................................................................c. Penghasilan Keluarga:( ) < Rp 250.000( ) Rp 1 juta 1,5 juta ( ) Rp 250.000 500.000( ) Rp 1,5 juta 2 juta ( ) Rp 500.000 1 juta( ) > 2 juta

N. Pola Seksualitas1. Masalah dalam hubungan seksual selama sakit: ( ) Tidak ada( ) Ada2. Upaya yang dilakukan pasangan: ( ) Perhatian ( ) Sentuhan( ) Lain-lain, seperti ...................................................................................................................

O. Pola Nilai & Kepercayaan1. Apakah tuhan dan agama penting untuk anda: ( ) Ya( ) Tidak2. Kegiatan keagamaan yang dilakukan di rumah (jenis dan frekuensi):.......................................................................................................................................................................................3. Kegiatan keagamaan yang tidak dapat dilakukan di RS: ........................................................4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya: .........................................

P. Pemeriksaan fisik1. Keadaan umum:.......................................................................................................................a. Kesadaran: ........................................................................................................................b. Tanda tanda vital:Tek.darah : ..........mmHgSuhu: ..............oCNadi: ..........x/mPernapasan: ..............x/m2. Kepala dan lehera. Kepala: Bentuk.......... Massa..........Distribusi Rambut ...................Warna kulit kepala............ Keluhan: pusing/sakit kepala/migren/lainnya, sebutkan .............................................b. Mata Bentuk .................................Konjungtiva ........................................ Pupil: ( ) Reaksi terhadap cahaya ( ) Isokor ( ) Meiosis ( ) Pin Point ( ) Midriasis Tanda radang:............................................................................................................... Fungsi penglihatan:( ) Baik( ) Kabur Penggunaan alat bantu:( ) ya( ) tidakApabila ya: ( ) kaca mata ( ) lensa kontak( ) minus.....ka/ki( ) plus....ka/ki Pemeriksaan mata terakhir: ......................................................................................... Riwayat operasi: .........................................................................................................c. Hidung Bentuk......................... Warna ............................... Pembengkakan...........Nyeri tekan........ Pendarahan......... Sinus ............... Riwayat Alergi......... Cara mengatasi ......................................................................... Penyakit yang pernah terjadi ......................................................................................d. Mulut dan tenggorokan Warna bibir ...................... Mukosa.................. Ulkus.........Lesi............ Massa........... Warna lidah............................Perdarahan gusi .............Karies...................................Gangg bicara................................................ Pemeriksaan gigi terakhir.............................................................................................e. Telinga Bentuk .............................Warna ......................Lesi......... Massa ......... Nyeri.......... Nyeri Tekan........... Fungsi Pendengaran ......... ....Alat bantu pendengaran .............................................. Masalah Yang Pernah Terjadi: ...................................................................................f. Leher Kekakuan.......... .....................Nyeri/nyeri tekan................................... Benjolan/ Massa....................Keterbatasan gerak........................ Vena jugularis : ..................Tiroid...............Limfe................. Trakea........................ Keluhan: ...................................................................................................................... Upaya untuk mengatasi ...............................................................................................3. Dada Bentuk ..........................................Pergerakan Dada .......................................................... Nyeri/nyeri tekan......Massa.........Peradangan......Taktil Fremitus ........................................Pola Nafas ................................................................. JantungInspeksi................................................................................................................................Palpasi .................................................................................................................................Perkusi .................................................................................................................................Auskultasi ............................................................................................................................. Paru:Inspeksi................................................................................................................................Palpasi ..................................................................................................................................Perkusi ................................................................................................................................Auskultasi ............................................................................................................................4. Payudara dan ketiak Benjolan/Massa: .........................Nyeri/nyeri tekan .............................................. Bengkak ....................... ...Kesimetrisan: ................................................................5. Abdomen Inspeksi: .............................................................................................................................. ... Auskultasi : .......................................................................................................................... Perkusi: ............................................................................................................................... Palpasi: ................................................................................................................................ ..6. Genitalia Inspeksi: ............................................................................................................ Palpasi: ............................................................................................................ Keluhan ...............................................................................................................................7. Ekstremitas Kekuatan otot: ............................................................................................................. Kontraktur ..............Pergerakan .........................Deformitas .......... Pembengkakan ...........Edema ............... Nyeri/nyeri tekan ..............Pus/luka ........................................................

8. Kulit dan Kuku Kulit : Warna .................Jaringan parut: .............Lesi........... Suhu........... Tekstur .............Turgor....................................................... Kuku : Warna .....................................Bentuk .................................................Lesi ........................................Pengisian Kapiler ..................................

Q. Hasil pemeriksaan penunjanga. Laboratorium ................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................ .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................ .................................................................................................................................................................................................................................................................................................b. Radiologi.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................R. Pengobatan................................................................................................................................................................................................................................................................................................... ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................