JURUSAN KEPERAWATANFAKULTAS KEDOKTERANUNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa:

NIM :

A. DATA UMUM KLIEN

Nama :......................................... No.RM

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Usia :......................................... Tgl. Masuk

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Jenis Kelamin :......................................... Tgl. Pengkajian

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Alamat :......................................... Sumber Informasi

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No. Telepon :......................................... Nama klg. Dekat yng bisa dihubungi:................

Status Pernikahan:......................................... ...........................................................................

Agama :......................................... Status

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Suku :.......................................... Alamat

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Pendidikan :......................................... No. Telepon

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Pekerjaan :......................................... Pendidikan

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Lama Bekerja :......................................... Pekerjaan

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Diagnosa Medis

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B. STATUS KESEHATAN SAAT INI

1. Keluhan Utama Saat MRS

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2. Keluhan Utama Saat Pengkajian

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3. Riwayat Penyakit Sekarang

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4. Riwayat Keperawatan

a. Riwayat Obstetri

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b. Riwayat Kehamilan, Persalinan, dan Nifas Yang Lalu

Anak ke Kehamilan Persalinan Komplikasi Nifas Anak

No Tahun Umur Kehamilan

Penyulit Jenis Penolong Penyulit Laserasi Infeksi Perdarahan Jenis BB PJ

5. Riwayat KB

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6. Riwayat Kesehatan

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7. Riwayat Keluarga

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Genogram

8. Riwayat Lingkungan Sosial

a. Pola Interaksi dengan Keluarga

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b. Hubungan Klien dengan Lingkungan Sekitarnya

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c. Lingkungan Rumah

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9. Kebutuhan Dasar

a. Pola Nutrisi

Jenis Rumah Rumah 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 ................................................... ...................................................

b. Pola Eliminasi

Jenis Rumah Rumah Sakit

BAB

Frekuensi/pola .................................................... ...................................................

Konsistensi .................................................... ...................................................

Warna & bau .................................................... ...................................................

Kesulitan .................................................... ...................................................

Upaya mengetasi .................................................... ...................................................

BAK

Frekuensi/pola .................................................... ...................................................

Konsistensi .................................................... ...................................................

Warna & bau .................................................... ...................................................

Kesulitan .................................................... ...................................................

Upaya mengetasi .................................................... ...................................................

c. Pola Tidur-Istirahat

Rumah Rumah Sakit

Tidur siang: Lamanya ...........................................

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- Jam .....s/d...... ........................................... ...................................................

- Kenyamanan stl tidur ........................................... ...................................................

Tidur malam: Lamanya ...........................................

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- Jam .....s/d...... ........................................... ...................................................

- Kenyamanan stl tidur ........................................... ...................................................

- Kebiasaan sbl tidur ........................................... ...................................................

- Kesulitan ........................................... ...................................................

- Upaya mengatasi ........................................... ...................................................

d. Pola Kebersihan Diri

Rumah Rumah Sakit

Mandi: Frekuensi ........................................... ..................................................

- Penggunaan sabun ........................................... ...................................................

Keramas: Frekuensi ...........................................

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- Penggunaan Shampo........................................... ...................................................

Gosok gigi: Frekuensi ...........................................

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- Penggunaan odol ........................................... ...................................................

Ganti baju: Frekuensi ...........................................

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Memotong kuku: Frekuensi.....................................

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Kesulitan ........................................... ...................................................

Upaya yang dilakuan ...........................................

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e. Pola Aktivitas-Latihan

Jenis Rumah Rumah Sakit

Makan/Minum ........................................................

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Mandi ....................................................... ...............................................................

Berpakaian ....................................................... ..............................................................

Toiletting ....................................................... ...............................................................

Mobilitas ....................................................... ..............................................................

Berpindah ...................................................... ...............................................................

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Berjalan ....................................................... ...............................................................

Naik tangga .......................................................

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Pemberian Skor: 0=mandiri, 1=alat bantu, 2=dibantu orang lain (1 orang), 3=dibantu orang lain (>1 orang), 4=tidak mampu

10. Pemeriksaan Fisik

1. Keadaan umum:.......................................................................................................................

a. Kesadaran: ........................................................................................................................

b. Tanda tanda vital: Tek.darah : ..........mmHg Suhu

: ..............oC

Nadi : ..........x/m Pernapasan : ..............x/m

2. Kepala dan leher

a. 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 ( ) tidak

Apabila 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 ......................................................................................

Frekuensi.......................................... Cara mengatasi ................................................

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 .................................................................

Jantung

Inspeksi................................................................................................................................

Palpasi .................................................................................................................................

Perkusi ................................................................................................................................

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Auskultasi ............................................................................................................................

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Paru:

Inspeksi................................................................................................................................

Palpasi .................................................................................................................................

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Perkusi ................................................................................................................................

Auskultasi ............................................................................................................................

4. Payudara dan ketiak

Benjolan/Massa: .........................Nyeri/nyeri tekan ..............................................

Bengkak ....................... ...Kesimetrisan: ................................................................

5. Abdomen

Inspeksi: .............................................................................................................................

Palpasi: ...............................................................................................................................

Perkusi: ...............................................................................................................................

Auskultasi: ...........................................................................................................................

6. Genitalia-Rektal

a. Genetalia

Inspeksi : .......................................................................................................................

Palpasi : .......................................................................................................................

b. Rektal

Inspeksi : .......................................................................................................................

Palpasi : .......................................................................................................................

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 ..................................

11. Hasil pemeriksaan penunjang

a. Laboratorium

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12. Diagnosa Medis

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13. Pengobatan

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