JURUSAN KEPERAWATANFAKULTAS KEDOKTERANUNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Tempat Praktik :

NIM : Tgl. Praktik :

A. Identitas Klien

Nama : Ny. Chotimah.................... No. RM : 135167............................

Usia : 63........ tahun Tgl. Masuk : 01 April 2015...................

Jenis kelamin : Perempuan....................... Tgl. Pengkajian : 06 April 2015...................

Alamat : Jl. Apel no 4...................... Sumber informasi : Klien................................

No. telepon : .......................................... Nama klg. dekat yg bisa dihubungi:................

Status pernikahan : Kawin................................ ..........................................

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

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

Pendidikan : SD..................................... No. telepon :.........................................

Pekerjaan : Ibu Rumah Tangga........... Pendidikan :.........................................

Lama berkerja :........................................... Pekerjaan :.........................................

B. Status kesehatan Saat Ini

1. Keluhan utama : Klien merasa sesak dan batuk berdahak..................................................

2. Lama keluhan : 1 bulan.......................................................................................................

3. Kualitas keluhan : ...................................................................................................................

4. Faktor pencetus : ...................................................................................................................

5. Faktor pemberat : ...................................................................................................................

6. Upaya yg. telah dilakukan : ....................................................................................................

7. Diagnosa medis :

a. COPD........................................................................... Tanggal 01 April 2015.................

b. ..................................................................................... Tanggal........................................

c. ..................................................................................... Tanggal........................................

C. Riwayat Kesehatan Saat Ini

Klien mengeluh sesak sejak ±3 tahun yang lalu dan bertambah berat sejak 1 bulan yang lalu. Klien

mengeluh batuk berdahak dan dahak berwarna putih dan susah dikeluarkan. Klien menyatakan

lidahnya terasa tebal dan pahit saat dibuat makan dan terjadi pengapuran di lututnya..................

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D. Riwayat Kesehatan Terdahulu

1. Penyakit yg pernah dialami:

a. Kecelakaan (jenis & waktu) : tidak ada...........................................................................

b. Operasi (jenis & waktu) : tidak ada...........................................................................

c. Penyakit:

Kronis : Hipertensi, pengapuran pada lutut.........................................................

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

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

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

Akut : Batuk selama 6 bulan.............................................................................

d. Terakhir masuki RS : 1 bulan yang lalu .............................................................

2. Alergi (obat, makanan, plester, dll):Tipe Reaksi Tindakan

Obat (Penicillin)........................... Muntah dan Gatal.................. Diberi salep, kompres hangat

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

3. Imunisasi:

(√) BCG ( ) Hepatitis( ) Polio ( ) Campak( ) DPT ( ) .................

4. Kebiasaan: Jenis Frekuensi Jumlah LamanyaMerokok ................................... ......................................... .........................................

Kopi ................................... ......................................... .........................................

Alkohol ................................... ......................................... .........................................

5. Obat-obatan yg digunakan:Jenis Lamanya Dosis

neuralgin...................................... jika sakit kepala..................... ..................................................

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

E. Riwayat Keluarga

Suami klien sakit hipertensi dan DM tipe 2 ............................................................................................

Orang tua klien memiliki riwayat asam urat............................................................................................

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GENOGRAM

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F. Riwayat LingkunganJenis Rumah Pekerjaan

Kebersihan ........................................................ bersih..............................................

Bahaya kecelakaan ........................................................ ........................................................

Polusi jauh dari jalan raya......................... ........................................................

Ventilasi baik................................................. baik.................................................

Pencahayaan baik................................................. baik.................................................

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

G. Pola Aktifitas-LatihanRumah Rumah Sakit

Makan/minum 0................................................... 0...................................................

Mandi 0................................................... 0...................................................

Berpakaian/berdandan 0................................................... 0...................................................

Toileting 0................................................... 0...................................................

Mobilitas di tempat tidur 0................................................... 0

Berpindah 0................................................... 0...................................................

Berjalan 0................................................... 0...................................................

Naik tangga 0................................................... 0...................................................

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

H. Pola Nutrisi MetabolikRumah Rumah Sakit

Jenis diit/makanan Nasi........................................ Tim............................................

Frekuensi/pola 3x/hari.................................... 3x/hari.......................................

Porsi yg dihabiskan satu entong............................ sedikit.......................................

Komposisi menu nasi, sayur, lauk..................... seimbang..................................

Pantangan ............................................... tidak ada...................................

Napsu makan turun...................................... turun.........................................

Fluktuasi BB 6 bln. terakhir turun...................................... turun.........................................

Jenis minuman air putih.................................. air putih.....................................

Frekuensi/pola minum sering..................................... sering........................................

Gelas yg dihabiskan 2-3 botol 500 ml..................... ..................................................

Sukar menelan (padat/cair) ............................................... ..................................................

Pemakaian gigi palsu (area) tidak ada................................ tidak ada...................................

Riw. masalah penyembuhan luka tidak ada................................ tidak ada...................................

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I. Pola EliminasiRumah Rumah Sakit

BAB:

- Frekuensi/pola 2x/hari.......................................... 2 hari sekali...............................

- Konsistensi biasa............................................ biasa..........................................

- Warna & bau biasa............................................ biasa..........................................

- Kesulitan kadang 3 hari tidak BAB.............. ..................................................

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

BAK:

- Frekuensi/pola 3-4x/hari....................................... 5-6x/hari....................................

- Konsistensi encer............................................ encer.........................................

- Warna & bau putih kekuningan......................... putih kekuningan.......................

- Kesulitan tidak ada...................................... tidak ada....................................

- Upaya mengatasi tidak ada...................................... tidak ada....................................

J. Pola Tidur-IstirahatRumah Rumah Sakit

Tidur siang:Lamanya 1 jam...................................... 1 jam............................................

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

- Kenyamanan stlh. tidur .............................................. ...................................................

Tidur malam: Lamanya 4-5 jam................................... 4-5 jam.........................................

- Jam …s/d… 09.00-tengah malam............. 09.00-tengah malam..................

- Kenyamanan stlh. tidur .............................................. ...................................................

- Kebiasaan sblm. tidur menonton TV........................ menonton TV.............................

- Kesulitan susah tidur lagi jika terbangun tidak bisa tidur karena panas.....

- Upaya mengatasi tiduran saat pagi/siang.......... tiduran saat pagi/siang..............

K. Pola Kebersihan DiriRumah Rumah Sakit

Mandi:Frekuensi 2 kali......................................... 1 kali.........................................

- Penggunaan sabun Ya............................................ Tidak.......................................

Keramas: Frekuensi 2 hari sekali.............................. 1 kali/hari..................................

- Penggunaan shampoo Ya............................................ Ya............................................

Gososok gigi: Frekuensi 2 kali perhari............................. 2 kali perhari.............................

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

Ganti baju:Frekuensi 2 kali perhari............................. 1 kali perhari.............................

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

Kesulitan Mobilisasi dari tempat tidur ke KM.................................................

Upaya yg dilakukan Memakai penyangga/tongkat. . . ..................................................

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L. Pola Toleransi-Koping Stres

1. Pengambilan keputusan: ( ) sendiri (√) dibantu orang lain, sebutkan, suami dan anak.............

2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri, dll):................

3. Yang biasa dilakukan apabila stress/mengalami masalah:..................................................................

4. Harapan setelah menjalani perawatan: semoga cepat sembuh dan tidak opname lagi......................

5. Perubahan yang dirasa setelah sakit: setelah diberi tata laksana dengan nebul klien merasa

nafasnya lebih mudah tetapi dalam beberapa jam kambuh lagi..........................................................

M. Konsep Diri

1. Gambaran diri:......................................................................................................................................

2. Ideal diri:...............................................................................................................................................

3. Harga diri:.............................................................................................................................................

4. Peran:...................................................................................................................................................

5. Identitas diri..........................................................................................................................................

N. Pola Peran & Hubungan

1. Peran dalam keluarga Istri dan Ibu......................................................................................................

2. Sistem pendukung: suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain, sebutkan:.............

3. Kesulitan dalam keluarga: ( ) Hub. dengan orang tua ( ) Hub.dengan pasangan

( ) Hub. dengan sanak saudara ( ) Hub.dengan anak

( ) Lain-lain sebutkan, tidak ada...................................................

4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS:..................................

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

5. Upaya yg dilakukan untuk mengatasi:..................................................................................................

O. Pola Komunikasi

1. Bicara: (√) Normal ( )Bahasa utama: Indonesia.....................

( ) Tidak jelas ( ) Bahasa daerah: Jawa.........................

( ) Bicara berputar-putar ( ) Rentang perhatian:.............................

( ) Mampu mengerti pembicaraan orang lain( ) Afek:...................................................

2. Tempat tinggal: ( ) Sendiri

( ) Kos/asrama

(√) Bersama orang lain, yaitu: Suami, Anak terakhir, Menantu, Cucu........................

3. Kehidupan keluarga

a. Adat istiadat yg dianut: Jawa.........................................................................................................

b. Pantangan & agama yg 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

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P. Pola Seksualitas

1. Masalah dalam hubungan seksual selama sakit: ( ) tidak ada ( ) ada

2. Upaya yang dilakukan pasangan:

(√) perhatian ( ) sentuhan ( ) lain-lain, seperti, .............................................................

Q. Pola Nilai & Kepercayaan

1. Apakah Tuhan, agama, kepercayaan penting untuk Anda, Ya/Tidak

2. Kegiatan agama/kepercayaan yg dilakukan dirumah (jenis & frekuensi): Sholat..............................

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

3. Kegiatan agama/kepercayaan tidak dapat dilakukan di RS: Sholat.....................................................

4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya:.....................................................

R. Pemeriksaan Fisik

1. Keadaan Umum: Klien terlihat ceria dan terbuka terhadap perawat....................................................

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

Kesadaran: Composmentis GCS: 4 5 6...........................................................................................

Tanda-tanda vital: - Tekanan darah : 130/80 mmHg - Suhu : 36 oC

- Nadi : 80 x/menit - RR : 20 x/menit

Tinggi badan: .....................................cm Berat Badan:.........................kg

2. Kepala & Leher

a. Kepala:

Rambut berwarna putih...................................................................................................

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b. Mata:

Penglihatan jelas, sklera tidak ikterik, konjungtiva tidak anemis, pupil isokor.................

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c. Hidung:

Kotor, tidak ada luka........................................................................................................

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d. Mulut & tenggorokan:

Mulut kering.....................................................................................................................

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e. Telinga:

Kotor, tidak pakai alat bantu............................................................................................

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f. Leher:

Trakea simetris, pembesaran tonsil (-), peningkatan JVP (-), kaku kuduk (-), pembesaran tiroid

(-), parotitis (-)................................................................................................................................

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3. Thorak & Dada:

Jantung

- Inspeksi: dada simetris.............................................................................................................

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- Palpasi: tidak terjadi pembesaran area jantung, tidak ada edema...........................................

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- Perkusi: dullness/redup............................................................................................................

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- Auskultasi: S1 S2 tunggal dan reguler......................................................................................

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Paru

- Inspeksi: dada simetris, terdapat pergerakan dinding dada, nafas reguler..............................

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- Palpasi: massa (-), edema (-)...................................................................................................

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- Perkusi: resonan.......................................................................................................................

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- Auskultasi: ronkhi (+), wheezing (+)............................................................................................

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4. Payudara & Ketiak

Tidak terkaji.................................................................................................................................

5. Punggung & Tulang Belakang

Tidak ada dekubitus....................................................................................................................

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6. Abdomen

Inspeksi: permukaan datar dan supel, ada striae di sisi kanan dan kiri..........................................

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Palpasi: nyeri tekan (-), ascites (-)...................................................................................................

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Perkusi: timpani...............................................................................................................................

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Auskultasi: bising usus (+)...............................................................................................................

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7. Genetalia & Anus

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

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

8. Ekstermitas

Atas: tidak ada edema, tidak sianosis, akral hangat, edema (-), kekuatan otot (5)......................

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Bawah: tidak ada edema, tidak sianosis, akral hangat, pengapuran sendi lutut...........................

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9. Sistem Neorologi

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10. Kulit & Kuku

Kulit: keadaan kulit normal, risiko dekubitus (-), luka (-), turgor kulit baik, kulit tampak

memerahan

Kuku: CRT < 3 detik, kuku kaki kehitaman

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S. Hasil Pemeriksaan Penunjang

Hasil Pemeriksaan Lab:

Hb : 14.8 g/dl

Leukosit : 7.300/cmm

Trombosit : 294.000

PCV : 44.7%

T. Terapi

Inj. Ceftriaxon 2x1...................................................................................................................................

Inj. Methylprednisolon.............................................................................................................................

Inj. Furosemid.........................................................................................................................................

Inj. Combivent nebul 3x1........................................................................................................................

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U. Persepsi Klien Terhadap Penyakitnya

Klien bertanya-tanya mengapa bisa sakit dan berharap agar cepat sembuh........................................

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V. Kesimpulan

Ny. Chotimah dengan keluhan sesak napas, batuk berdahak dan susah dikeluarkan dengan

diagnosa medis COPD...........................................................................................................................

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