JURUSAN KEPERAWATANFAKULTAS KEDOKTERANUNIVERSITAS BRAWIJAYA
PENGKAJIAN DASAR KEPERAWATAN
Nama Mahasiswa:
NIM :
A. DATA UMUM KLIEN
Nama :......................................... 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
:.......................................
Diagnosa Medis
:..........................................................................................................................
B. STATUS KESEHATAN SAAT INI
1. Keluhan Utama Saat MRS
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
2. Keluhan Utama Saat Pengkajian
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
3. Riwayat Penyakit Sekarang
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
4. Riwayat Keperawatan
a. Riwayat Obstetri
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.
.................................................................................................................................................
.................................................................................................................................................
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
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
6. Riwayat Kesehatan
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
7. Riwayat Keluarga
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Genogram
8. Riwayat Lingkungan Sosial
a. Pola Interaksi dengan Keluarga
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
b. Hubungan Klien dengan Lingkungan Sekitarnya
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
c. Lingkungan Rumah
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
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 ...........................................
..................................................
- Jam .....s/d...... ........................................... ...................................................
- Kenyamanan stl tidur ........................................... ...................................................
Tidur malam: Lamanya ...........................................
...................................................
- 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 ...........................................
...................................................
- Penggunaan Shampo........................................... ...................................................
Gosok gigi: Frekuensi ...........................................
...................................................
- Penggunaan odol ........................................... ...................................................
Ganti baju: Frekuensi ...........................................
...................................................
Memotong kuku: Frekuensi.....................................
....................................................
Kesulitan ........................................... ...................................................
Upaya yang dilakuan ...........................................
...................................................
e. Pola Aktivitas-Latihan
Jenis Rumah Rumah 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
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 ................................................................................................................................
.
Auskultasi ............................................................................................................................
.
Paru:
Inspeksi................................................................................................................................
Palpasi .................................................................................................................................
.
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
.................................................................................................................................................
.
.................................................................................................................................................
.................................................................................................................................................
............................................................................................................................................... .
.................................................................................................................................................
...............................................................................................................................................
.................................................................................................................................................
.
.................................................................................................................................................
.................................................................................................................................................
............................................................................................................................................... .
.................................................................................................................................................
...............................................................................................................................................
12. Diagnosa Medis
.................................................................................................................................................
.................................................................................................................................................
13. Pengobatan
.................................................................................................................................................
.
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
.................................................................................................................................................
................................................................................................................................................
Top Related