PENGKAJIAN DASAR KEPERAWATAN

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa    :                                                  Tempat Praktik        :

NIM                          :                                                  Tgl. Praktik               :

 

A.  Identitas Klien

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

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

Jenis kelamin                 :...........................................    Tgl. Pengkajian     :.....................................

Alamat                            :...........................................    Sumber informasi :.....................................

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

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

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

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

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

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

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

B.  Status kesehatan Saat Ini

1.   Keluhan Utama

a.   Saat MRS                 :.........  ...................................................................................................

                                                 .....……………………………………………............................................

                                                 ........... ..............................................................................................  ....                                                 .……………………………………………………………………………….

b.   Saat Pengkajian      :....... .……………  …………………………………………………………..

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

                                               ………………………………………………………………………………..

                                          .……………………………………………………………………………….

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

2. Riwayat Kesehatan Saat ini

.......................................... ………………………………………………………………………………..

........................................... ……………………………………………………………………………….

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

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

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

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

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

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

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

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

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

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

C.  Riwayat Kesehatan Terdahulu

1.   Penyakit yg pernah dialami:

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

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

c.   Penyakit:

·      Kronis      :...........................................................................................................................                         ............................................................................................................................       

·      Akut         :...........................................................................................................................       

d.   Terakhir masuki RS               :.................................................................................................

2.   Alergi (obat, makanan, plester, dll):

                           Tipe                                         Reaksi                                        Tindakan

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

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

3.   Imunisasi:

            (  ) BCG              (  )  Hepatitis

            (  ) Polio              (  )  Campak

            (  ) DPT              (  )  .................

4.   Kebiasaan:

 Jenis                                 Frekuensi                             Jumlah                                 Lamanya

Merokok                   ...................................    .........................................    .................................

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

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

5.   Obat-obatan yg digunakan:

                           Jenis                                     Lamanya                                          Dosis

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

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

D.  Riwayat Keluarga

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

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

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

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

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

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

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

GENOGRAM

E.  Riwayat Lingkungan

               Jenis                                         Rumah                                              Pekerjaan

·      Kebersihan                        ........................................................    ................................................

·      Bahaya kecelakaan          ........................................................    ................................................

·      Polusi                                ........................................................    ................................................

·      Ventilasi                             ........................................................    ................................................

·      Pencahayaan                    ........................................................    ................................................

F.  Pola Aktifitas-Latihan

                                                                     Rumah                                          Rumah Sakit

·      Makan/minum                         .....................................................    .............................................

·      Mandi                                      .....................................................    .............................................

·      Berpakaian/berdandan           .....................................................    .............................................

·      Toileting                                   .....................................................    .............................................

·      Mobilitas di tempat tidur          .....................................................    .............................................

·      Berpindah                                .....................................................    .............................................

·      Berjalan                                   .....................................................    .............................................

·      Naik tangga                             .....................................................    .............................................

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

G.  Pola Nutrisi Metabolik

                                                                           Rumah                                    Rumah Sakit

·      Jenis diit/makanan                           ...............................................    ..........................................

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

·      Porsi yg dihabiskan                          ...............................................    ..........................................

·      Komposisi menu                              ...............................................    ..........................................

·      Pantangan                                        ...............................................    ..........................................

·      Napsu makan                                  ...............................................    ..........................................

·      Fluktuasi BB 6 bln. terakhir             ...............................................    ..........................................

·      Jenis minuman                                ...............................................    ..........................................

·      Frekuensi/pola minum                     ...............................................    ..........................................

·      Gelas yg dihabiskan                        ...............................................    ..........................................

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

·      Pemakaian gigi palsu (area)            ...............................................    ..........................................

·      Riw. masalah penyembuhan luka   ...............................................    ..........................................

H.  Pola Eliminasi

                                                                  Rumah                                          Rumah Sakit

·      BAB:                                    

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

-    Konsistensi                           .....................................................    ............................................

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

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

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

·      BAK:

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

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

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

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

I.    Pola Tidur-Istirahat

                                                                           Rumah                                    Rumah Sakit

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

-    Jam …s/d…                                                                             ....                                             

-    Kenyamanan stlh. tidur                                                            ....                                             

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

-    Jam …s/d…                                                                             ....                                             

-    Kenyamanan stlh. tidur                                                            ....                                             

-    Kebiasaan sblm. tidur                                                              ....                                             

-    Kesulitan                                                                                  ....                                             

-    Upaya mengatasi                                                                     ....                                             

J.   Pola Kebersihan Diri

                                                                           Rumah                                    Rumah Sakit

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

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

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

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

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

-    Penggunaan pasta gigi                                                                   ..........................................

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

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

·      Kesulitan                                       ..................................................    ..........................................

·      Upaya yg dilakukan                      ..................................................    ..........................................

K.  Pola Toleransi-Koping Stres

1.   Pengambilan keputusan:     ( ) sendiri      ( ) dibantu orang lain,  sebutkan,...............................

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:........................................................................................

5.   Perubahan yang dirasa setelah sakit:..........................................................................................

L.  Konsep Diri

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

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

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

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

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

M. Pola Peran & Hubungan

1.   Peran dalam keluarga...................................................................................................................

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,...................................................................

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

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

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

N.  Pola Komunikasi

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

                        (  ) 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 keluarga

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

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

O.  Pola Seksualitas

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

2.   Upaya yang dilakukan pasangan:

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

P.  Pola Nilai & Kepercayaan

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

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

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

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

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

Q.  Pemeriksaan Fisik

1.   Keadaan Umum:...........................................................................................................................

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

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

·      Kesadaran:...............................................................................................................................

·        Tanda-tanda vital:   - Tekanan darah :……… mmHg           - Suhu  :………^oC

-  Nadi                 :……...  x/menit          - RR     :……… x/menit

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

2.   Kepala & Leher

a.   Kepala:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       

b.   Mata:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                

c.   Hidung:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                

d.   Mulut & tenggorokan:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                

e.   Telinga:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   

f.    Leher:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                

3.   Thorak & Dada:

·      Jantung

-    Inspeksi:..............................................................................................................................        .............................................................................................................................................

-    Palpasi:................................................................................................................................        .............................................................................................................................................

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

-    Auskultasi:...........................................................................................................................        .............................................................................................................................................       

·      Paru

-    Inspeksi:..............................................................................................................................        .............................................................................................................................................

-    Palpasi:................................................................................................................................        .............................................................................................................................................

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

-    Auskultasi:...........................................................................................................................        .............................................................................................................................................

4.   Payudara & Ketiak

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

5.   Punggung & Tulang Belakang

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

6.   Abdomen

·      Inspeksi:...................................................................................................................................

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

·      Palpasi:.....................................................................................................................................

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

·      Perkusi:....................................................................................................................................

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

·      Auskultasi:................................................................................................................................

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

7.   Genetalia & Anus

·      Inspeksi:...................................................................................................................................

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

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

·      Palpasi:.....................................................................................................................................

8.   Ekstermitas

·      Atas:.........................................................................................................................................

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

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

·      Bawah:.....................................................................................................................................

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

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

9.   Sistem Neorologi

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

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

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

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

10. Kulit & Kuku

·      Kulit: ........................................................................................................................................

………………………………………………………………………………………………………...

………………………………………………………………………………………………………...

·      Kuku: …………………………………………………………………………………………………

…………………………………………………………………………………..…………………….

              …………………………………………………………………………………………………………

R.  Hasil Pemeriksaan Penunjang

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

S.  Terapi

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

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

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

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

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

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

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

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

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

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

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

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

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

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

T.  Persepsi Klien Terhadap Penyakitnya

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

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

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

download file