YAYASAN EKA HARAP PALANGKA RAYA

SEKOLAH TINGGI ILMU KESEHATAN

PROGRAM STUDI S1 KEPERAWATAN
Jalan Beliang No.110 Palangka Raya Telp/Fax. (0536)
3327707
FORMAT ASUHAN KEPERAWATAN DIABETES MELITUS
Nama Mahasiswa
: .
NIM
: .
Ruang Praktek
: .
Tanggal Praktek
: .
Tanggal & Jam Pengkajian
: .
I. PENGKAJIAN
A.
IDENTITAS PASIEN
Nama
: ..
Umur
: ..
Jenis Kelamin
:
..
Suku/Bangsa
:
..
Agama
:
..
Pekerjaan
: ..
Pendidikan
: ..
Status Perkawinan
:
..
Alamat
:
..
Tgl MRS
: ..
Diagnosa Medis
B.

: ..

RIWAYAT KESEHATAN /PERAWATAN

1. Keluhan Utama :
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2.
Riwayat Penyakit Sekarang:
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3. Riwayat Penyakit Sebelumnya (riwayat penyakit dan riwayat
operasi)
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4.

Riwayat Penyakit Keluarga

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GENOGRAM KELUARGA:

C.

PEMERIKASAAN FISIK
1.
Keadaan Umum:
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2.
Status Mental :
a. Tingkat Kesadaran : .
b. Ekspresi wajah
: .
c. Bentuk badan
: .
d. Cara berbaring/bergerak ......................................................:
.
e. Berbicara
: .
f. Suasana hati
: .
g. Penampilan
: .
h. Fungsi kognitif :
Orientasi waktu :
.

 Orientasi Orang :
.
Orientasi Tempat ..........................................................:
.
i. Halusinasi :
Dengar/Akustic Lihat/Visual

Lainnya
j. Proses berpikir : Blocking
Circumstansial
Flight oh ideas
Lainnya ...............................................
k. Insight : Baik
Mengingkari
Menyalahkan
orang lain
m. Mekanisme pertahanan diri :
Adaptif

Maladaptif
n. Keluhan lainnya :
.
3.

Tanda-tanda Vital :
a.
Suhu/T
: .0C Axilla Rektal Oral
b. Nadi/HR
: x/mt
c. Pernapasan/RR : ....x/tm
d. Tekanan Darah/BP
: .....mm Hg

4.

PERNAPASAN (BREATHING)
Bentuk Dada
: ...........................................................
Kebiasaan merokok
: ...Batang/hari

Batuk, sejak

Batuk darah, sejak

Sputum, warna..............................

Sianosis

Nyeri dada

Dyspnoe nyeri dada

Orthopnoe
Lainnya
...

Sesak nafas saat inspirasi

Saat aktivitas
Saat istirahat
Type Pernafasan
Dada
Perut

Dada dan perut

Kusmaul Cheyne-stokes Biot
Lainnya
Irama Pernafasan
Teratur
Tidak teratur
Suara Nafas

Vesukuler Bronchovesikuler
Bronchial Trakeal

Suara Nafas tambahan

Wheezing
Ronchi kering
Ronchi basah (rales)
Lainnya
Keluhan lainnya :
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Masalah Keperawatan :
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5.

CARDIOVASCULER (BLEEDING)

Nyeri dada Kram kaki

Pucat

Pusing/sinkop
Clubing finger
Sianosis

Sakit Kepala
Palpitasi
Pingsan

Capillary refill > 2 detik

< 2 detik

Oedema : Wajah
Ekstrimitas atas
Anasarka
Ekstrimitas bawah

Asites, lingkar perut . cm

Ictus Cordis
Terlihat
Tidak melihat
Vena jugularis
Tidak meningkat ............................
Meningkat
Suara jantung
Normal,.
Ada kelainan
Keluhan lainnya :
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Masalah Keperawatan :
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6. PERSYARAFAN (BRAIN)
Nilai GCS :
E
: .
V
: .
M : .
Total Nilai GCS
:

Kesadaran
:
Compos Menthis
Somnolent
Delirium
Apatis
Soporus
Coma
Pupil
: Isokor
Anisokor
Midriasis
Meiosis

Refleks Cahaya : Kanan

Positif
Negatif
Kiri
Positif
Negatif

Nyeri, lokasi ..

Vertigo
Gelisah
...................
Aphasia Kesemutan

Bingung
Disarthria
...................
Kejang
Trernor

Pelo
Uji Syaraf Kranial :
Nervus Kranial I : .......................................................................
Nervus Kranial II : .......................................................................
Nervus Kranial III :......................................................................
Nervus Kranial IV :......................................................................
Nervus Kranial V : .......................................................................
Nervus Kranial VI :......................................................................
Nervus Kranial VII :......................................................................
Nervus Kranial VIII ......................................................................:
Nervus Kranial IX :......................................................................
Nervus Kranial X

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

Nervus Kranial XI :......................................................................

Nervus Kranial XII :......................................................................
Uji Koordinasi :
Ekstrimitas Atas :
Jari ke jari
Positif
Negatif
Jari ke hidung
Positif
Negatif
Ekstrimitas Bawah
:
Tumit ke
jempul kaki
Positif
Negatif
Uji Kestabilan Tubuh
:
Positif
Negatif
Refleks :
Bisep
: Kanan +/- Kiri +/Skala.
Trisep
:
Kanan +/- Kiri +/Skala. Brakioradialis
:
Kanan
+/ Kiri +/Skala. Patella :
Kanan +/ Kiri +/Skala.
Akhiles
: Kanan +/- Kiri +/Skala.
Refleks Babinski Kanan +/- Kiri +/Refleks lainnya : .......................................................................
Uji sensasi
: .......................................................................
.......................................................................
Keluhan lainnya :

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Masalah Keperawatan :
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7. ELIMINASI URI (BLADDER) :
Produksi Urine : .mlx/hr
Warna
:
Bau
:
Tidak ada masalah/lancer Menetes
Inkotinen
Oliguri
Nyeri
Retensi
Poliuri
Panas
Hematuri
Dysuri
Nocturi
Kateter
Cystostomi
Keluhan Lainnya :
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Masalah Keperawatan :
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8. ELIMINASI ALVI (BOWEL) :
Mulut dan Faring
Bibir
: ..............................................................................
Gigi
: ..............................................................................
Gusi
: ..............................................................................
Lidah
: ..............................................................................
Mukosa
: ..............................................................................
Tonsil
: ..............................................................................
Rectum
:
Haemoroid :
BAB
: .x/hr
Warna :.. . Konsistensi :
.

Tidak ada masalah

Diare

Konstipasi
Kembung

Feaces berdarah
Melena
Obat
pencahar
Lavement
Bising usus
: ......................................................................
Nyeri tekan, lokasi ......................................................................:
Benjolan, lokasi : ......................................................................
Keluhan lainnya :
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Masalah Keperawatan :

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9. TULANG - OTOT INTEGUMEN (BONE) :
Kemampuan pergerakan sendi
Bebas

Terbatas
Parese, lokasi ........................................................................
Paralise, lokasi .......................................................................
Hemiparese, lokasi ................................................................
Krepitasi, lokasi .....................................................................
Nyeri, lokasi ...........................................................................
Bengkak, lokasi .....................................................................
Kekakuan, lokasi ....................................................................
Flasiditas, lokasi ....................................................................
Spastisitas, lokasi ..................................................................
Ukuran otot
Simetris
Atropi
Hipertropi
Kontraktur
Malposisi
Uji kekuatan otot : Ekstrimitas atas.. Ekstrimitas
bawah..
Deformitas tulang, lokasi........................................................
Peradangan, lokasi.................................................................
Perlukaan, lokasi....................................................................
Patah tulang, lokasi................................................................
Tulang belakang
Normal
Skoliosis
Kifosis
Lordosis
10.
Riwayat alergi

Suhu kulit
Warna kulit
Ikterik/kuning

KULIT-KULIT RAMBUT
Obat........................................................
Makanan.................................................
Kosametik...............................................
Lainnya...................................................
Hangat
Panas
Dingin
Normal
Sianosis/ biru...............

tua/hyperpigmentasi
Turgor

Tekstur

Lesi :

Putih/ pucat

Coklat

Baik
Cukup
Kurang
Halus
Kasar
Macula, lokasi
Pustula, lokasi.........................................
Nodula, lokasi.........................................
Vesikula, lokasi.......................................
Papula, lokasi.........................................
Ulcus, lokasi............................................

Jaringan parut lokasi....................................................................

Tekstur rambut............................................................................
Distribusi rambut.........................................................................
Bentuk kuku
Simetris
Irreguler
Clubbing Finger Lainnya...........
Masalah Keperawatan :
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11.
SISTEM PENGINDERAAN :
a. Mata/Penglihatan
Fungsi penglihatan :
Berkurang

Kabur

Ganda

Buta/gelap
Gerakan bola mata :
Bergerak normal
Diam
Bergerak spontan/nistagmus
Visus :
Mata Kanan (VOD) :..........................................
Mata kiri (VOS)
:...........................................
Selera
Normal/putih Kuning/ikterus
Merah/hifema Konjunctiva Merah muda Pucat/anemic
Kornea
Bening
Keruh
Alat bantu Kacamata
Lensa kontak Lainnya.
Nyeri
.............................................................................:
Keluhan lain.............................................................................:

b. Telinga / Pendengaran :
Fungsi pendengaran :
Berkurang

Berdengung
Tuli
c. Hidung / Penciuman:
Bentuk :
Simetris
Asimetris
Lesi
Patensi
Obstruksi
Nyeri tekan sinus
Transluminasi
Cavum Nasal
Warna.. Integritas..
Septum nasal Deviasi
Perforasi
Peradarahan
Sekresi, warna
Polip
Kanan
Kiri
Kanan dan Kiri
Masalah Keperawatan :
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12.
LEHER DAN KELENJAR LIMFE
Massa
Ya
Tidak
Jaringan Parut
Ya
Tidak
Kelenjar Limfe
Teraba
Tidak teraba
Kelenjar Tyroid
Teraba
Tidak teraba
Mobilitas leher
Bebas
Terbatas
13.
SISTEM REPRODUKSI
a. Reproduksi Pria
Kemerahan, Lokasi.....................................
Gatal-gatal, Lokasi......................................
Gland Penis.................................................
Maetus Uretra.............................................
Discharge, warna........................................
Srotum ......................................................
Hernia ......................................................
Kelainan
Keluhan lain .
a. Reproduksi Wanita
Kemerahan, Lokasi.....................................
Gatal-gatal, Lokasi......................................
Perdarahan.................................................
Flour Albus .................................................
Clitoris ........................................................
Labis
......................................................
Uretra ......................................................
Kebersihan : Baik
Cukup
Kurang
Kehamilan :
Tafsiran partus ...........................................:

Keluhan lain.............................................................................
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Payudara :
Simetris
Asimetris
Sear
Lesi
Pembengkakan
Nyeri tekan
Puting : Menonjol
Datar Lecet
Mastitis
Warna areola ...........................................................................
ASI
Lancar
Sedikit Tidak keluar
Keluhan lainnya........................................................................
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Masalah Keperawatan :
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D.

POLA FUNGSI KESEHATAN

1. Persepsi Terhadap Kesehatan dan Penyakit :
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2. Nutrisida Metabolisme
TB
:
Cm
BB sekarang
:
Kg
BB Sebelum sakit
:
Kg
Diet :
Biasa
Cair
Saring
Lunak
Diet Khusus :
Rendah garam
Rendah kalori
TKTP
Rendah Lemak
Rendah Purin
Lainnya.
Mual
Muntah.kali/hari
Kesukaran menelan
Ya
Tidak
Rasa haus
Keluhan lainnya...........................................................................
....................................................................................................

Pola Makan
Sehari-hari
Frekuensi/hari
Porsi
Nafsu makan
Jenis Makanan
Jenis Minuman
Jumlah
minuman/cc/24 jam
Kebiasaan makan
Keluhan/masalah
Masalah Keperawatan

Sesudah Sakit

Sebelum Sakit

3. Pola istirahat dan tidur

Masalah Keperawatan

4. Kognitif :

Masalah Keperawatan

5. Konsep diri (Gambaran diri, ideal diri, identitas diri, harga diri,
peran ) :

Masalah Keperawatan

6. Aktivitas Sehari-hari

Masalah Keperawatan

7. Koping Toleransi terhadap Stress

Masalah Keperawatan

8. Nilai-Pola Keyakinan

Masalah Keperawatan

E.

SOSIAL - SPIRITUAL
1. Kemampuan berkomunikasi

2. Bahasa sehari-hari

3. Hubungan dengan keluarga :

4. Hubungan dengan teman/petugas kesehatan/orang lain :

5. Orang berarti/terdekat :

6. Kebiasaan menggunakan waktu luang :

7. Kegiatan beribadah :

F.

DATA PENUNJANG (RADIOLOGIS, LABORATO RIUM,

PENUNJANG LAINNYA)

G.

PENATALAKSANAAN MEDIS

Palangka Raya,

Mahasiswa

( )

ANALISIS DATA
DATA SUBYEKTIF
DAN DATA OBYEKTIF

KEMUNGKINAN
PENYEBAB

MASALAH

PRIORITAS MASALAH

RENCANA KEPERAWATAN
Nama Pasien...............................................................................................: ..
Ruang Rawat..............................................................................................: ..
Diagnosa
Keperawatan

Tujuan (Kriteria hasil)

Intervensi

Rasional

IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari/Tanggal, Jam

Implementasi

Evaluasi (SOAP)

Tanda tangan
dan
Nama Perawat