JURUSAN KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS 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:.........................................

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Agama

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

Status

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

Suku

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

Alamat

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

Pendidikan

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

No. Telepon

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

Pekerjaan

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

Pendidikan

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

Lama Bekerja

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

Pekerjaan

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

Diagnosa Medis :..........................................................................................................................

B. STATUS KESEHATAN SAAT INI

1. Keluhan Utama Saat MRS
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2. Keluhan Utama Saat Pengkajian
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3. Riwayat Penyakit Sekarang

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4. Riwayat Keperawatan
a. Riwayat Obstetri
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b. Riwayat Kehamilan, Persalinan, dan Nifas Yang Lalu
Anak ke
No

Tahun

Kehamilan
Umur
Kehamilan

Penyulit

Persalinan
Jenis

Penolong

Komplikasi Nifas
Penyulit

Laserasi

Infeksi

Perdarahan

Anak
Jenis

BB

PJ

5. Riwayat KB
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6. Riwayat Kesehatan
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7. Riwayat Keluarga
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Genogram

8. Riwayat Lingkungan Sosial

a. Pola Interaksi dengan Keluarga
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b. Hubungan Klien dengan Lingkungan Sekitarnya
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c. Lingkungan Rumah
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9. Kebutuhan Dasar
a. Pola Nutrisi
Jenis

Rumah

Rumah Sakit

Makan
Jenis diit/makanan

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Frekuensi/pola

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Porsi yang dihabiskan ...................................................

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Komposisi menu

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Pantangan

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Nafsu makan

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Fluktuasi BB 6 bl trhr

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

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Gelas yang dihabiskan ...................................................

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Sukar menelan

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Pemakaian gigi palsu ...................................................

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Minum
Jenis minuman

Riw.masalah
penyembuhan luka

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b. Pola Eliminasi
Jenis

Rumah

Rumah Sakit

BAB
Frekuensi/pola

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Konsistensi

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Warna & bau

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Kesulitan

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Upaya mengetasi

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Konsistensi

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Warna & bau

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Kesulitan

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Upaya mengetasi

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BAK

Frekuensi/pola

c. Pola Tidur-Istirahat
Rumah

Rumah Sakit

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

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

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

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

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

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

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- Kebiasaan sbl tidur

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- Kesulitan

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- Upaya mengatasi

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d. Pola Kebersihan Diri

Rumah
Mandi: Frekuensi

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Penggunaan sabun

Rumah Sakit
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Keramas: Frekuensi

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

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

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- Penggunaan odol

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

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

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Kesulitan

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Upaya yang dilakuan

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e. Pola Aktivitas-Latihan
Jenis

Rumah

Rumah Sakit

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

Mandi

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Berpakaian

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Toiletting

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Mobilitas

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Berpindah

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Berjalan

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Naik tangga

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Pemberian Skor: 0=mandiri, 1=alat bantu, 2=dibantu orang lain (1 orang), 3=dibantu orang lain
(>1 orang), 4=tidak mampu
10. Pemeriksaan Fisik
1. Keadaan umum:.......................................................................................................................
a. Kesadaran: ........................................................................................................................
b. Tanda tanda vital: Tek.darah
Nadi

: ..........mmHg

Suhu

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

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

Pupil: ( ) Reaksi terhadap cahaya ( ) Isokor ( ) Meiosis ( ) Pin Point ( ) Midriasis

Tanda radang:...............................................................................................................

Fungsi penglihatan:

( ) Baik

( ) Kabur

Penggunaan alat bantu:

( ) ya

( ) tidak

Konjungtiva ........................................

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...........

f.

Fungsi Pendengaran ......... ....Alat bantu pendengaran ..............................................

Masalah Yang Pernah Terjadi: ...................................................................................

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

Lesi ........................................

Bentuk .................................................

Pengisian Kapiler ..................................

11. Hasil pemeriksaan penunjang

a. Laboratorium
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12. Diagnosa Medis
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13. Pengobatan
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