JURUSAN KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa

Tempat Praktik

NIM

Tgl. Praktik

A. Identitas Klien
Nama

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

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

Usia

:............. tahun

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

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

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

Tgl. Masuk

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

B. Status kesehatan Saat Ini

1. Keluhan utama

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

2. Lama keluhan

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

3. Kualitas keluhan

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

4. Faktor pencetus

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

5. Faktor pemberat

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

6. Upaya yg. telah dilakukan

7. Diagnosa medis

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

a.

.................................................................................... Tanggal.......................................

b.

.................................................................................... Tanggal.......................................

c.

.................................................................................... Tanggal.......................................

C. Riwayat Kesehatan Saat Ini

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

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
D. 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

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

.................................................... .............................................. .................................................
E. Riwayat Keluarga
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

.............................................................................................................................................................
.............................................................................................................................................................
GENOGRAM

F. Riwayat Lingkungan
Jenis

Rumah

Pekerjaan

Kebersihan

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

Bahaya kecelakaan

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

Polusi

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

Ventilasi

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

Pencahayaan

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

G. 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

H. 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 .............................................. .................................................

I. Pola Eliminasi
Rumah

Rumah Sakit

BAB:
- Frekuensi/pola

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

- Konsistensi

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

- Warna & bau

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

- Kesulitan

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

- Upaya mengatasi

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

BAK:
- Frekuensi/pola

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

- Konsistensi

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

- Warna & bau

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

- Kesulitan

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

- Upaya mengatasi

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

J. Pola Tidur-Istirahat
Rumah
Tidur siang:Lamanya

Rumah Sakit

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

- Jam s/d

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

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

- Kenyamanan stlh. tidur

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

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

 Tidur malam: Lamanya

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

- Jam s/d

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

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

- Kenyamanan stlh. tidur

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

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

- Kebiasaan sblm. tidur

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

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

- Kesulitan

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

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

- Upaya mengatasi

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

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

K. Pola Kebersihan Diri

Rumah
Mandi:Frekuensi
- Penggunaan sabun
Keramas: Frekuensi
- Penggunaan shampoo
Gososok gigi: Frekuensi
- Penggunaan odol

Rumah Sakit

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

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

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

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

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

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

Ganti baju:Frekuensi

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

Memotong kuku: Frekuensi

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

Kesulitan

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

Upaya yg dilakukan

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

L. 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:.................................................................................................

M. Konsep Diri
1. Gambaran diri:...................................................................................................................................
2. Ideal diri:.............................................................................................................................................
3. Harga diri:...........................................................................................................................................
4. Peran:.................................................................................................................................................

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

N. Pola Peran & Hubungan

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

O. 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

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

( ) ada

2. Upaya yang dilakukan pasangan:

( ) perhatian

( ) sentuhan

( ) lain-lain, seperti, ............................................................

Q. Pola Nilai & Kepercayaan

1. Apakah Tuhan, agama, kepercayaan penting untuk Anda, Ya/Tidak
2. Kegiatan agama/kepercayaan yg dilakukan dirumah (jenis & frekuensi):.........................................
....................................................................................................................................................
3. Kegiatan agama/kepercayaan tidak dapat dilakukan di RS:...............................................................
4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya:.....................................................
R. Pemeriksaan Fisik
1. Keadaan Umum:
Kesadaran:....................................................................................................................................

Tanda-tanda vital: - Tekanan darah : mmHg

- Nadi

:... x/menit

Tinggi badan: ....................................cm

2. Kepala & Leher
a. Kepala
Bentuk

:
: ..

Distribusi rambut : ..
b. Mata
:
Bentuk : ..
Pupil : ( ) reaksi terhadap cahaya
( ) Pin point

- Suhu :oC
- RR

: x/menit

Berat Badan:........................kg

Massa: ..
Warna kulit kepala : ..
Konjungtiva : ..
( ) isokor
( )Miosis
( ) Midriasis

Tanda-tanda radang : ..
Funsi penglihatan : ( ) Baik
( ) Kabur
Penggunaan alat bantu : ( ) Ya ( ) Tidak
Apabila ya menggunakan : () Kaca mata
( ) Lensa kontak
( ) Minus .ka/ki
( ) Plus.ka/ki( ) silinderka/ki
Pemeriksaan mata terakhir :
Riwayat Operasi :
c. Hidung
:
Bentuk: . Warna .
Pembengkakan
Nyeri tekan ..
Perdarahan ..
Sinus
Riw. Alergi
Cara mengatasinya ..
Penyakit yg pernah terjadi .
Frekuensi ..
Cara mengatasi
d. Mulut dan Tenggorokan :
Warna bibir .. Mukosa ..
Ulkus ... Lesi
Massa ..
Warna Lidah ..
Perdarahan gusi .
Karies ..
Kesulitan menelan Gigi geligi ...
Sakit tenggorok .Gangguan bicara

Pemeriksaan gigi terakhir .

e. Telinga
:
Bentuk ..
Warna ..Lesi
Massa .
Nyeri ..
Fs. Pendengaran.Alat bantu pendengaran.
Masalah yg pernah terjadi
Upaya untuk mengatasi..
f.

Leher
:
Kekakuan .. Nyeri/Nyeri tekan ..
Benjolan/massa .. Keterbatasan gerak ..
Vena jugularis .. Tiroid..limfe..
TrakeaKeluhan.
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 ..
Bengkak
5. Abdomen :

Nyeri/nyeri tekan ..
Kesimetrisan

Inspeksi:...........................................................................................................................................
.........................................................................................................................................................
Palpasi:............................................................................................................................................
.........................................................................................................................................................
Perkusi:............................................................................................................................................
.........................................................................................................................................................
Auskultasi:........................................................................................................................................
6. Punggung dan Punggung dan Tulang belakang
Nyeri/nyeri tekan Kesimetrisan
7. Genetalia :
Inspeksi
Palpasi ..
Perempuan : Siklus mentruasi ...
Kontrasepsi
Kehamilan .
Keluhan ..
Pria
: Keluhan ..
8. Ekstremitas (kekuatan otot, kontrakturm deformitas, edema, luka, nyeri/nyeri tekan,
pergerakan)
Atas :

Bawah :

9. Sistem Neurologi :
10. Kulit dan kuku :
Kulit :
warna ..
Lesi ..
Tekstur

jaringan parut
Suhu
Turgor ..

Kuku :
Warna ..
Lesi ..

Bentuk
CRT

S. Hasil Pemeriksaan Penunjang

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

T. Terapi
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................

U. Persepsi Klien Terhadap Penyakitnya

.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
V. Kesimpulan
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
W. Perencanaan Pulang
Tujuan pulang:....................................................................................................................................
Transportasi pulang:...........................................................................................................................
Dukungan keluarga:...........................................................................................................................
Antisipasi bantuan biaya setelah pulang:...........................................................................................
Antisipasi masalah perawatan diri setalah pulang:.............................................................................
Pengobatan:.......................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Rawat jalan ke:...................................................................................................................................
....................................................................................................................................................
Hal-hal yang perlu diperhatikan di rumah:........................................................................................

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

Keterangan lain:

ANALISA DATA
No.

Data

Etiologi

Masalah
keperawatan

ANALISA DATA
No.

Data

Etiologi

Masalah
keperawatan

ANALISA DATA
No.

Data

Etiologi

Masalah
keperawatan

DAFTAR DIAGNOSA KEPERAWATAN

(BERDASARKAN PRIORITAS)
Ruang

Nama Pasien:

Diagnosa

No.

Tanggal

Dx

Muncul

Diagnosa Keperawatan

RENCANA ASUHAN KEPERAWATAN

Diagnosa Keperawatan No. 1

Tanggal

Tanda

Teratasi

Tangan

Tujuan :

Kriteria Hasil :

NOC
No.

Indikator

Keterangan Penilaian :
1

Intervensi NIC :

RENCANA ASUHAN KEPERAWATAN

Diagnosa Keperawatan No. 2

Tujuan :

Kriteria Hasil :

NOC
No.

Indikator

Keterangan Penilaian :
1

Intervensi NIC :

RENCANA ASUHAN KEPERAWATAN

Diagnosa Keperawatan No. 3

Tujuan :

Kriteria Hasil :

NOC
No.

Indikator

Keterangan Penilaian :
1

Intervensi NIC :

RENCANA ASUHAN KEPERAWATAN

Diagnosa Keperawatan No. 4

Tujuan :

Kriteria Hasil :

NOC
No.

Indikator

Keterangan Penilaian :
1

Intervensi NIC :

RENCANA ASUHAN KEPERAWATAN

Diagnosa Keperawatan No. 5

Tujuan :

Kriteria Hasil :

NOC
No.

Indikator

Keterangan Penilaian :
1

Intervensi NIC :

IMPLEMENTASI
Nama Klien

Tanggal Pengkajian :

Diagnosa Medis
Tgl

No. Dx
Kep

:
Jam

Tindakan Keperawatan

Respon Klien

TTD &
Nama
Terang

IMPLEMENTASI
Nama Klien

Tanggal Pengkajian :

Diagnosa Medis
Tgl

No. Dx
Kep

:
Jam

Tindakan Keperawatan

Respon Klien

TTD &
Nama
Terang

IMPLEMENTASI
Nama Klien

Tanggal Pengkajian :

Diagnosa Medis
Tgl

No. Dx
Kep

:
Jam

Tindakan Keperawatan

Respon Klien

TTD &
Nama
Terang

EVALUASI
Hari/

No Dx

Tanggal

Kep

Evaluasi

Tanda
Tangan

/ Jam
S:

O:

A: Masalah sudah teratasi/belum teratasi

P: Intervensi dihentikan/ dilanjutkan dan
didelegasikan kepada perawat
dinas .........:
1. NIC :
2. NOC:

EVALUASI
Hari/

No Dx

Tanggal

Kep

Evaluasi

Tanda
Tangan

/ Jam
S:

O:

A: Masalah sudah teratasi/belum teratasi

P: Intervensi dihentikan/ dilanjutkan dan
didelegasikan kepada perawat
dinas .........:
1. NIC :
2. NOC:

EVALUASI
Hari/

No Dx

Tanggal

Kep

Evaluasi

Tanda
Tangan

/ Jam
S:

O:

A: Masalah sudah teratasi/belum teratasi

P: Intervensi dihentikan/ dilanjutkan dan
didelegasikan kepada perawat
dinas .........:
1. NIC :
2. NOC:

EVALUASI
Hari/

No Dx

Tanggal

Kep

Evaluasi

Tanda
Tangan

/ Jam
S:

O:

A: Masalah sudah teratasi/belum teratasi

P: Intervensi dihentikan/ dilanjutkan dan
didelegasikan kepada perawat
dinas .........:
1. NIC :
2. NOC:

EVALUASI
Hari/

No Dx

Tanggal

Kep

Evaluasi

Tanda
Tangan

/ Jam
S:

O:

A: Masalah sudah teratasi/belum teratasi

P: Intervensi dihentikan/ dilanjutkan dan
didelegasikan kepada perawat
dinas .........:
1. NIC :
2. NOC:

EVALUASI
Hari/

No Dx

Tanggal

Kep

Evaluasi

Tanda
Tangan

/ Jam
S:

O:

A: Masalah sudah teratasi/belum teratasi

P: Intervensi dihentikan/ dilanjutkan dan
didelegasikan kepada perawat
dinas .........:
1. NIC :
2. NOC: