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JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN


Nama Mahasiswa

Tempat Praktik

NIM

Tgl. Praktik

A. Identitas Klien
Nama

:Tn. H................................. No. RM

:235151.............................

Usia

:60......... tahun

:26/03/2015.......................

Jenis kelamin

:Laki0laki............................ Tgl. Pengkajian

Alamat

:Blimbing............................ Sumber informasi :klien dan keluarga............

No. telepon

:.......................................... Nama klg. dekat yg bisa dihubungi:Ny W.......

Status pernikahan

:menikah.............................

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

Agama

:islam.................................. Status

:Istri...................................

Suku

:bugis.................................. Alamat

:Blimbing...........................

Pendidikan

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

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

Pekerjaan

:swasta............................... Pendidikan

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

Lama berkerja

:.......................................... Pekerjaan

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

Tgl. Masuk

:27/03/2015.......................

B. Status kesehatan Saat Ini


1. Keluhan utama

: klien mengatakan nyeri saat BAK,...........................................................

2. Lama keluhan

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

3. Kualitas keluhan

: ringan.......................................................................................................

4. Faktor pencetus

: BPH.........................................................................................................

5. Faktor pemberat

: nyeri semakin bertambah jika BAK..........................................................

6. Upaya yg. telah dilakukan


7. Diagnosa medis

: periksa ke poli ...........................................................................

a.

Hernia Ventralis........................................................... Tanggal 26/03/15.........................

b.

BPH............................................................................ Tanggal26/03/15..........................

c.

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

C. Riwayat Kesehatan Saat Ini


Pasien mengeluh nyeri sejak 1 minggu yang lalu, perut terasa berat dan makan sedikit serta perut
terasa penuh. Klien mengatakan BAB lama dan sedikit, dan terasa sakit saat BAK. BAK menetes
dan tidak terasa sakit jika minum obat...........................................................................................
......................................................................................................................................................
D. Riwayat Kesehatan Terdahulu
1. Penyakit yg pernah dialami:
a. Kecelakaan (jenis & waktu)

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

b. Operasi (jenis & waktu)

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

c. Penyakit:
Kronis

: HT terkontrol, sering pasang kateter.....................................................


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

Akut

: BPH......................................................................................................

d. Terakhir masuki RS

:Januari 2015

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


Tipe
Reaksi
Tindakan
.................................................... .............................................. .................................................
Tidak ada.................................... .............................................. .................................................
3. Imunisasi:
( ) BCG
( ) Polio
( ) DPT
4. Kebiasaan:
Jenis
Merokok

( ) Hepatitis
( ) Campak
( ) .................
Frekuensi
Jumlah
Lamanya
tidak aada.................. ........................................ ........................................

Kopi

tidak ada.................... ........................................ ........................................

Alkohol

tidak ada.................... ........................................ ........................................

5. Obat-obatan yg digunakan:
Jenis
Lamanya
Dosis
Pasien lupa nama obat............... .............................................. .................................................
.................................................... .............................................. .................................................
E. Riwayat Keluarga
Pasien mengatakan, seingat saya, tidak ada yang punya penyakit seperti saya sus, orang tua saya
menunggal juga bukan karena sakit, karena sudah tua.......................................................................
.............................................................................................................................................................
GENOGRAM

F. Riwayat Lingkungan
Jenis
Kebersihan

Rumah
Pekerjaan
....................................................... .......................................................

Bahaya kecelakaan

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

Polusi

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

Ventilasi

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

Pencahayaan

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

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

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

G. Pola Aktifitas-Latihan
Makan/minum

Rumah
Rumah Sakit
0.................................................. 0..................................................

Mandi

0.................................................. 0..................................................

Berpakaian/berdandan

0.................................................. 0..................................................

Toileting

0.................................................. 0..................................................

Mobilitas di tempat tidur

0.................................................. 0

Berpindah

0.................................................. 0..................................................

Berjalan

0.................................................. 0..................................................

Naik tangga

0.................................................. 0..................................................

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

H. Pola Nutrisi Metabolik


Jenis diit/makanan

Rumah
Rumah Sakit
padat..................................... padat........................................

Frekuensi/pola

3x sehari................................ 3x sehari..................................

Porsi yg dihabiskan

sedikit.................................... sedikit.......................................

Komposisi menu

nasi syur lauk........................ nasi sayur lauk.........................

Pantangan

tidak ada................................ tidak ada..................................

Napsu makan

normal................................... normal......................................

Fluktuasi BB 6 bln. terakhir

tidak ada................................ tidak ada..................................

Jenis minuman

air putih................................. air putih....................................

Frekuensi/pola minum

sering.................................... sering.......................................

Gelas yg dihabiskan

1,5 liter.................................. 1,5 liter.....................................

Sukar menelan (padat/cair)

tidak...................................... tidak.........................................

Pemakaian gigi palsu (area)

tidak...................................... tidak.........................................

Riw. masalah penyembuhan luka tidak ada................................ tidak ada..................................

I. Pola Eliminasi
BAB:

Rumah

Rumah Sakit

- Frekuensi/pola

2x sehari..................................... belum........................................

- Konsistensi

normal......................................... belum........................................

- Warna & bau

normal......................................... belum........................................

- Kesulitan

sakit saat BAB, konstipasi........... belum........................................

- Upaya mengatasi

pergi ke dokter............................ belum........................................

BAK:
- Frekuensi/pola

sering.......................................... 4x..............................................

- Konsistensi

normal......................................... normall......................................

- Warna & bau

normal......................................... normal.......................................

- Kesulitan

sakit saat dibuat BAK, menetes. . sakit saat BAK, menetes...........

- Upaya mengatasi

Ke dokter..................................... -................................................

J. Pola Tidur-Istirahat
Tidur siang:Lamanya

Rumah
Rumah Sakit
.............................................. ....................................................

- Jam s/d

tidak tidur siang....................

belum........................................

- Kenyamanan stlh. tidur

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

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

Tidur malam: Lamanya

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

- Jam s/d

7 jam sehari..........................

3 jam.........................................

- Kenyamanan stlh. tidur

nyaman.................................

tidak nyaman.............................

- Kebiasaan sblm. tidur

tidak ada...............................

tidak ada...................................

- Kesulitan

tidak ada...............................

sedikit cemas (hospitalisasi)......

- Upaya mengatasi

--...........................................

istri menenangkan klien.............

K. Pola Kebersihan Diri


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

Rumah
Rumah Sakit
2x sehari.................................. masih 1x...................................
ya............................................

ya............................................

tidak terkaji............................... belum.......................................


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

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

minimal 2x sehari..................... 1x.............................................


ya............................................

ya............................................

Ganti baju:Frekuensi

minimal 2x sehari..................... 1x.............................................

Memotong kuku: Frekuensi

tidak terkaji............................... belum.......................................

Kesulitan

tidak ada.................................. pasien tidak biasa mandi


................................................. Dengan air dingin

Upaya yg dilakukan

-................................................ tidak ada..................................

L. Pola Toleransi-Koping Stres


1. Pengambilan keputusan:

( ) sendiri

( v) dibantu orang lain, sebutkan,istri................................

2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri,
dll):perawatan diri...............................................................................................................................
3. Yang biasa dilakukan apabila stress/mengalami masalah:berdiskusi dengan istri..............................
4. Harapan setelah menjalani perawatan:sembuh, bisa bekerja lagi, dan BPH teratasi.........................

5. Perubahan yang dirasa setelah sakit: tidak bebas beraktifitas...........................................................


M. Konsep Diri
1. Gambaran diri:tidak terkaji..................................................................................................................
2. Ideal diri: tidak terkaji..........................................................................................................................
3. Harga diri: tidak terkaji........................................................................................................................
4. Peran: tidak terkaji..............................................................................................................................
5. Identitas diri tidak terkaji.....................................................................................................................
N. Pola Peran & Hubungan
1. Peran dalam keluarga : suami, dan seorang ayah yang mempunyai 6 orang anak............................
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,tidak ada...................................................
4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS:tidak ada...................
5. Upaya yg dilakukan untuk mengatasi:--..............................................................................................
O. Pola Komunikasi
1. Bicara:

( v ) Normal

( )Bahasa utama:Indonesia......................

( ) Tidak jelas

( ) Bahasa daerah:indonesia..................

( ) Bicara berputar-putar

( ) Rentang perhatian:............................

(v ) Mampu mengerti pembicaraan orang lain( ) Afek:..................................................


2. Tempat tinggal:

(v) Sendiri
( )Kos/asrama
( )Bersama orang lain, yaitu:.........................................................................

3. Kehidupan keluarga
a. Adat istiadat yg dianut:adat bugis-jawa.......................................................................................
b. Pantangan & agama yg dianut: hal-hal yang diharaamkan agama & Islam.................................
c. Penghasilan keluarga:tidak terkaji
( ) < 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: (v ) tidak ada

( ) ada

2. Upaya yang dilakukan pasangan:


(v ) perhatian

( ) sentuhan

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

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: baik.........................................................................................................................
......................................................................................................................................................
Kesadaran: komposmentis............................................................................................................

Tanda-tanda vital: - Tekanan darah :160/90 mmHg


- Nadi

:88... x/meni

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

- Suhu :36,3oC
- RR

:18 x/menit

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

2. Kepala & Leher


a. Kepala:
Persebaran rambut tidak merata, rambut warna putih hekitaman, terlihat lepek, ..........
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
b. Mata:
Mata simetris, tidak ada anemis....................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
c. Hidung:
Hidung simetris, brsih tidak ada sekret..........................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
d. Mulut & tenggorokan:
Mulut bersih,simetris......................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
e. Telinga:
Telingan bersih, simetris................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
f. Leher:
Leher bersih, simetris, ................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
3. Thorak & Dada:

Jantung
- Inspeksi: tidak terkaji...............................................................................................................
................................................................................................................................................
- Palpasi:tidak terkaji.................................................................................................................
................................................................................................................................................
- Perkusi:tidak terkaji.................................................................................................................
................................................................................................................................................
- Auskultasi: tidak terkaji...........................................................................................................
................................................................................................................................................
Paru
- Inspeksi: tidak terkaji...............................................................................................................
................................................................................................................................................
- Palpasi: tidak terkaji................................................................................................................
................................................................................................................................................
- Perkusi: tidak terkaji................................................................................................................
................................................................................................................................................
- Auskultasi: tidak terkaji..............................................................................................................
..................................................................................................................................................
..................................................................................................................................................
4. Payudara & Ketiak
tidak terkaji................................................................................................................................
5. Punggung & Tulang Belakang
tidak terkaji................................................................................................................................
6. Abdomen
Inspeksi: perut besar,.....................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
Palpasi: tidak terkaji.......................................................................................................................
....................................................................................................................................................
Perkusi: kembug............................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Auskultasi: BU (+)..........................................................................................................................
......................................................................................................................................................
7. Genetalia & Anus
Inspeksi: tidak terkaji.....................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Palpasi: tidak terkaji.....................................................................................................................

8. Ekstermitas
Atas:normal, tidak ada luka, tidak ada bengkak...........................................................................
...........................................................................................................................................
...........................................................................................................................................
Bawah: normal, tidak ada luka, tidak ada bengkak......................................................................
...........................................................................................................................................
...........................................................................................................................................
9. Sistem Neorologi
GCS : 4 5 6..................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
10. Kulit & Kuku
Kulit: sawo matang, keriput

Kuku: pendek, bersih...........................................................................................................................

S. Hasil Pemeriksaan Penunjang


Hasil pemeriksaan Radiologi

Hepar : membesar, sudut tajam, permukaan rata, intensitas echo tidak meningkat,
homogen, tampak nodul, kista, kalsifikasi, vena porta, billiar duct dan v, Hepatica tidak
melebar, tampak samar-samar

Gall Blader : tak membesar, dinding tak menebal, tak tampak batu/polip

Lien, panreas : tak tampak kelainan

Ren Dextra : tak membesaar, tepi reguler, intensitas echo tak meningkat, batas korteks
dg medula jelas, tak tampak nodul /kista/ batu, sinus renalis tidak melebar

Ren Sinistra : tak membesaar, tepi reguler, intensitas echo tak meningkat, batas
korteks dg medula jelas, tak tampak nodul /kista/ batu, sinus renalis tidak melebar

Buli : terisi cukup urine, tak tampak penebalan dinding, tak tampak massa, batu

Kelenjar Prostat : membesar uk 6,2cm x 4,9cm x 6 cm, IPP : 1,9cm


Kalsifikasi (-), tak tampak massa

Kesan : Hypertrophy prostat uk 6,2cm x 4,9cm x 6 cm, IPP : 1,9cm


Kalsifikasi (-), tak tampak massa
Fatty Liver grade 3

Hasil Pemeriksaan Lab :

Darah Lengkap
Hb : 14,1
Leukosit : 5.300

LED : 33
Trombosit : 217.000
PVC : 41,8

Faal hemostasis
Waktu perdarahan : 100
Waktu pembekuan : 400

Diabetes
Gula darah sesaat/ reduksi : 97/TK

Faal Ginjal
Ureum : 30
Kreatinin : 1,04

Faal hati
SGOT : 21
SGPT : 27

T. Terapi
Akan dilakukan operasi pada hari selasa 31 maret 2015......................................................................
.............................................................................................................................................................

U. Persepsi Klien Terhadap Penyakitnya


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V. Kesimpulan
.............................................................................................................................................................
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W. Perencanaan Pulang
Tujuan pulang:....................................................................................................................................
Transportasi pulang:...........................................................................................................................
Dukungan keluarga:...........................................................................................................................
Antisipasi bantuan biaya setelah pulang:...........................................................................................
Antisipasi masalah perawatan diri setalah pulang:.............................................................................
Pengobatan:.......................................................................................................................................

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Rawat jalan ke:...................................................................................................................................
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Hal-hal yang perlu diperhatikan di rumah:........................................................................................
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Keterangan lain:.................................................................................................................................