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JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN


Nama Mahasiswa

Tempat Praktik

: R. Kenanga RST Supraun

NIM

Tgl. Praktik

: 20 Maret 2014

A. Identitas Klien
Nama

: Nn. Anggi.......................... No. RM

: 207320............................

Usia

: 21........ tahun

: 19 Maret 2014 pk. 13.30

Jenis kelamin

: Perempuan....................... Tgl. Pengkajian

Alamat

: Jln. Brigjen S. Riadi VII/30 Sumber informasi : klien dan keluarga (ibu)...

No. telepon

: - ....................................... Nama klg. dekat yg bisa dihubungi:Ny. YUliati

Status pernikahan

: Belum menikah.................

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

Agama

: Islam................................. Status

: Orang tua (Ibu)................

Suku

: Jawa................................. Alamat

: Jln. Brigjen S.Riadi VII/30

Pendidikan

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

: - ......................................

Pekerjaan

: Swasta (pabrik unggul)..... Pendidikan

: - ......................................

Lama berkerja

: - ....................................... Pekerjaan

: - ......................................

Tgl. Masuk

: 20 Maret 2014.................

B. Status kesehatan Saat Ini


1. Keluhan utama

: pusing dan mual, panas, nyeri otot kalau digunakan untuk berjalan........

2. Lama keluhan

: keluhan dirasakan mulai jumat (14 Maret 2014).......................................

3. Kualitas keluhan

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

4. Faktor pencetus

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

5. Faktor pemberat

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

6. Upaya yg. telah dilakukan


7. Diagnosa medis

: berobat ke bidan lalu ke Puskesmas.........................................

a.

.................................................................................... Tanggal 19 Maret 2014...............

b.

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

c.

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

C. Riwayat Kesehatan Saat Ini


Pusing sedikit dan agak mual........................................................................................................
Muntah (-)......................................................................................................................................
Batuk (-).........................................................................................................................................
Pilek / hidung tersumbat (-)............................................................................................................
Demam (-).....................................................................................................................................
Mimisan (-).....................................................................................................................................
Telapak tangan gatal dan kaki gatal (+).........................................................................................
Nafsu makan (+) meningkat

BAB (+) 1x encer lendir (-), darah (-)


BAK normal...................................................................................................................................
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
( ) Polio
( ) DPT
4. Kebiasaan:
Jenis
Merokok

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

Kopi

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

Alkohol

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

5. Obat-obatan yg digunakan:
Jenis
Lamanya
Dosis
.................................................... .............................................. .................................................
.................................................... .............................................. .................................................
E. Riwayat Keluarga
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
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.................................................. ....................................................

Berpakaian/berdandan

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

Toileting

0.................................................. 2..................................................

Mobilitas di tempat tidur

0.................................................. 2

Berpindah

0.................................................. 2..................................................

Berjalan

0.................................................. 2..................................................

Naik tangga

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

Frekuensi/pola

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

Porsi yg dihabiskan

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

Komposisi menu

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

Pantangan

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

Napsu makan

baik....................................... .................................................

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
BAB:

Rumah

Rumah Sakit

- Frekuensi/pola

2x................................................ 1x..............................................

- Konsistensi

.................................................... lembek......................................

- Warna & bau

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

- Kesulitan

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

- Upaya mengatasi

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

BAK:
- Frekuensi/pola

.................................................... 2x..............................................

- Konsistensi

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

- Warna & bau

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

- Kesulitan

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

- Upaya mengatasi

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

J. Pola Tidur-Istirahat
Tidur siang:Lamanya

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

- Jam s/d

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

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

- Kenyamanan stlh. tidur

lebih nyaman........................

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

Tidur malam: Lamanya

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

- Jam s/d

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

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

- Kenyamanan stlh. tidur

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

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

- Kebiasaan sblm. tidur

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

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

- Kesulitan

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

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

- Upaya mengatasi

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

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

K. Pola Kebersihan Diri


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

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

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

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

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

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

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

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

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. 250.000 500.000
( ) Rp. 500.000 1 juta

( ) Rp. 1 juta 1.5 juta


( ) Rp. 1.5 juta 2 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 : klien terlihat lemas di tempat tidurnya ditemani dengan ibunya. Terpasang infus
RL. Wajah klien terlihat lusuh, kemungkinan klien belum mandi. Saat diajak berkomunikasi respon
klien sangat bagus. Kontak mata (+) namun nada bicaranya pelan...................................................
......................................................................................................................................................
Kesadaran:GCS 456 (compos mentis)..........................................................................................

Tanda-tanda vital: - Tekanan darah : 110/80 mmHg


- Nadi

: 85..... x/meni

Tinggi badan: 158..............................cm

- Suhu : 36,6oC
- RR

: 20 x/menit

Berat Badan: 55...................kg

2. Kepala & Leher


a. Kepala:
Secara umum pada kepala tidak ada lesi, kemerahan atau tanda-tanda peradangan
yang lain........................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
b. Mata:
Isokor.............................................................................................................................
Kojungtiva anemis (-).....................................................................................................
......................................................................................................................................
......................................................................................................................................
c. Hidung:
Sumbatan (-)..................................................................................................................
tidak ada lesi (-).............................................................................................................

tanda-tanda peradangan (-)...........................................................................................


perdarahan (-)................................................................................................................
d. Mulut & tenggorokan:
Sumbatan (-)..................................................................................................................
lesi (-).............................................................................................................................
tanda-tanda peradangan (-)...........................................................................................
......................................................................................................................................
e. Telinga:
Lesi (-)...........................................................................................................................
tanda-tanda peradangan (-)...........................................................................................
sumbatan (-)..................................................................................................................
perdarahan (-)................................................................................................................
f. Leher:
Lesi (-)...........................................................................................................................
benjolan (-)....................................................................................................................
......................................................................................................................................
......................................................................................................................................
3. Thorak & Dada:
Jantung
- Inspeksi:ictus cordis terlihat....................................................................................................
................................................................................................................................................
- Palpasi:...................................................................................................................................
................................................................................................................................................
- Perkusi:...................................................................................................................................
................................................................................................................................................
- Auskultasi : BJ 1 tunggal S1 dan S2 tunggal reguler..............................................................
................................................................................................................................................
Paru
- Inspeksi :dada simetris, lesi (-)................................................................................................
................................................................................................................................................
- Palpasi :..................................................................................................................................
................................................................................................................................................
- Perkusi :resonan.....................................................................................................................
................................................................................................................................................
- Auskultasi:ronki (-), wheezing (-)...............................................................................................
..................................................................................................................................................
..................................................................................................................................................
4. Payudara & Ketiak
Dalam batas normal...................................................................................................................
5. Punggung & Tulang Belakang

Dalam batas normal...................................................................................................................


6. Abdomen
Inspeksi :perut rata, tidak ada lesi, warna kulit rata........................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
Palpasi:nyeri tekan (+) di area epigastrik.......................................................................................
....................................................................................................................................................
Perkusi : splenomegali soft............................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Auskultasi :BU (+) normal..............................................................................................................
......................................................................................................................................................
7. Genetalia & Anus
Inspeksi : dalam batas normal, tidak ada keluhan saat BAK/BAB..................................................
.............................................................................................................................................
.............................................................................................................................................
Palpasi: dalam batas normal.......................................................................................................
8. Ekstermitas
Atas:akral hangat.........................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
Bawah:akral hangat.....................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
9. Sistem Neorologi
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
10. Kulit & Kuku
Kulit:

Warna kulit rata diseluruh tubuh......................................................................................................


Kuku:
CRT < 2 detik

S. Hasil Pemeriksaan Penunjang

TERLAMPIR
T. Terapi
Infus RL 30 tts/mnt................................................................................................................................
Vip Albumin 3x2....................................................................................................................................
Asam Mefenamat 3x1...........................................................................................................................
Trolit 3x1 sachet...................................................................................................................................
Imunos 3x1 ..........................................................................................................................................
Lab : Hb, hematocrit, trombosit
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:.................................................................................................................................