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FORMAT PENGKAJIAN ASUHAN KEPERAWATAN MODEL DOENGES

FORMAT PENGKAJIAN ASUHAN KEPERAWATAN


MODEL DOENGES
INFORMASI UMUM
A. Identitas Klien.
Nama:................................................................
Usia:..................................................................
Jenis kelamin:....................................................
Agama

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

Suku bangsa:.....................................................
Pendidikan:.......................................................
Pekerjaan:..........................................................
Alamat

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

Tanggal masuk :................................................ Waktu :................................................


No. Rekam Medik:...........................................
B. Identitas Penanggung Jawab.
C. Alasan Masuk Rumah Sakit :
D.

AKTIVITAS/ISTIRAHAT
Gejala (subjektif)
Pekerjaan :......................................................... Aktivitas/hobby :.................................
Aktivitas waktu luang:....................................................................................................
Perasaan bosan/tidak puas :............................................................................................
Keterbatasan karena kondisi :.........................................................................................
Tidur: Jam:........................................................ Tidur Siang:.........................................
Alat bantu:......................................................................................................................
Insomnia:................................................. yang berhubungan dengan:..................
................................................................. Rasa segar saat bangun:.......................
Lain-lain :...............................................................................................................
Tanda (objektif)
Respon

terhadap

Kardiovaskuler :...........................................

aktivitas
Pernafasan :

yang

teramati:

Status mental (y.i, menarik diri/letargi):..........................................................................


Pengkajian neuromuskuler:.............................................................................................
Massa/tonus otot :..................................................................................................
Postur:....................................................................................................................
Tremor:...................................................................................................................
Rentang gerak:.......................................................................................................
Kekuatan :..............................................................................................................
Deformitas :...........................................................................................................

SIRKULASI
Gejala (subjektif)
Riwayat tentang : Hipertensi :........................................................................................
Masalah Jantung :...........................................................................................................
Demam Rematik :..................................................................................................
Edema mata kaki/kaki :..........................................................................................
Flebitis :.................................................................................................................
Penyembuhan lambat :...........................................................................................
Klaudikasi :............................................................................................................
Ekstremitas : Kesemutan :....................... Kebas :.................................................
Batuk/hemoptisis :.................................................................................................
Perubahan frekwensi/jumlah urine :.......................................................................
Tanda (objektif)
TD : kanan dan kiri : baring/duduk/berdiri :...................................................................
Tekanan nadi :........................................................................................................
Gap auskultatori :...................................................................................................
Nadi (palpasi) : Karotis :.................................................................................................
Temporaslis :............................................ Jugularis :.............................................
Radialis :.................................................. Femoralis :............................................
Popliteal :................................................. Postibial :.............................................
Dorsalis Pedis :......................................................................................................
Jantung (palpasi) :
Getaran :.................................................. Dorongan :...........................................
Bunyi Jantung : Frekuensi :.............................. Irama :..................................................
Kualitas :.................................................. Friksi Gesek :.......................................
Murmur :................................................................................................................
Bunyi Nafas : Desiran Vascular :....................................................................................

Destensi vena Jugularis :........................................................................................


Ekstremitas : suhu :.......................................... Warna :.................................................
Pengisian kapiler :.................................... Tanda Homans :..................................
Varises :................................................... Abnormalitas kuku :.............................
Penyebaran/kualitas rambut :.................................................................................
Warna :.............................................................. Membran mukosa :...............................
Bibir :....................................................... Punggung kuku :..................................
Konjungtiva :........................................... Sklera :.................................................
Diaforesis :.............................................................................................................
INTEGRITAS EGO
Gejala (subjektif)
Faktor stress :..................................................................................................................
Cara menangani stress :...................................................................................................
Masalah-masalah finansial :............................................................................................
Status hubungan :...........................................................................................................
Faktor-faktor budaya :....................................................................................................
Agama :............................................................. Kegiatan keagamaan :..........................
Gaya hidup :..................................................... Perubahan terakhir :.............................
Perasaan-perasaan : Ketidakberdayaan :.........................................................................
Keputusasaan :.......................................................................................................
Ketidakberdayaan :................................................................................................
Tanda (objektif)
Status emosional (beri tanda cek untuk yang sesuai) :
Tenang :................................................... Cemas :................................................
Marah :..................................................... Menarik diri :.......................................
Takut :...................................................... Mudah tersinggung :............................
Tidak sabar :............................................. Euforik :...............................................
Respon-respon fisiologis yang terobsesi :.......................................................................
ELIMINASI
Gejala (subjektif)
Pola BAB:......................................................... Penggunaan laxatif :............................
Karakter feses :................................................. BAB terakhir :.....................................
Riwayat perdarahan :........................................ Haemorrhoid :......................................
Konstipasi :....................................................... Diare :..................................................
Pola BAK :....................................................... Inkontinensia/kapan :...........................

Dorongan :............................................... Frekuensi :............................................


Retensi :.................................................................................................................
Karakter urine :...............................................................................................................
Nyeri/rasa terbakar/kesulitan BAK :...............................................................................
Riwayat penyakit ginjal/kandung kemih :......................................................................
Penggunaan Diuretik :....................................................................................................
Tanda (objektif)
Abdomen : Nyeri tekan :.................................. lunak/keras :.........................................
Massa :..................................................... Ukuran/lingkar abdomen :...................
Bising usus :...........................................................................................................
Haemorrhoid :.................................................................................................................
Perabaan kandung kemih :..............................................................................................
BAK terlalu sering :........................................................................................................
MAKANAN/CAIRAN
Gejala (subjektif)
Diit biasa (tipe) :............................................................................................................
Jumlah makanan per hari :..............................................................................................
Makan terakhir/masukan : ................................ Pola diit :.............................................
Kehilangan selera makan :..............................................................................................
Mual/muntah :.................................................................................................................
Nyeri ulu hati/salah cerna :..............................................................................................
Yang berhubungan dengan : ................... Disembuhkan oleh :............................
Alergi/intoleransi makanan :..........................................................................................
Masalah-masalah mengunyah/menelan :........................................................................
Gigi :.....................................................................................................................
Berat badan biasa : ........................................... Perubahan berat badan :......................
Penggunaan Diuretik :....................................................................................................
Tanda (objektif)
Berat badan sekarang : ..................................... Tinggi badan :.....................................
Bentuk tubuh : ................................................. turgor kulit :........................................
Kelembaban/kering membran mukosa :.........................................................................
Edema : Umum : .............................................. Dependen :..........................................
Periorbital : .............................................. Asites :................................................
Distensi vena jugularis :.................................................................................................
Pembesaran tiroid : .......................................... Hernia/massa :.....................................
Halitosis :.......................................................................................................................

Kondisi : gigi/gusi :.........................................................................................................


Penampilan lidah :..........................................................................................................
Membran mukosa :................................................................................................
Bising usus :...................................................................................................................
Bunyi nafas :..................................................................................................................
Urine S/A atau kemstiks :..............................................................................................
HIGIENE
Gejala (subjektif)
Aktivitas sehari-hari : tergantung/mandiri :....................................................................
Mobilitas : ............................................... Makan :...............................................
Higiene :................................................... Berpakaian :........................................
Toileting :..............................................................................................................
Waktu mandi yang diinginkan :............................................................................
Pemakaian alat bantu/prostetik :...........................................................................
Bantuan diberikan oleh :........................................................................................
Tanda (objektif)
Penampilan umum :.........................................................................................................
Cara berpakaian :.............................................. Kebiasaan pribadi :..............................
Bau badan : ...................................................... Kondisi kulit kepala :...........................
Adanya kutu :................................................................................................................
NEUROSENSORI
Gejala (subjektif)
Rasa ingin pingsan/pusing :............................................................................................
Sakit kepala : lokasi nyeri : .............................. Frekuensi :............................................
Kesemutan/kebas/kelemahan (lokasi) :...........................................................................
Stroke (gejala sisa) :.......................................................................................................
Kejang : ............................................................ Tipe :...................................................
Aura : ...................................................... Frekuensi :...........................................
Status postikal : ....................................... Cara mengontrol :...............................
Mata : Kehilangan penglihatan :....................................................................................
Pemeriksaan terakhir :...........................................................................................
Glaukoma : .............................................. Katarak :.............................................
Telinga : Kehilangan pendengaran :...............................................................................
Pemeriksaan terakhir :............................................................................................
Epistaksis : ....................................................... Indera penghidu :................................

Tanda (objektif)
Status mental :...............................................................................................................
Terorientasi/disorientasi : Waktu :.........................................................................
Tempat : ......................................................................
Orang : .......... ............................................................
Kesadaran : ............................................. Mengantuk :........................................
Letargi : ................................................... Stupor :...............................................
Koma : .................................................... Kooperatif :.........................................
Menyerang : ............................................ Delusi :.................................................
Halusinasi : .............................................. Afek (gambarkan) :.............................
...............................................................................................................................
Memori : Saat ini : ............................................ Yang lalu :...........................................
Kaca mata : ...................................................... Kontan lensa :.....................................
Alat bantu dengar :........................................................................................................
Ukuran/reaksi pupil : kanan/kiri :...................................................................................
Facial droop : ................................................... Menelan :............................................
Genggaman tangan/lepas : kanan/kiri :..........................................................................
Postur : ............................................................. Reflek tendon dalam :........................
Paralisis :........................................................................................................................
NYERI/KETIDAKNYAMANAN
Gejala (subjektif)
Lokasi : ............................................................ Intensitas (1-10 di mana 10 sangat
nyeri ) Frekwensi :
Kualitas : .......................................................... Durasi :................................................
Penjalaran : ....................................................... faktor-faktor pencetus :......................
Cara menghilangkan, faktor-faktor yang
berhubungan :...............................................
Tanda (objektif)
Mengkerutkan muka :....................................... Menjaga area yang sakit :....................
Respon emosional : .......................................... Penyempitan fokus :...........................
PERNAFASAN
Gejala (subjektif)
Dispnea, yang berhubungan dengan batuk/sputum:......................................................
Riwayat bronkhitis : ......................................... Asthma :..............................................
Tuberkulosa :............................................ Emfisema :..........................................

Pneumonia kambuhan : ........................... Pemajanan terhadap udara berbahaya :


Perokok : .......................................................... Pak/hari :.............................................
Lama dalam tahun :..............................................................................................
Penggunaan alat bantu pernafasan :...............................................................................
Oksigen :...............................................................................................................
Gejala (objektif)
Pernafasan : Frekuensi : ................................... Kedalaman :.........................................
Simetris :...............................................................................................................
Penggunaan otot-otot asesoris : ....................... Nafas cuping hidung :.........................
Fremitus :.......................................................................................................................
Bunyi nafas :..................................................................................................................
Egofoni :........................................................................................................................
Sianosis : .......................................................... Jari tubuh :..........................................
Karakteristik sputum :....................................................................................................
Fungsi mental/gelisah :...................................................................................................
KEAMANAN
Gejala (subjektif)
Alergi/sensivitas : ............................................. Reaksi :...............................................
Perubahan sistem imun sebelumnya :.............................................................................
Penyebab :.............................................................................................................
Riwayat penyakit hubungan seksual (tanggal/tipe) :.....................................................
Perilaku resiko tinggi :...................................................................................................
Periksaan :.............................................................................................................
Transfusi darah/jumlah : ................................... Kapan :................................................
Gambaran reaksi :.................................................................................................
Riwayat cedera kecelakaan :..........................................................................................
Fraktur/dislokasi :..........................................................................................................
Artritis/sendi tak stabil :.................................................................................................
Masalah punggung :.......................................................................................................
Perubahan pada tahi lalat : ............................... Pembesaran nodus :............................
Kerusakan penglihatan, pendengaran :..........................................................................
Protese : ........................................................... Alat ambulatori :.................................
Tanda (objektif)
Suhu tubuh : ..................................................... Diaforesis :..........................................
Integritas kulit :..............................................................................................................
Jaringan parut .......................................... Kemerahan :........................................

Laserasi : ................................................. Ulserasi :.............................................


Ekimosis : ................................................ Lepuh :................................................
Luka bakar (derajat/persen) : .................. Drainase :............................................
Tandai lokasi pada diagram dibawah ini :

Muka

Belakang

Kekuatan umum : ............................................. Tonus otot :.........................................


Cara berjalan : .................................................. ROM :.................................................
Parestesia/paralisis :........................................................................................................
Hasil kultur, pemeriksaan sistem imun :.........................................................................
SEKSUALITAS : (Komponen dari Interaksi Sosial)
Aktif melakukan hubungan seksual :.............................................................................
Penggunaan kondom :..........................................................................................
Masalah-masalah/kesulitan seksual :.....................................................................
Perubahan terakhir dalam frekuensi/minat :..........................................................
Wanita
Gejala (subjektif)
Usia menarke : ................................................. Lamanya siklus :.................................
Durasi :..................................................................................................................
Periode menstruasi terakhir : ............................ Menopause :........................................
Rabas vaginal : ................................................. Perdarahan antar periode :..................

Melakukan pemeriksaan payudara sendiri/mammogram :.............................................


PAP smear terakhir :......................................................................................................
Tanda (objektif)
Pemeriksaan payudara :.................................................................................................
Kutil genital/lesi :...........................................................................................................
Pria
Gejala (subjektif)
Rabas penis : .................................................... Gangguan prostat :..............................
Sirkumsisi : ....................................................... Vasektomi :.........................................
Melakukan pemeriksaan sendiri : ..................... Payudara/Testis :.................................
Protoskopi/pemeriksaan prostat terakhir :......................................................................
Tanda (objektif)
Pemeriksaan : ................................................... Payudara/penis/testis :.........................
Kutil genital/lesi :...........................................................................................................
INTERAKSI SOSIAL
Gejala (subjektif)
Status perkawinan : .......................................... Lama :.................................................
Hidup dengan : ....................................... masalah-masalah/stress :......................
Keluarga besar :.............................................................................................................
Orang pendukung lain :.................................................................................................
Peran dalam struktur keluarga :.....................................................................................
Masalah-masalah yang berhubungan dengan penyakit/kondisi :...................................
Perubahan bicara : Penggunaan alat bantu komunikasi :...............................................
Adanya Laringektomi :.........................................................................................
Tanda (objektif)
Bicara : Jelas : .................................................. Tidak jelas :.........................................
Tidak dapat dimengerti : ......................... Afasia :................................................
Pola bicara tidak biasa/kerusakan :.......................................................................
Penggunaan alat bantu bicara :.............................................................................
Komunikasi verbal/non verbal dengan keluarga/orang dekat lain :...............................
Pola interaksi keluarga (perilaku) :.................................................................................
PENYULUHAN/PEMBELAJARAN
Gejala (subjektif)
Bahasa dominan (khusus) : .............................. Melek huruf :......................................
Tingkat pendidikan :......................................................................................................

Ketidakmampuan belajar (khusus) :...............................................................................


Keterbatasan kognitif :..................................................................................................
Keyakinan kesehatan/yang dilakukan :..........................................................................
Orientasi spesifik terhadap perawatan kesehatan (seperti dampak dari agama/kultural
yang dianut) :
Faktor resiko keluarga (tandai hubungan) :...................................................................
Diabetes : ................................................ Tuberkulosis :......................................
Penyakit jantung : ................................... Stroke :................................................
TD Tinggi : .............................................. Epilepsi :.............................................
Penyakit ginjal : ...................................... Kanker :..............................................
Penyakit jiwa : ........................................ Lain-lain :.............................................
Obat yang diresepkan (lingkari dosis terakhir) :............................................................
Obat

Dosis

Waktu

Diminum secara teratur

Tujuan

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Obat-obat tanpa resep : obat-obat bebas : .....................................................................


Obat-obat jalanan :................................................................................................
Tembakau :............................................................................................................
Perokok tembakau :..............................................................................................
Penggunaan alkohol (jumlah/frekuiensi) :......................................................................
Diagnosa saat masuk per dokter :..................................................................................
Alasan dirawat per pasien :............................................................................................
Riwayat keluhan terakhir :.............................................................................................
Harapan pasien terhadap perawatan ini :.......................................................................
Penyakit dan/atau perawatan/pembedahan sebelumnya :..............................................
Bukti kegagalan untuk perbaikan :................................................................................
Pemeriksaan fisik lengkap terakhir :..............................................................................
Pertimbanagan Rencana Pulang
DRG yang menunjukan lama dirawat rata-rata :...........................................................
Tanggal informasi didapatkan :.....................................................................................
1. Tanggal pulang yang diantisipasi :.....................................................................
2. Sumber-sumber yang tersedia : orang :...............................................................
Keuangan :.........................................................................................................
3. Perubahan-perubahan yang diantisipasi dalam situasi kehidupan setelah
pulang :

4. Area yang mungkin membutuhkan perubahan/bantuan :...................................


Penyiapan makanan :........................................ Berbelanja :.........................................
Transportasi : .................................................... Ambulasi :...........................................
Obat/terapi IV : ................................................ Pengobatan :.......................................
Perawatan luka : ............................................... Peralatan :...........................................
Bantuan perawatan diri (khusus) :.................................................................................
Gambaran fisik rumah (khusus) :...................................................................................
Bantuan merapihkan/pemeliharaan rumah :...................................................................
Fasilitas kehidupan selain rumah (khusus) :..........................................................