FORMAT PENGKAJIAN KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN HANG TUAH SURABAYA

Nama Mhs

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

Jam

Tgl Pengkajian

:...................................................... No Rekam Medik :...........................................

Tgl MRS

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

Ruang

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

Nama

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

Pekerjaan

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

Umur

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

Suku Bangsa

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

Agama

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

Jenis Kelamin

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

Pendidikan

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

Status perkawinan

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

Alamat

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

Penanggung biaya

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

Diagnosa Medis

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

Riwayat Sakit dan kesehatan

Riwayat

penyakit

sekarang

Riwayat

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

penyakit

..

dahulu

........

Riwayat

....

penyakit

keluarga

..

Riwayat

Allergi
..
Keadaan umum :
Baik
Sedang
Lemah
Koma
Kesadaran :
Compos mentis
Delirium
Sopor
Somnolen
Vital Sign : Nadi :..........x/menit Suhu:.............C
RR :.........x/menit
Tensi:....../.........mmHg

B1 : Breath/Pernapasan
Irama pola napas :

Reguler

ireguler

Ket :.............................................................................................................................................................
Jenis : normal
kussmaul
cepat & dangkal
Suara napas : Vesikuler

Bronkovesikuler

Wheezing

Stridor

Ronkhi

Ket : .............................................................................................................................................................
Sesak napas : Tidak ada Ada
Jika ada : ada ketika aktivitas
ada ketika istritahat
Alat Bantu Napas : Tidak ada Ada

orthopnea

Jenis : ..........................................................................................................................................................
Lain lain :..................................................................................................................................................
......................................................................................................................................................................
Masalah Keperawatan :...............................................................................................................................

B2 (Blood}

.....................................................................................................................................................................
Irama Jantung : reguler

irreguler

Nyeri dada :

tidak ada

ada

Bunyi jantung :
CRT:

s1 s2 tunggal

< 2 detik

murmur

gallop

> 2 detik

Akral:
HKM
dingin
lembab
basah
Masalah :...........................................................................................................................................
...............

Persarafan B3 Brain

...........................................................................................................................................................
GCS : eye :................... verbal:...................
Reflek fisiologis : patella
Reflek Patologis:

kremaster

babinsky

motorik:..............................

trisep
brudzinsky

bisep

cahaya : .../...
kernig

Istirahat tidur : ............... jam/hari

Ggn tidur : Insomnia

Lain-lain

Pupil : Isokor

Anisokor

Sklera Konjugtiva :

anemis

Gangguan penglihatan : ya
Ggn pendengaran :
Ggn penciuman : ya
Masalah

ya

Ket :......................................
ikterus
tidak

tidak
tidak

Keperawatan:.............................................................................................................................
..................................................................................................................................................

B4 Bladder

Kebersihan : Bersih

kotor

Urin jumlah. Cc/hari

warna: ............... bau :....................

Alat bantu : kateter

pispot

tidak ada

Kandung kencing: membesar

Gangguan miksi : Anuria

nyeri tekan
disuria

Normal

hematuria

inkotinensia

retensi

nokturia
Masalah:...........................................................................................................................................

B5 Bowel

.........................................................................................................................................................
Nafsu makan: baik

menurun

Porsi makan : habis

tidak

Minum................... cc /hari.

frekuensi:............................
keterangan:.............................

Jenis :..................

Mulut & tenggorokan

Mulut : bersih

kotor

Mukosa : lembab

lembab

kering

stomatits

Abdomen
Perut: tegang

kembung

acites

nyeri tekan

Peristaltik :.. x/menut

Pmbesaran hepar :

ya

Pembesaran lien: ya
Buang air besar ../menit.

tidak
tidak
Teratur:

ya

tidak

Konsistensi:............... Warna:...................... Bau:.........................

Hematesesis : ada
tidak
Melena: ada
tidak
Masalah:............................................................................................................................................

Muskuloskletal

...........................................................................................................................................................
Kemampuan pergerakan sendi : bebas

Turgor: Baik

sedang

terbatas

Udema: ada

Kekuatan otot

Warna kulit : ikterus sianotik kemerahan pucat

tidak ada

jelek
lokasi:...........

hiperpigmentasi bersisik normal

Masalah :.......................................................................................................................................
................................

& Integumen

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

Endokrin

Pembesaran Tyroid : ya

tidak

Hiperglikemia :

ya

tidak

Hipoglikemia :

ya

tidak

Luka Ganggren:

ada

tidak

lokasi :....................................

Lain lain
Masalah:.........................................................................................................................................

Personal Hygiene

........................................................................................................................................................
Mandi

:......... x/

Keramas

: ....... x /

Ganti pakaian

:........

Sikat gigi

: ...........x/

x/

Memotong kuku
:............x/hari
Masalah :...........................................................................................................................................
...............

Psikosoiocultural

...........................................................................................................................................................
Konsep diri :
.......................................................................................................................................................
Ideal diri:...........................................................................................................................................
Gambaran diri:...........................................................................................................................
Peran diri:..........................................................................................................................................
Harga diri:..........................................................................................................................................
Identitas diri:.........................................................................................................................
Orang paling dekat : :.............................................................................................................
Kegiatan ibadah: :....................................................................................................................
Hubungan dgn lingkungan sekitar:.........................................................................................
Masalah :...........................................................................................................................................
........
......................................................................................................................................

Data Penunjang / Hasil pemeriksaan diagnostik

Darah Lengkap :

Kimia Klinik :

Foto Rontgen :

Lain lain :

Terapi Medis

Surabaya,

(Nama perawat dan tanda tangan)

ANALISA DATA

Data

Masalah

Etiologi

DS :

DO :

DS :

DO :

DS :

DO :

Prioritas Masalah Keperawatan

NO

MASALAH KEPERAWATAN

TANGGAL
ditemukan

teratasi

PARAF
(nama)

Rencana Asuhan Keperawatan

No

Masalah

Tujuan

Kriteria Hasil

Intervensi

Rasional

IMPLEMENTASI & EVALUASI

No

Hari/Tgl

Masalah Keperawatan

Implementasi

Evaluasi
S
O
A
P