PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBER

FORMAT PENGKAJIAN KEPERAWATAN MEDIKAL (REUMATIK)

Nama Mahasiswa :
NIM :
Tempat Pengkajian :
Tanggal :

I. Identitas Klien
Nama : No. RM :
Umur : Pekerjaan :
Jenis : Status :
Kelamin Perkawinan
Agama : Tanggal MRS :
Pendidikan : Tanggal :
Pengkajian
Alamat : Sumber :
Informasi

II. Riwayat Kesehatan

1. Diagnosa Medik:
...............
....................

2. Keluhan Utama: ..
.....
.

3. Riwayat penyakit sekarang:

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

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

4. Riwayat kesehatan terdahulu:

a. Penyakit yang pernah dialami:
...............
....................



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



...............
....................
c.Imunisasi:
...............
....................

d.Kebiasaan/pola hidup/life style:

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


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


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

e. Obat-obat yang digunakan:

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


...................................
...............
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 ...............
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5. Riwayat penyakit keluarga:

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




...........
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Genogram:

III. Pengkajian Keperawatan

1. Persepsi kesehatan & pemeliharaan kesehatan

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 Interpretasi :



.

2. Pola nutrisi/ metabolik (ABCD)

- Antropometeri


Interpretasi :

- Biomedical sign :







Interpretasi :

- Clinical Sign :






Interpretasi :

-
Diet Pattern (intake makanan dan cairan):

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Interpretasi :

3. Pola eliminasi:
BAK
- Frekuensi :
.
.
- Jumlah :
.
.
- Warna :
.
.
- Bau :
.
.
- Karakter :
.
.
- BJ :
.
.
- Alat Bantu :
.
.
- Kemandirian : mandiri/dibantu
- Lain :
.
.

BAB
- Frekuensi :
.
.
- Jumlah :
.
.
- Konsistensi :
.
.

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 - Warna :
.
.
- Bau :
.
.
- Karakter :
.
.
- BJ :
.
.
- Alat Bantu :
.
.
- Kemandirian : mandiri/dibantu
- Lain :
.
.

Interpretasi :
Balance cairan:

4. Pola aktivitas & latihan

c.1. Aktivitas harian (Activity Daily Living)
Kemampuan perawatan diri 0 1 2 3 4
Makan / minum
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi / ROM
Ket: 0: tergantung total, 1: dibantu petugas dan alat, 2: dibantu
petugas, 3: dibantu alat, 4: mandiri
Status Oksigenasi :

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Fungsi kardiovaskuler :



Terapi oksigen :



Interpretasi :



.

5. Pola tidur & istirahat

Durasi :


Gangguan tidur :

.
Keadaan bangun tidur :
..
Lain-lain :


Interpretasi :



.

6. Pola kognitif & perceptual

Fungsi Kognitif dan Memori :



Fungsi dan keadaan indera :

........................
.......................................................................................................
......................................
Interpretasi :

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.

7. Pola persepsi diri
Gambaran diri :



Identitas diri :



Harga diri :



Ideal Diri :



Peran Diri :



Interpretasi :



.

8. Pola seksualitas & reproduksi
Pola seksualitas




Fungsi reproduksi
...........................................................
.......................................................................................................
.......................................................................................................
........................................................................
Interpretasi :



.

9. Pola peran & hubungan

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..................
.......................................................................................................
.......................................................................................................
.......................................................................................................
..........
Interpretasi :



.

10.Pola manajemen koping-stress






Interpretasi :



.

11.System nilai & keyakinan






Interpretasi :



.

IV. Pemeriksaan Fisik

Keadaan umum:
..
..........................................




Tanda vital:

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 - Tekanan Darah : mm/Hg
- Nadi : X/mnt
- RR : X/mnt
- Suhu : C

Interpretasi :

Pengkajian Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi)

1. Kepala







2. Mata







3. Telinga
.
..
.......................................

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4. Hidung







5. Mulut





6. Leher





7. Dada
.

....

...



8. Abdomen






9. Urogenital





10.Ekstremitas

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11.Kulit dan kuku






12.Keadaan lokal

Pemeriksaan
1. Tangan

Teknik untuk memeriksa sendi kecil dari tangan dan kaki. Ibu jari dan jari telunjuk
tangan pemeriksa digunakan dengan lembut untuk mengembalikan cairan
intaartikular dan untuk mengetahui nyeri tekan pada garis sendi.

2. Pergelangan tangan

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 Dorsum pergelangan tangan dipalpasi menggunakan jempol pemeriksa untuk
mengetahui nyeri tekan dan pembengkakan. Pergelangan tangan harus diperiksa
dalam posisi sedikit fleksi untuk menunjukkan secara optimal garis sendi yang
dipalpasi dari radiocarpal, metakarpal, dan sendi carpometacarpal.

3. Bahu

Gerak sendi glenohumeral diperiksa dengan siku tertekuk sampai 90 o dan lengan
atas di abduksi parsial. Posisi rotasi internal dan eksternal bahu kemudian
diperiksa. Perawatan harus diambil untuk memobilisasi tulang skapula
menggunakan teknik tersebut.

4. Lutut

Garis sendi lutut yang di palpasi pada aspek medial dan lateral untuk mengetahui
nyeri tekan sugestif dari sinovitis. Stabilitas ligamen cruciatum juga dapat dinilai

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 dalam posisi ini menggunakan tanda tonjolan atau pattella tanda tekan, efusi
dapat dideteksi di lutut dengan sendi sepenuhnya diperluas.

5. Pergelangan kaki

Palpasi untuk nyeri tekan dan pembengkakan di pergelangan kaki, dilakukan di

medial dan lateral tendon ekstensor pada bagian anterior sendi bawag malleoli.

V. Terapi (jenis terapi, dosis, rute, indikasi, KI, implikasi

keperawatan)
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 Beberapa terapi yang dapat diberikan:
1. Disease modifying anti-rheumatic drugs (DRMARDs) seperti
azathioprine, ciclosporin A, D-peniciallamine, gold salts,
hydroxychloroquine, leflunomide, merhotrexate (MTX),
minocycline suldasalazine (SSZ): obat yang diberikan sedini
mungkin setelah timbulnya gejala
2. Paracetamol dengan atau tanpa codein, dan non steroidal anti
inflammatory drugs (NSAIDs): untuk penyakit kronis
3. NSAID seperti ibuprofen, naproxen, diclofenac.

VI. Pemeriksaan Penunjang & Laboratorium (bisa dikembangkan)

N Jenis Nilai normal Hasil
o pemeriksaan (rujukan) (hari/tanggal)
nilai Satua
n

Pemeriksaan Penunjang
1. Digital Radiography

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Panduan Profesi Ners Keperawatan Medikal PSIK UNEJ 2014
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 2. Computed Tomography

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 3. Magnetic Resonance Imaging

4. Scintigraphic Techniques

5. Arthrography

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 ,
...........................20...
Pengambil Data,

(-
__________________________)
NIM

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Lampiran 9
ANALISA DATA
N DATA PENUNJANG ETIOLOGI MASALAH
O

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Lampiran 10

DIAGNOSA KEPERAWATAN

Daftar Diagnosa Keperawatan (sesuai prioritas):

N Diagnosa Tanggal Tanggal Keterang
o perumusan pencapai an
an

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Lampiran 11

PERENCANAAN KEPERAWATAN
N DIAGNOSA TUJUAN DAN INTERVENSI RASIONAL
O KRITERIA
HASIL

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LAMPIRAN 12

CATATAN PERKEMBANGAN
DIAGNOSA:
WAKTU IMPLEMENTASI PARAF EVALUASI
JAM:

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Lampiran 13

FORMAT RESUME KASUS KELOLAAN HARIAN

S (Subjektif):
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O (Objektif):
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A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan

DO):
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P(Perencanaan):
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I (Implementasi):
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E (Evaluasi):
S (Subjektif)
: ...............................................................................................................
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A (analisa) :
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(Perencanaan: .........................................................................................
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 DAFTAR PUSTAKA

Department of Social Protection. 2009. Rheumatoid Arthritis. [serial

online] www.welfare.ie/en/downloads/protocol14.pdf. [6 Agustus 2016].

Klippel et al. 2008. Primer on the Rheumatic Diseases. [serial online]

http://www.springer.com. [6 Agustus 2016].

Singh et al. 2015. American College of Rheumatology Guideline for the

Treatment of Rheumatoid Arthritis. Special Article Arthritis Care &
Research American College of Rheumatology. [serial online]
www.rheumatology.org/Portals/0/Files/ACR 2015 RA Guideline.pdf
[6 Agustus 2016].

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