JURUSAN KEPERAWATAN P

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FAKULTAS KEDOKTERAN G
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UNIVERSITAS BRAWIJAYA
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PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Blok :Endokrin

NIM : Trigger :Diabetes melitus

A. Identitas Klien
Nama : Ny. W ........................... No. RM : ....................................
Usia : 65 ..... tahun Tgl. Masuk : ....................................
Jenis kelamin :Perempuan ................... Tgl. Pengkajian : ....................................
Alamat : ..................................... Sumber informasi .....................................:
Klien dan keluarga
No. telepon : ..................................... Nama klg. dekat yg bisa dihubungi: ..........
Status pernikahan : ..................................... ....................................
Agama : ..................................... Status : ....................................
Suku : ..................................... Alamat : ....................................
Pendidikan : ..................................... No. telepon : ....................................
Pekerjaan : ..................................... Pendidikan : ....................................
Lama berkerja : ..................................... Pekerjaan : ....................................

B. Status kesehatan Saat Ini

1. Keluhan utama : Luka di tumit kiri semakin membengkak dan keluar pusnya.
2. Lama keluhan : Satu bulan sebelum masuk rumah sakit.
3. Kualitas keluhan : Terasa panas seperti terbakar dan nyeri skala 6.
4. Faktor pencetus : Diabetes melitus
5. Faktor pemberat : Darah tinggi sejak 10 tahun yang lalu
6. Upaya yg. telah dilakukan :Diperiksakan ke dokter dan diberi obat oral. Oleh cucunya
luka tersebut di buka atau diiris dan keluar pusnya
7. Diagnosa medis :
a. Diabetes melitus .................................................. Tanggal .................................
b. ............................................................................ Tanggal .................................
c. ............................................................................ Tanggal .................................

C. Riwayat Kesehatan Saat Ini

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Ny. W usia 65 tahun datang ke rumah sakit dengan keluhan luka di tumit kaki kiri dan terasa
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panas seperti terbakar dengan nyeri skala 6. Klien terdeteksi diabetes mellitus saat menjalani
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perawatan di rumah sakit saat ini.
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D. Riwayat Kesehatan Terdahulu
1. Penyakit yg pernah dialami:
a. Kecelakaan (jenis & waktu) : ..................................................................................
b. Operasi (jenis & waktu) : ..................................................................................
c. Penyakit:
Kronis : Hipertensi sejak 10 tahun yang lalu .............................................
Akut : .....................................................................................................
d. Terakhir masuki RS : ..................................................................................
2. Alergi (obat, makanan, plester, dll):
Tipe Reaksi Tindakan
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3. Imunisasi:
( ) BCG ( ) Hepatitis
( ) Polio ( ) Campak
( ) DPT ( ) ................

4. Kebiasaan:
Jenis Frekuensi Jumlah Lamanya
Merokok ............................... .................................... ....................................
Kopi ............................... .................................... ....................................
Alkohol ............................... .................................... ....................................

5. Obat-obatan yg digunakan:
Jenis Lamanya Dosis
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E. Riwayat kehamilan dan persalinan
1. Prenatal

2. Natal

3. Postnatal
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F. Riwayat pertumbuhan dan perkembangan
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1. Pertumbuhan

2. Perkembangan

G. Riwayat Keluarga
Di keluarga tidak ada yang menderita sakit yang sama dengan klien.
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GENOGRAM

H. Riwayat Lingkungan
Jenis Rumah Pekerjaan
Kebersihan .................................................. ..................................................
Bahaya kecelakaan .................................................. ..................................................
Polusi .................................................. ..................................................
Ventilasi .................................................. ..................................................
Pencahayaan .................................................. ..................................................
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I. Pola Aktifitas-Latihan
Rumah Rumah Sakit
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Makan/minum ............................................... ...............................................
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Mandi ............................................... G
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Berpakaian/berdandan ............................................... ...............................................
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Toileting ............................................... ...............................................
Mobilitas di tempat tidur ...............................................
Berpindah ............................................... ...............................................
Berjalan ............................................... ...............................................
Naik tangga ............................................... ...............................................
Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang
lain, 4 = tidak mampu

J. Pola Nutrisi Metabolik

Rumah Rumah Sakit
Jenis diit/makanan .......................................... ............................................
Frekuensi/pola .......................................... ............................................
Porsi yg dihabiskan .......................................... ............................................
Komposisi menu .......................................... ............................................
Pantangan .......................................... ............................................
Napsu makan .......................................... ............................................
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 ........................................ ............................................

K. Pola Eliminasi
Rumah Rumah Sakit
BAB:
- Frekuensi/pola ............................................... .............................................
- Konsistensi ............................................... .............................................
- Warna & bau ............................................... .............................................
- Kesulitan ............................................... .............................................
- Upaya mengatasi ............................................... .............................................

BAK:
- Frekuensi/pola
- Konsistensi
- Warna & bau
- Kesulitan
- Upaya mengatasi
L. Pola Tidur-Istirahat
Tidur siang:Lamanya
- Jam s/d
- Kenyamanan stlh. tidur
Tidur malam: Lamanya
- Jam s/d
- Kenyamanan stlh. tidur
- Kebiasaan sblm. tidur
- Kesulitan
- Upaya mengatasi
M. Pola Kebersihan Diri
Mandi:Frekuensi
- Penggunaan sabun
Keramas: Frekuensi
- Penggunaan shampoo
Gososok gigi: Frekuensi
- Penggunaan odol
Ganti baju:Frekuensi
Memotong kuku: Frekuensi
Kesulitan
Upaya yg dilakukan
N. Pola Toleransi-Koping Stres
1. Pengambilan keputusan:
2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri, dll): .
3. Yang biasa dilakukan apabila stress/mengalami masalah: ...................................................
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Rumah
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( ) sendiri ( ) dibantu orang lain, sebutkan, .........................
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Rumah Sakit
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4. Harapan setelah menjalani perawatan: ..................................................................................
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5. Perubahan yang dirasa setelah sakit: ...................................................................................
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O. Konsep Diri 8
1. Gambaran diri: ......................................................................................................................
2. Ideal diri: ................................................................................................................................
3. Harga diri: ..............................................................................................................................
4. Peran: ....................................................................................................................................
5. Identitas diri ...........................................................................................................................

P. 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: ..................................................................................

Q. Pemeriksaan Fisik
1. Keadaan Umum:
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Kesadaran: Komposmentis
Tanda-tanda vital: - Tekanan darah : 160/100
mmHg - Suhu : 36,5 oC

- Nadi : 80 x/menit - RR : 20 x/menit

Tinggi badan: .............................. cm Berat Badan: ................... kg
2. Kepala & Leher
a. Kepala:
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b. Mata:
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c. Hidung:
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d. Mulut & tenggorokan:
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e. Telinga:
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f. Leher:
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3. Thorak & Dada:
Jantung
- Inspeksi: .....................................................................................................................
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- Palpasi: .......................................................................................................................
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- Perkusi: ......................................................................................................................
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- Auskultasi: ..................................................................................................................
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Paru
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- Inspeksi: .....................................................................................................................
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- Palpasi: .......................................................................................................................
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- Perkusi: ......................................................................................................................
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- Auskultasi: ....................................................................................................................

4. Payudara & Ketiak

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5. Punggung & Tulang Belakang
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6. Abdomen
Inspeksi: ...........................................................................................................................
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Palpasi: ..............................................................................................................................
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Perkusi: .............................................................................................................................
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Auskultasi: ........................................................................................................................
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7. Genetalia & Anus
Inspeksi: ...........................................................................................................................
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Palpasi: ...........................................................................................................................
8. Ekstermitas
Atas: ...............................................................................................................................
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Bawah:
Terdapat luka di tumit kaki kiri dengan diameter luka 5 cm, dan kedalaman luka 1 cm,
serta nampak jaringan nekrotik. Di sekitar luka tampak kemerahan dan bengkak.

9. Sistem Neorologi
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10. Kulit & Kuku
Kulit:

Kuku:

R. Hasil Pemeriksaan Penunjang

leukosit : 25,1103/l. Glukosa sewaktu 515 mg/dl.

S. Terapi
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