PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Tempat Praktik :

NIM : Tanggal Praktik :

A. Identitas Klien
Nama No. RM : .........................................
Usia : ............................... Tgl. Masuk : .........................................
Usia : ................................ Tgl. Pengkajian : .........................................
Jenis Kelamin : ................................ Sumber Informasi : ........................................
Alamat : .......................................... Nama Klg. Dekat yg bias dihubungi..............
No. Telepon : ........................................
Satus Pernikahan Status : .........................................
Sumber Informasi : ....................................... Alamat : .........................................
Suku : ........................................ No. telepon :..........................................
Pendidikan : ........................................ Pendidikan : .........................................
Pekerjaan : ......................................... Pekerjaan : .........................................
Lama Bekerja : .........................................

B. Status Kesehatan Saat Ini

1. Keluhan Utama
a. Saat MRS : ..................................................................................................
...................................................................................................
...................................................................................................
b. Saat Pengkajian : ..................................................................................................
...................................................................................................
...................................................................................................
c. DiagnosaMedis ....................................................................................................
...................................................................................................
...................................................................................................
2. Riwayat Kesehatan Saat Ini
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
C. Riwayat Kesehtan Terdahulu
1. Penyakit Yang Pernah Dialami
a. Kecelakaan (Jenis & Waktu) : .............................................................................
b. Operasi (Jenis & waktu) : .............................................................................
c. Penyakit
Kronis :...........................................................................................................
............................................................................................................
............................................................................................................
Akut : ..........................................................................................................
d. Terakhir Masuk Rs :.............................................................................................
2. Alergi (Obat, makanan, plester, dll)
Tipe Reaksi Tindakan

3. Imunisasi
( ) BCG ( ) Hepatitis
( ) POLIO ( ) Campak
( ) DPT ( ) ..

Jenis
Merokok
Kopi
Alkohol

4. Kebiasaan

Frekuensi Jumlah Lamanya

5. Obat-obatan yang digunakan

Lamanya
Jenis Dosis

D. Riwayat Keluarga
..........................................................................................................................................
 ..........................................................................................................................................
..........................................................................................................................................
GENOGRAM

E. Riwayat Lingkungan
Rumah Pekerjaan
Jenis

Rumah Sakit
Kebersihan
Bahaya Kecelakaan

Polusi

Ventilasi

Penvahayaan

F. Pola

Jenis Aktifitas Lain
Rumah Rumah Sakit

MAkan/Minum

Mandi


Berpakaian/berdandan

Toileting

Mobilitis 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

Pola Nutrisi Metabolik

Rumah Rumah
Jenis makanan
Frekuensi/pola
Porsi yang dihabiskan

Komposisi menu

Pantangan

Napsu makan
G. Pola Eliminasi

Rumah Rumah Sakit

BAB

-frekuensi/pola
-Konsistensi
-warna/bau
-kesulitan
-upaya mengatasi

BAK

-frekuensi/pola

-Konsistensi

-warna/bau

-kesulitan

-upaya mengatasi

H. Pola Istirahat Tidur

Rumah

Tidur siang: lamanya I.

-jams/d ola Kebersihan Diri
-kenyamanan stlh.tidur
Tidur malam: lamanya
Mandi: frekuensi
-jam..s/d.. sabun
-penggunaan
Keramas : frekuensi
Kenyamanan stlh tidur
-pengguaan
-kesulitan sampo
Gosok gigi: frekuensi
-upaya mengatasi
-penggunaan odol Rumah
Ganti baju: frekuensi
Memotong kuku:
frekuensi Rumah
Rumah
Kesulitan upaya yang

dilakukan



J. Pola Toleransi-Koping Stress


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

K. Konsep Diri
1. Gambaran diri : ..........................................................................................................
2. Ideal diri : ...................................................................................................................
3. Harga diri: ..................................................................................................................
4. Peran : ........................................................................................................................
5. Identitas diri : .............................................................................................................

L. Pola Peran & Hubungan

1. Peran dalam keluarga ................................................................................................
2. System 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/huubngan dengan keluarga selama perawatan di RS: ..........
....................................................................................................................................
5. Upaya yang dilakukan untuk mengatasi : ..................................................................
M. Pola Komunikasi
1. Bicara : ( ) Normal ( ) bahasa utama ..............................
( )Tidak jelas ( ) Bahasa daerah: ............................
( ) Bicara Berputar-putar ( ) rentang perhatian : ......................
( ) mampu mengerti pembicaran orang lain ( )Afek : ..............................
2. Tempat tinggal
( ) sendiri
( ) kos / asrama
( ) bersama orang lain, sebutkan : .............................................................................
3. Kehidupan keluarga
a. Adat istiadat yang dianut : ...................................................................................
b. Pantangan & agama yang dianut : .......................................................................
c. Penghasilan keluarga
( ) < Rp.250.000 ( ) Rp. 1 juta-1,5 juta
 ( ) Rp. 250.000 500.000 ( ) Rp. 1,5 juta 2 juta
( ) Rp. 500.000 1 juta ( ) > Rp. 2 juta

N. Pola seksualitas
1. Masalah dalam hubungan seksual selama sakit : ( ) tidak ada ( ) Ada
2. Upaya yang dilakukan pasangan ;
( ) perhatian ( ) Sentuhan ( ) Lain-lain: ..................................

O. Pola nilai & Kepercayaan

1. Apakah tuhan, agama, kepercayaan penting untuk anda: Ya / Tidak
2. Kegiatan agama / kepercayaan yang dilakukan di rumah (Jenis & frekuensi) : ........
....................................................................................................................................
3. Kegiatan agama/ kepercayaan tidak dapat dilakukan di RS : ....................................
4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya : ...........................
5.
P. Pemeriksaan Fisik
1. Keadaan Umum : .......................................................................................................
....................................................................................................................................
Kesadaran :...........................................................................................................
Tanda tanda vital : - Tekanan darah : mmHg -Suhu : c
Nadi : x/m - RR : x/m
Tinggi badan : cm Berat badan : cm

2. Kepala dan leher

a. Kepala : ................................................................................................................
..............................................................................................................................
..............................................................................................................................
b. Mata : ...................................................................................................................
..............................................................................................................................
..............................................................................................................................
c. Hidung : ...............................................................................................................
..............................................................................................................................
..............................................................................................................................

d. Hidung & tenggorokan : ......................................................................................

..............................................................................................................................
 ..............................................................................................................................
e. Telinga : ...............................................................................................................
..............................................................................................................................
..............................................................................................................................
f. Leher : ..................................................................................................................
..............................................................................................................................
..............................................................................................................................
3. Thorak & Dada
Jantung
- Inspeksi : ........................................................................................................

- Palpasi : ..........................................................................................................
........................................................................................................................
- Perkusi............................................................................................................

- Auskultasi ......................................................................................................

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

Paru
- Inspeksi : ........................................................................................................
........................................................................................................................
- Palpasi : ..........................................................................................................

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

- Perkusi : .........................................................................................................

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

- Auskultasi : ....................................................................................................

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

4. Payudara & Ketiak

....................................................................................................................................
5. Punggung & Tulang Punggung

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

6. Abdomen :
Inspeksi : ..............................................................................................................
 ..............................................................................................................................
Palpasi : ................................................................................................................

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

Perkusi : ...............................................................................................................

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

Auskultasi : ..........................................................................................................

..............................................................................................................................
7. Genetalia & Anus :
Inspeksi : ..............................................................................................................
..............................................................................................................................
Palapasi : ..............................................................................................................

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

8. Ekstremitas
Atas ......................................................................................................................
..............................................................................................................................
Bawah ..................................................................................................................

..............................................................................................................................
9. Sistem Neurologi
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
10. Kulit & Kuku
Kulit
..............................................................................................................................
..............................................................................................................................
Kuku
..............................................................................................................................
..............................................................................................................................
Pemeriksaan Penunjang/Diagnostik Medik
No. Hasil Nilai Rujukan
PEMERIKSAAN RADIOLOGI
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
TINDAKAN DAN TERAPI
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
 ANALISA DATA
Nama : No. RM:
Dx Medis :
Data penunjang Penyebab Masalah

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...

... ...
 DIAGNOSA KEPERAWATAN
Nama : No. RM:
Dx Medis :
No. Tgl. Muncul Diagnosa Keperawatan Tgl. Teratasi
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
....................
 RENCANA TINDAKAN KEPERAWATAN

Nama : No. RM:

Dx Medis :
No. Diagnosa keperawatan NOC NIC
.. .. ............................
.. .. ............................
.. .. ............................
............................
.. ..
............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
............................
.. ..
............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
............................
.. ..
............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
............................
.. .. ............................
.. .. ............................
.. .. ............................
............................
.. ..
............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
............................
.. ..
............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
............................
.. ..
............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
............................
.. ..
............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
.. .. ............................
 IMPLEMENTASI KEPERAWATAN
Nama : No. RM:
Dx Medis :
Tgl / No. Implementasi TTD
Jam Dx
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
 EVALUASI KEPERAWATAN
Nama : No. RM:
Dx Medis :
Tgl / No. Implementasi TTD
Jam Dx
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................