PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Tempat Praktik :

NIM : Tanggal Praktik :

A. Identitas Klien
Nama : ............................... 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 : .........................................

No. RM : .........................................
B. Status Kesehatan Saat Ini
1. Keluhan Utama
a. Saat MRS : ..................................................................................................
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b. Saat Pengkajian : ..................................................................................................
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c. Diagnosa Medis ...................................................................................................
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2. Riwayat Kesehatan Saat Ini
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C. Riwayat Kesehtan Terdahulu
1. Penyakit Yang Pernah Dialami
a. Kecelakaan (Jenis & Waktu) : .............................................................................
b. Operasi (Jenis & waktu) : .............................................................................
c. Penyakit
 Kronis :...........................................................................................................
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............................................................................................................
 Akut : ..........................................................................................................
d. Terakhir Masuk Rs :.............................................................................................
2. Alergi (Obat, makanan, plester, dll)
Tipe Reaksi Tindakan

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3. Kebiasaan :
Jenis Frekuensi Jumlah Lamanya
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4. Obat-obatan yang digunakan :

Jenis Lamanya Dosis

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D. Riwayat Keluarga
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GENOGRAM
E. Riwayat Lingkungan
Rumah Pekerjaan
Jenis
…………………………………… ……………………………………
 Kebersihan
…………………………………… ……………………………………
 Bahaya Kecelakaan
 Polusi …………………………………… ……………………………………
 Ventilasi …………………………………… ……………………………………
 Pencahayaan …………………………………… ……………………………………

F. Pola Aktifitas Lain

Jenis Rumah Rumah Sakit

 MAkan/Minum …………………………………… ……………………………………
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 Mandi ……………………………………
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 Berpakaian/berdandan ……………………………………
…………………………………… ……………………………………
 Toileting
…………………………………… ……………………………………
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 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

G. Pola Nutrisi

Rumah Rumah Sakit

………………………………… ……………………………………
 Jenis makanan
………………………………… ……………………………………
 Frekuensi/pola
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 Porsi yang dihabiskan
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 Komposisi menu ……………………………………
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 Pantangan ……………………………………
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 Napsu makan ……………………………………
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 Jenis minuman ……………………………………
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 Frekuensi/pola ……………………………………
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 Gelas yang dihabiskan
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 Sukar menelan
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 Pemakaian gigi palsu
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 Riw. Penyembuhan luka ……………………………………
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H. Pola Eliminasi

 BAB
-frekuensi/pola Rumah Rumah Sakit
…………………………………… ……………………………………
-Konsistensi
…………………………………… ……………………………………
-warna/bau
…………………………………… ……………………………………
-kesulitan
…………………………………… ……………………………………
-upaya mengatasi
…………………………………… ……………………………………
 BAK
-frekuensi/pola …………………………………… ……………………………………
-Konsistensi …………………………………… ……………………………………
-warna/bau …………………………………… ……………………………………
-kesulitan …………………………………… ……………………………………

-upaya mengatasi …………………………………… ……………………………………

I. Pola Istirahat Tidur

Rumah Rumah Sakit

 Tidur siang: lamanya …………………………………… ……………………………………
 Mandi: frekuensi
-jam…s/d… …………………………………… ……………………………………
-penggunaan sabun
-kenyamanan stlh.tidur …………………………………… ……………………………………
 Keramas : frekuensi …………………………………… ……………………………………
 -pengguaan
Tidur malam: lamanya
sampo
…………………………………… ……………………………………
 Gosok gigi: frekuensi
-jam..s/d..
-penggunaan …………………………………… ……………………………………
Kenyamanan odolstlh tidur
 Ganti baju: frekuensi …………………………………… ……………………………………
-kesulitan
 Memotong kuku: …………………………………...... ……………………………………
-upaya mengatasi
frekuensi …………………………………......
 Kesulitan upaya yang
dilakukan
J. Pola Kebersihan Diri
Rumah Rumah Sakit

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Mandi : Frekuensi
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Penggunaan sabun ……………………………………
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Keramas : Frekuensi ……………………………………
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Penggunaan Shampo …………………………………… ……………………………………
Gosok Gigi : Frekuensi …………………………………… ……………………………………
Penggunaan odol …………………………………… ……………………………………

Ganti baju : Frekuensi …………………………………… ……………………………………

……………………………………

…
 Memotong kuku : Frekuensi
Kesulitan
Upaya yang dilakukan

K. 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 :.........................................................................

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

O. 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 : ................................................................................................................
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b. Mata : ...................................................................................................................
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c. Hidung : ...............................................................................................................
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 d. tenggorokan : .......................................................................................................
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e. Telinga : ...............................................................................................................
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f. Leher : ..................................................................................................................
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3. Thorak & Dada
 Jantung
- Inspeksi : ........................................................................................................

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

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

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

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

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

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4. Payudara & Ketiak

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5. Punggung & Tulang Punggung

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

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 Perkusi : ...............................................................................................................

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 Auskultasi : ..........................................................................................................

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

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

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9. Sistem Neurologi
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10. Kulit & Kuku
 Kulit
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 Kuku
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P. Hasil Pemeriksaan Penunjang

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R. Persepsi Klien Terhadap Penyakitnya

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S. Perencanaan Pulang
Tujuan pulang .................................................................................................................
Transportasi puang ..........................................................................................................
Dukungan keluarga .........................................................................................................
Antisipasi bantuan biaya setelah pulang .........................................................................
Antisipasi masalah perawatan diri setelah pulang ..........................................................
Pengobatan ......................................................................................................................
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Rawat jalan ke .................................................................................................................
Hal- hal yang perlu diperhatikan di rumah .....................................................................
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Keterangan lain ...............................................................................................................
PEMERIKSAAN RADIOLOGI
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TINDAKAN DAN TERAPI
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 ANALISA DATA

Nama: No. RM:

Diagnosa Medis :
Data penunjang Penyebab Masalah

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

Nama : ……………………………… No.RM : …………………………………..

Diagnosa Medis : ………………………………
Tgl Diagnosa Keperawatan NOC NIC
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 IMPLEMENTASI

Nama Klien : Tanggal Pengkajian :

Diagnosa Medis :

Tanggal No. Dx Jam Tindakan Keperawatan Respon Klien TTD & Nama
Keperawatan Terang
Tanggal No. Dx Jam Tindakan Keperawatan Respon Klien TTD & Nama
Keperawatan Terang
 IMPLEMENTASI DAN EVALUASI
Nama :
Dx Medis :
Tgl / No Implementasi
jam Dx
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No. RM:
evaluasi Tanda
Tangan
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 CATATAN PERKEMBANGAN

Nama Klien : Tanggal :

Dx Medis : Ruang :

S O A P I E