PENGKAJIAN PASIEN

Nama & NIM Mahasiswa :

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Tempat Praktik :______________________________________
Tanggal & jam pengkajian :______________________________________
Persetujuan Preceptor/Pembimbing Klinik : Diajukan/Revisi/Disetujui
Nama Preceptor/Pembimbing Klinik :______________________________________
Tanda Tnagan :______________________________________

I. Identitas Diri Klien

Nama : __________________________________________________
Tanggal & jam masuk RS : __________________________________________________
Tempat/tanggal lahir : __________________________________________________
Umur : __________________________________________________
Jenis Kelamin : __________________________________________________
Alamat : __________________________________________________
Status perkawinan : __________________________________________________
Agama : __________________________________________________
Suku : __________________________________________________
Pendidikan : __________________________________________________
Pekerjaan : __________________________________________________
No.CM : __________________________________________________

II. Status Kesehatan Saat Ini

1. Alasan dirawat
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2. Keluhan utama
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3. Faktor pencetus
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4. Lama keluhan
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5. Timbul keluhan
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6. Faktor yang memperberat
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7. Upaya yang dilakukan untuk membuat rasa sakit/ keluhan klien terasa semakin parah
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8. Pemeriksaan penunjang yang telah dilakukan sebelum sakit
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9. Diagnosa Medik
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III. Riwayat Kesehatan lalu
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1. Penyakit, kecelakaan, operasi, rawat inap yang pernah dialami :
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2. Alergi
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3. Imunisasi
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4. Kebiasaan
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5. Penggunaan obat-obatan :
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IV. _____________________________________________________________________________
Riwayat Keluarga
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V. Pengkajian Basic Promoting Physiology Of Healty

1. Osigenasi

a. Sesak napas : Ya ( ) Tidak ( )

Frekuensi : ____________________________________________
Kapan terjadi : ____________________________________________
Kemungkin faktor pencetus : ____________________________________________
Faktor yang memperberat : ____________________________________________
Faktor yang meringankan : ____________________________________________
b. Batuk : Ya ( ) Tidak ( )
c. Sputum : Ya ( ) Tidak ( )
d. Nyeri Dada : Ya ( ) Tidak ( )
Hal yang dilakukan untuk meringankan nyeri dada :
 e. Riwayat Penyakit :
Asma ( )
TB ( )
Batuk darah ( )
Chest surgery/ Trauma dada ( )
Paparan dengan penderita TB ( )
Riwayat merokok : Pasif/ Aktif

Masalah Keperawatan : :____________________________________________

2. Aktivitas dan latihan

Pekerjaan :______________________________________________________________

Olahraga rutin :______________________________________________________________

Alat bantu : Walker/Kruk/Kursi roda/ Tongkat

Terapi : Traksi ( ) di :_____________________________________________

Gips ( ) di :_____________________________________________

Kemampuan melakukan ROM : Pasif/Aktif

Kemampuan ambulansi :____________________________________________

Kemampuan ADL Indeks Barthel

Kemampuan Perawatan Diri Sebelum Sakit Setelah sakit

0 1 2 3 0 1 2 3
Makan/Minum
Mandi
Perawatan Diri
Berpakaian
BAK
BAB

Toileting

Berpindah
Mobilitas
Naik turun tangga

Keterangan : Interpretasi hasil

Skor 20 : Mandiri

Skor 12-19 : Ketergantungan Ringan

Skor 9-11 : Ketergantungan Sedang

Skor 5-8 : Ketergantungan Berat

Skor 0-4 : Ketergantungan Total

Masalah Keperawatan :________________________________________________________

3. Pola Nutrisi

a. Program diit di RS : __________________________________________________

b. BB sebelm sakit : __________________________________________________
c. BB 1 bulan terakhir : __________________________________________________
d. BB saan pengkajian : __________________________________________________
e. TB : __________________________________________________
f. IMT dan Interpretasi : __________________________________________________
g. Intake Makanan :
Sebelum sakit Saat pegkajian
Menu makanan
setiap hari

Ferkuensi minum
per hari

Nafsu makan

Porsi Yang
dihabiskan

Keluhan yang
dirasakn : mual,
muntah, keslitan
menelan, sariawan

Makana yang disukai : __________________________________________________

Makanan pantangan : __________________________________________________

Masalah keperawatan : __________________________________________________

4. Pola Eliminasi Bowel dan Bladder

a. Bowel/Nuang Air Besar (BAB)

Sebelum sakit Saat pengkajian

Frekuensi per hari
Kebiasaan waktu BAB
konsitensi

Bau
Warna
Keluhan : Konstipasi, diare,
inkontenensia bowel
Penggunaan obat pencahar

Masalah Keperawatan :______________________________________________________

b. Bladder / Buang Air Kecil ( BAK)

Riwayat penyakit dahulu : Penyakit ginjal/Batu ginjal/Injuri/trauma

Sebelum sakit Saat pengkajian

Frekuensi per hari

Pancaran

Bau

Warna

Darah dalam urine

Pemakaian kateter

Keluhan:
Nyeri saat BAK, Burning Sensation,
Bladder terasa penuh setelah BAK,
perasaan tidak tuntas
Urine tampung, total

Riwayat penyakit dahulu :_____________________________________________

 Masalah Keperawatan :_______________________________________________
5. Cairan & Elektrolit
a. Jumlah kebutuhan cairan per hari :______________________________________
b. Intake Minum :_____________________________________________________
Sebelum sakit Saat pengkajian
Jenis minuman
Frekuensi minum per hari
Jumlah minum (ml) dalam 24 jam
Keluhan

c. Support iv line (jenis cairan, tetesan, tempat pemasangan) :__________________

d. Turgor kulit, mukosa bibir :___________________________________________
e. Perhitungan balance cairan :___________________________________________

Masalah Keperawatan :

6. Pola Tidur dan Istirahat

Sebelum sakit Saat pengkajian
Jumlah jam tidur siang
Jumlah jam tidur malam
Kebiasaan pengantar tidur
Penggunaan obat tidur
Kesulitan tidur: menjelang tidur,
mudah/sering terbangun, merasa
tidak segar saat bangun
Gangguan lingkungan

Masalah Keperawatan :
7. Kenyamanan dan nyeri
Nyeri: ya/tidak, skala nyeri : _______________________________________________
Paliatif/Provokatif : ________________________________________________
Qualitas : ________________________________________________
 Region : ________________________________________________
Severity : ________________________________________________
Time : ________________________________________________
Ambulasi di tempat tidur : mandiri/tergantung/ dengan bantuan
Masalah Keperawatan :
8. Sensori, persepsi dan kognitif
Gangguan penglihatan : ya/tidak
Ganguan pendengaran : ya/tidak
Gangguan penciuman : ya/tidak
Gangguan sensasi taktil : ya/tidak
Gangguan pengecapan : ya/tidak
Riwayat penyakit : eye surgery ( )
Otitis media ( )
Luka sulit sembuh ( )
Masalah Keperawatan :____________________________________________

VI. Pengkajian Fisik

Kepala, mata, telinga, hidung dan tenggorokan

Kepala : Bentuk ________________________________________________________
Keluhan yang berhubungan : pusing/sakit kepala : ______________________
Mata : Ukuran pupil : __________________ isokor/anisokor : __________________
Reaksi cahaya (ka/ki) : _________________________________________
Akomodasi : _________________________________________
Bentuk : _________________________________________
Konjungtiva : ____________ sklera : ______________________
Fungsi penglihatan : Baik/kabur/tidak jelas
Alat bantu : _________________________________________
Tanda-tanda radang : _________________________________________
Pemeriksaan mata terakhir : _______________________________________
Operasi : _________________________________________
Hidung : Reaksi alergi : _________________________________________
Cara mengatasi : _________________________________________
Frekuensi influenza : _________________________________________
 Sinus : _______________ Perdarahan : _______________
Mulut dan tenggorokan :
Kesulitan berbicara : _________________________________________
Kesulitan menelan : _________________________________________
Pernafasan : Suara paru : _________________________________________
Pola napas : _________________________________________
Batuk : _______________Darah : ___________________
Sputum : _________________________________________
Nyeri dada : _________________________________________
Kemampuan melakukan aktivitas : __________________________________
Ro thorak terakhir : __________________ Hasil : _________________
Sirkulasi : Nadi perifer : _________________________________________
Capillary refill : _________________________________________
Distensi vena jugularis : _________________________________________
Suara jantung : _________________________________________
Suara jantung tambahan : _________________________________________
Irama jantung (monitor EKG) : _____________________________________
Nyeri dada : _______________ Edema : ___________________
Palpitasi : _________________Baal : ___________________
Clubbing finger : _________________________________________
Keadaan ekstremitas : _________________________________________
Syncope : _________________________________________
Reproduksi : Kehamilan : _________________________________________
Payudara : _________________________________________
Perdarahan : _________________________________________
Pemeriksaan papsmear terakhir : ____________________________________
Hasil : _________________________________________
Keputihan : _________________________________________
Prostat : _________________________________________
Penggunaan kateter : _________________________________________
Neurosis : Tingkat kesadaran : ___________GCS __________________________
Disorientasi : _________________________________________
Tingkah laku menyimpang : _______________________________________
Riwayat epilepsy/Kejang/Parkinson : ________________________________
 Reflek : _________________________________________
Kekuatan menggenggam : _________________________________________
Pergerakan ekstermitas : _________________________________________
Musculoskeletal :
Nyeri : _________________________________________
Kemampuan latihan gerak : ________________________________________
Kekuatan otot ekstremitas atas : ____________________________________
Kekuatan otot ekstremitas bawah : __________________________________
Kulit : Warna : _________________________________________
Integritas : _________________________________________
Turgor : _________________________________________

VII. Pemeriksaan Penunjang

1. Data Laboratorium :
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2. Pemeriksaan Penunjang Lain :
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VIII. Pengobatan :
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IX._________________________
Pengkajian Persepsi dan Pemeliharaan Kesehatan
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X. Analisa Data

No. Data Etiologi/Faktor Problem

Resiko

XI. Prioritas Diagnosa Keperawatan

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XII. Perencanaan Keperawatan

No. Diagnosa Kriteria Hasil (NOC) Intervensi (NIC)

XIII. Implementasi

Tanggal No Jam Implementasi Respon Ttd &

Dx. nama
terang
XIV. Evaluasi

Tanggal No Jam Implementasi Respon Ttd &

Dx. nama
terang