Format Pengkjian 13 Domain

FORMAT ASUHAN KEPERAWATAN (MA : ..................
)
PROGRAM STUDI D III KEPERAWATAN
AKADEMI KESEHATAN KARYA HUSADA YOGYAKARTA
A. PENGKAJIAN
I. Identitas Pasien
Nama Pasien :
Umur :
Jenis Kelamin :
Pendidikan :
Pekerjaan :
Agama :
Suku :
Alamat :
No Rekam Medis :
Diagnosa Medis :
Ruang/Rumah Sakit :
Tgl Masuk RS :
Tgl Pengkajian :
II. Identitas Penanggung Jawab/Orang Tua/Wali

Nama :
Umur :
Jenis Kelamin :
Pendidikan :
Pekerjaan :
Agama :
Suku :
Alamat :
III. Keluhan Utama

Keluhan yang dirasakan oleh pasien pada saat pengkajian
IV. Riwayat Penyakit Sekarang (alasan masuk Rumah Sakit)

Diisi data kapan mulai ada keluhan.
semakin lemes dan panas, kmdian di bawa ke RS mondok di bangsala bakung.

V. Pemeriksaan Tanda-Tanda Vital (saat pengkajian)
Kesadaran : ..........................
TD : ............... mm Hg
Nadi : ............... x/mnt
Suhu Badan : ............... o Celcius
Pernafasan : ............... x/mnt
Format pengkajian 13 domain NANDA

Prodi D III Keperawatan Akes Karya Husada Yogyakarta
“Mencetak Perawat Profesional yang berkarakter” Page 1
VI. PENGKAJIAN DENGAN 13 DOMAIN NANDA
1. PROMOSI KESEHATAN
DATA SUBYEKTIF
a. Riwayat penyakit yang lalu (riwayat operasi, riwayat dirawat di rumah sakit)
3 th yll menderita tipes. TBC 1 tahun yang llu dan pengobatan tuntas. TBC sekarag
masa terapi bulan ke
3 .....................................................................................................................................
...
b. Perubahan kondisi kesehatan akhir-akhir ini
Pasien mengatakan mudah sakit , meskioun hanya flu atau masuk angin. Pasien tidak
mengalami penurunan daya tahan tubuh
c. Riwayat penyakit keluarga (sertakan genogram)
Bapak penderit asma, dan DM sejak 5 th yll.
Genogram :
d. Persepsi anak/orang tua terhadap penyebab sakitnya saat ini dan upaya-upaya yang
telah dilakukan
pendapat penyebab sakitnya, misal sakit merupakaan cobaan, sakitnya karena
kutukan, sakit karena gangguan roh halus
e. Upaya-upaya penyembuhan yang dilakukan saat ini (terapi, obat-obatan, suplemen

dan herbal)
Berobat ke alternatif, minum obat herbal ,pergi ke layanan kesehatan , dll
f. Riwayat alergi obat/makanan/lainnya

Alergi terhadap udang, seafood. Alergi amoksilin.
Tidak riwayat alergi baik terhadap obat atau makanan.
g. Rencana antisipasi untuk pulang (Discharge Planning) atau perawatan selanjutnya

- Edukasi minum banyak
- Kontrol sesuai jadwal
h. Perilaku-perilaku yang berresiko terhadap gangguan kesehatan di antaranya : riwayat

konsumsi alkohol, tembakau/rokok dan obat-obat terlarang, kopi, teh yang
berlebihan, makanan-makanan instan dan makanan yang mengandung bahan
makanan tambahan (zat pengawet, zat pewarna, penambah rasa)
Minum kopi 4 gls / perhari, merokok 1 bgks/ hari sejak smp, konsumsi fast food / mie
instan hampir setiap hari.
Konsumsi kratingdeng 2 btl/hari sejak 2 tahun yg ll
i. Riwayat kehamilan dan persalinan (untuk anak & maternitas)

- G3P2A1, pemeriksaan terhadap diri sendiri : sadari
- Pre natal : riwayat konsumsi obat-obatan, umur kehamilan saat
kehamilan, riwayat ANC (berapa kali, di mana)
- Natal : cara persalinan, persalinan ditolong oleh, APGAR SCORE
- Post natal : riwayat hiperbilirubinemia
- Riwayat persalinan yang lalu
........................................................................................................................................
........................................................................................................................................
j. Riwayat Immunisasi (jenis immunisasi, jumlah pemberian, waktu pemberian,

ketepatan waktu)

........................................................................................................................................
........................................................................................................................................
k. Riwayat alergi dan riwayat sensitifitas

........................................................................................................................................
........................................................................................................................................
l. Ketaatan terhadap program terapi (misal : terapi sitostatika, diet, obat TBC,
latihan/aktifitas, dll)
tBC : minum dan kontrol teratur. Obat sering lupa
DATA OBYEKTIF
a. Vital Sign : Suhu, Nadi, Tekanan Darah dan Respirasi Rate
........................................................................................................................................
........................................................................................................................................
b. Observasi perilaku kepatuhan terhadap program terapi yang diberikan

Pasien minum obat secara teratur
c. Pengobatan saat ini (Obat, herbal, vitamin)
Obat Dosis Frekuensi

parasetamol 500 mg tiap 8 jam per oral
amoksilin 500 mg tiap 8 jam peroral
gentamicyn 20 mg tiap 8 jam per IV
2. NUTRISI
DATA SUBYEKTIF
a. Riwayat Berat Badan (perubahan berat badan sebelum masuk rumah sakit)
Sebelum sakit 50 kg, selama sakit 45
kg ....................................................................................................................................
....
b. Kebiasaan makan dan minum sehari-hari (waktu, jenis, jumlah, frekuensi makan dan
minum)
Jenis : nasi, snak, sayur buah, lauk
Jumalh : 1100kkal
Minum : 5 gls /hari
Frek : 3 kali per hari/ tidak tentu
c. Makan dan minum yang dikonsumsi terakhir (sebelum dikaji) (jenis , jumlah dan
selera makan
Makanterakhir pagi jam 7
d. Perubahan nafsu makan (penyebab susah makan hilang atau berubah bisa
dikarenakan perubahan sensasi/rasa, mual-muntah, batuk, sesak nafas, nyeri,
hipertermi, dll)
Nafsu makan mengalami penurunan karena nyeri di ulu hati, mual/ lidah terasa
pahit, sulit menelam, perut sebah, sariawan

e. Kesulitan menelan, mengunyah dan mencerna makanan/minuman
Sulit menguyah karema giginya sakit, bvanyak yg ompong
f. Makanan dan minuman yang disukai dan yang tidak disukai

........................................................................................................................................
........................................................................................................................................
g. Penggunaan alat makan (sendok, piring khusus)

........................................................................................................................................
........................................................................................................................................
h. Pembatasan diet atau makanan yang dianjurkan

Mengurangi garam.
i. Penggunaan suplemen, vitamin, makanan energi

........................................................................................................................................
........................................................................................................................................
j. Penggunaan alat bantu nutrisi (misal : NGT)

........................................................................................................................................
........................................................................................................................................
k. Riwayat alergi makanan

........................................................................................................................................
........................................................................................................................................
l. Riwayat masalah dengan kulit, penyembuhan luka (rash, luka, luka terbuka)
........................................................................................................................................
........................................................................................................................................
m. Riwayat masalah yang berkaitan dengan komplemen gigi geligi (gigi lubang, caries,
jumlah)
........................................................................................................................................
........................................................................................................................................
n. Riwayat makan kaji sesuai usia anak (untuk Keperawatan Anak)

BAYI BALITA
- Pemberian ASI Eksklusif - Pemberian ASI
- Susu Formula (tipe & - Susu Formula (tipe & Jumlah)
Jumlah) - Pengenalan makanan padat
- Pengenalan makanan padat termasuk makanan selingan
termasuk makanan (usia & jenis)
selingan (usia & jenis) - Perilaku makan sendiri
- Perilaku makan sendiri
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
DATA OBYEKTIF
a. Keadaan umum (penampilan umum : wajah tampak kuyu, sayu, lemah, lemas, pucat)

.........................................................................................................................................
.........................................................................................................................................
b. Body Mass Index/BMI (kurus, sedang, gemuk, obesitas)

.........................................................................................................................................
.........................................................................................................................................
c. Penampilan kulit (warna, lesi, area tekan, kelembaban, textur, area terbuka, dressing,
rash, scars, ekimosis dan diaphoresis)
.........................................................................................................................................
.........................................................................................................................................
d. Suhu tubuh
.........................................................................................................................................
.........................................................................................................................................
e. Tinggi badan, berat badan

.........................................................................................................................................
.........................................................................................................................................
f. Kondisi mulut, bibir, membran mukosa, sclera, konjunctiva

.........................................................................................................................................
.........................................................................................................................................
g. Turgor kulit
.........................................................................................................................................
.......................................................................................................................................
h. Kondisi gigi, gusi, perdarahan gusi

.........................................................................................................................................
.........................................................................................................................................
i. Kondisi luka atau bekas-bekas luka

.........................................................................................................................................
.........................................................................................................................................
j. Kondisi rambut, kulit dan kuku (integritas, warna)

.........................................................................................................................................
.........................................................................................................................................
k. Intake oral dan cairan intravena

.........................................................................................................................................
.........................................................................................................................................
l. Observasi kehilangan berlebihan melalui rute-rute normal (diare, muntah,
keringat/diaphoresis, perdarahan, dll)
.........................................................................................................................................
.........................................................................................................................................
m. Observasi adanya oedem, peningkatan JVP, CVP, efusi pleura, perubahan suara
jantung (adanya bunyi S 3)
.........................................................................................................................................
.........................................................................................................................................

n. Program diet saat ini
.........................................................................................................................................
.........................................................................................................................................
o. Hasil laboratorium : HCT, Hb, Level Thyroid, gula darah, kimia darah, Level Kolesterol,
protein, Urinalisis (BJ, Protein, Glukosa, Keton)
.........................................................................................................................................
.........................................................................................................................................
3. ELIMINATION
DATA SUBYEKTIF
a. BAB dan BAK (frekuensi, waktu, karakteristik, warna, bau, jumlah, konsistensi dan
keluhan : konstipasi, inkontinensia)
.........................................................................................................................................
.........................................................................................................................................
b. Kapan BAB dan BAK terakhir

.........................................................................................................................................
.........................................................................................................................................
c. Penggunaan laxative atau diuretik

.........................................................................................................................................
.........................................................................................................................................
d. Alat bantu BAK (misal : kateter, ureterostomy), penggunaan alat bantu ekskratory BAB
(misal : colostomi)
.........................................................................................................................................
.........................................................................................................................................
e. Catat penggunaan popok atau rutinitas toileting, catat alat -alat khusus yang
digunakan
.........................................................................................................................................
.........................................................................................................................................
OBYEKTIF
a. Pengkajian gastrointestinal : kontur abdomen, suara usus, flatus, massa, distensi,
haemoroid, drainage, spider nevii, ascites
.........................................................................................................................................
.........................................................................................................................................
b. Observasi BAB dan BAK (waktu, karakteristik, warna, bau, sedimen, jumlah,
konsistensi )
.........................................................................................................................................
.........................................................................................................................................
c. Periksa warna, karakter dan kualitas output dari tempat ekstratori lain : drain, WSD,
NGT, muntah, sputum
.........................................................................................................................................
.........................................................................................................................................
d. Pengkajian sistem pernafasan : suara nafas, batuk, jenis batuk, frekuensi nafas

.........................................................................................................................................
.........................................................................................................................................
e. Hasil Laboratorium : Urinalisis, feses rutin, kultur feses, test fungsi ginjal, analisa gas
darah (AGD)
.........................................................................................................................................
.........................................................................................................................................
4. AKTIFITAS / ISTIRAHAT
DATA SUBYEKTIF
a. Tipe dan keteraturan latihan
........................................................................................................................................
........................................................................................................................................
b. Aktifitas yang dilakukan di rumah/di tempat kerja

........................................................................................................................................
........................................................................................................................................
c. Perasaan/persepsi respon terhadap aktifitas (pusing, lemah, dll)

........................................................................................................................................
........................................................................................................................................
d. Kegiatan-kegiatan rekreasional/menyenangkan
........................................................................................................................................
........................................................................................................................................
e. Aktifitas-aktifitas pada saat waktu luang (hobi)

........................................................................................................................................
........................................................................................................................................
f. Kemampuan untuk makan, mandi, toileting, mobilitas di tempat tidur, berpakaian,

berhias, memasak, belanja, pemeliharaan rumah
........................................................................................................................................
........................................................................................................................................

g. Penggunaan alat bantu aktifitas/protese
........................................................................................................................................
........................................................................................................................................
h. Riwayat masalah sendi dan tulang belakang atau kelemahan

........................................................................................................................................
........................................................................................................................................
i. Riwayat merokok, berapa banyak dan berapa lama

........................................................................................................................................
........................................................................................................................................
j. Riwayat penyakit individu/keluarga : jantung, hipertensi, Asma, TB

........................................................................................................................................
........................................................................................................................................
k. Riwayat bisa melakukan motorik kasar dan motorik halus

........................................................................................................................................
........................................................................................................................................
l. Jumlah jam tidur dalam 24 jam

........................................................................................................................................
........................................................................................................................................
m. Frekuensi periode istirahat

........................................................................................................................................
........................................................................................................................................
n. Jam berapa tidur malam

........................................................................................................................................
........................................................................................................................................
o. Waktu terbangun siang hari

........................................................................................................................................
........................................................................................................................................
p. Masalah yang dirasakan, kesulitan tidur, sering terbangun lebih awal

........................................................................................................................................
........................................................................................................................................
q. Kebiasaan tidur/istirahat yang terbalik (siang tidur, malam istirahat)

........................................................................................................................................
........................................................................................................................................
r. Keluhan saat bangun tidur

........................................................................................................................................
........................................................................................................................................
s. Sering mimpi atau mimpi buruk yang nampak menjengkelkan (nightmare) atau
mempengaruhi

........................................................................................................................................
........................................................................................................................................
t. Penggunaan bantuan tidur (seperti obat)

........................................................................................................................................
........................................................................................................................................
u. Kondisi lingkungan seperti penggunaan bantal untuk tidur, tipe tempat tidur yang
digunakan
........................................................................................................................................
........................................................................................................................................
v. Rutinitas dan ritual pengantar waktu tidur, item keamanan

........................................................................................................................................
........................................................................................................................................
DATA OBYEKTIF
a. Kaji tingkat ketergantungan : level 0, 1, 2, 3, 4
Level 0 : mandiri
Level 1 : membutuhkan penggunaan alat bantu
Level 2 : membutuhkan supervisi/pengawasan orang lain
Level 3 : membutuhkan bantuan dari orang lain
Level 4 : ketergantungan/tidak berpartisipasi
........................................................................................................................................
........................................................................................................................................
b. Postur gaya berjalan

........................................................................................................................................
........................................................................................................................................
c. Tes range of motion (ROM) sendi

........................................................................................................................................
........................................................................................................................................
d. Tes kekuatan, tonus dan massa otot

........................................................................................................................................
........................................................................................................................................
e. Tes keseimbangan
........................................................................................................................................
........................................................................................................................................
f. Palpasi nadi : teraba atau tidak, rate, irama dan kualitas

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

g. Catat bunyi jantung dan adanya mur-mur
........................................................................................................................................
........................................................................................................................................
h. Ukur tekanan darah, catat adanya perubahan dengan posisi atau aktifitas
........................................................................................................................................
........................................................................................................................................
i. Auskultasi bunyi nafas, catat adanya suara nafas tambahan

........................................................................................................................................
........................................................................................................................................
j. Catat jumlah dan karakter pernafasan, adanya kesulitan/kelainan (retraksi, batuk,

sputum, penggunaan otot aksesoris) kebutuhan penggunaan O2
........................................................................................................................................
........................................................................................................................................
k. Kaji status vaskuler, misal : pulsasi perifer, varises, cappilary refill, tanda perubahan
kulit atropik, warna kulit dan kuku, edema, kulit kering/lembab
........................................................................................................................................
........................................................................................................................................
l. Observasi personal hygiene umum, penampilan berpakaian dan berhias

........................................................................................................................................
........................................................................................................................................
m. Hasil observasi pola istirahat/tidur, gangguan istirahat/tidur, kesadaran dan status

mental
........................................................................................................................................
........................................................................................................................................
n. Hasil pemeriksaan lab, x-ray (rontgen), EKG, AGD, enzym jantung, pulse oksimetri,
sputum kultur
........................................................................................................................................
........................................................................................................................................
5. PERSEPSI KOGNISI
DATA SUBYEKTIF
a. Status pendengaran : kebutuhan alat bantu pendengaran, waktu tes pendengaran
terakhir
........................................................................................................................................
........................................................................................................................................
b. Status penglihatan : kebutuhan untuk penggunaan kaca mata, pemeriksaan mata

terakhir
........................................................................................................................................
........................................................................................................................................

c. Masalah dengan pengecap dan pembau
........................................................................................................................................
........................................................................................................................................
d. Masalah dengan sensasi perabaan, baal, kesemutan

........................................................................................................................................
........................................................................................................................................
e. Nyeri (level, lokasi, frekuensi, durasi, karakter, kondisi yang memberatkan, metode
penyembuhan, level toleransi)
........................................................................................................................................
........................................................................................................................................
f. Komunikasi : bahasa utama, bahasa lain, tingkat pendidikan, kemampuan membaca
dan menulis
........................................................................................................................................
........................................................................................................................................
g. Perasaan berputar
........................................................................................................................................
........................................................................................................................................
h. Riwayat pingsan, kejang atau sakit kepala

........................................................................................................................................
........................................................................................................................................
i. Riwayat sakit kepala, lokasi, frekuensi, faktor-faktor penyebab

........................................................................................................................................
........................................................................................................................................
j. Memori (tanyakan kepada keluarga, apakah ada gangguan memori jangka panjang ,
jangka menengah atau jangka pendek)
........................................................................................................................................
........................................................................................................................................
k. Kemampuan memecahkan masalah (bagaimana pasien memecahkan masalah dan

mengambil keputusan, ketidakmampuan mempelajari ketrampilan baru, ketidak
mampuan mempelajari informasi baru, ketidakmampuan melakukan ketrampilan
yang telah dipelajari sebelumnya)
........................................................................................................................................
........................................................................................................................................
l. Usia anak bisa bicara, menyusun tingkatan, perilaku atau kesulitan

belajar di sekolah (keperawatan anak)
............................................................................................................
............................................................................................................
........................................................

DATA OBYEKTIF
f. Tes pendengaran, penglihatan (visus), peraba, pembau, persyafan
.........................................................................................................................................
.........................................................................................................................................
g. Tes orientasi : waktu, tempat dan orang

.........................................................................................................................................
.........................................................................................................................................
h. Kaji tingkat kesadaran, ukur dengan respon terhadap stimulus, periode kebingungan
.........................................................................................................................................
.......................................................................................................................................
i. Bahasa yang digunakan

.........................................................................................................................................
.........................................................................................................................................
j. Kualitas, kecepatan dan artikulasi berbicara

.........................................................................................................................................
.........................................................................................................................................
k. Tes memori sekarang, hal yang baru dipelajari sesuai indikasi

.........................................................................................................................................
.........................................................................................................................................
l. Kemampuan membuat kalimat, membaca, menulis, proses berfikir

.........................................................................................................................................
.........................................................................................................................................
6. PERSEPSI DIRI
DATA SUBYEKTIF
a. Bagaimana perasaan anda saat ini (merasa lemah, putus asa, tidak berdaya, tidak
berguna, rendah diri, depresi, kehilangan kontrol)
jelaskan...........................................................................................................................
........................................................................................................................................
b. Apakah masalah/sakit saat ini mempengaruhi kehidupan anda (apakah pasien

merasa terhina, merasa diasingkan, merasa diperlakukan tidak manusiawi)
........................................................................................................................................
........................................................................................................................................
c. Bagaimana penilaian pasien terhadap diri sendiri

- Citra Tubuh
Bagaimana pandangan anda terhadap tubuh anda saat ini, bagian mana yang
anda sukai dan tidak anda sukai
..................................................................................................................................
..................................................................................................................................

- Identitas diri
Apa status dan posisi anda sebelum dirawat, apakah anda puas dengan status
dan posisi anda saat ini (di sekolah, di tempat kerja, kelompok atau masyarakat,
di keluarga)
..................................................................................................................................
..................................................................................................................................
- Peran
Apa tugas dan peran yang anda emban di sekolah, keluarga, kelompok atau
masyarakat
Bagaimana kemampuan anda dalam melaksanakan tugas tersebut
..................................................................................................................................
..................................................................................................................................
- Ideal diri
Apa harapan anda terhadap tubuh, posisi, status, tugas dan peran
Apa harapan anda terhadap lingkungan (keluarga, sekolah, tempat kerja,
masyarakat)
Apa harapan anda terhadap penyakit anda
..................................................................................................................................
..................................................................................................................................
- Harga diri
Bagaimana hubungan anda dengan orang lain kaitannya dengan kondisi citra
tubuh, identitas diri, peran, ideal diri
Bagaimana penilaian orang lain terhadap diri dan kehidupan anda
..................................................................................................................................
..................................................................................................................................
DATA OBYEKTIF
a. Amati respon pasien saat berinteraksi (ada tidak kontak mata, intonasi suara,
intensitas bicara, ada tidak perhatian, pengalihan perhatian)
........................................................................................................................................
........................................................................................................................................
b. Ukur skala kecemasan (skala 1 = antisipasi/relaks, 2 = cemas ringan, 3 = cemas

sedang, 4 = cemas berat, 5 = panik)
Ringan = sadar, lebih waspada, lahan persepsi meningkat
Sedang = lahan persepsi menurun,
Berat = lahan persepsi menyempit, hanya terfokus pada permasalahan saat itu
Panik = pasien tidak mampu mengontrol /tidak mampu melakukan sesuatu
meskipun dengan perintah
........................................................................................................................................
........................................................................................................................................
c. Ukur skala asertifitas (skala 1 s.d 5 untuk rentang asertif s.d marah)
........................................................................................................................................
........................................................................................................................................
d. Catat tanda verbal dan non verbal yang mengindikasikan ekspresi diri
........................................................................................................................................
........................................................................................................................................

7. PERAN HUBUNGAN
DATA SUBYEKTIF
a. Bentuk struktur keluarga (jelaskan tipe keluarga = tradisional (keluarga inti, extended
family), non tradisional (poliandri, poligami)
........................................................................................................................................
........................................................................................................................................
b. Status perkawinan orang tua : kawin, janda/duda (cerai/mati)

........................................................................................................................................
........................................................................................................................................
c. Cara hidup : sendiri, dengan keluarga, teman sekamar, dll

........................................................................................................................................
........................................................................................................................................
d. Apakah ada dukungan dari keluarga atau orang-orang terdekat

........................................................................................................................................
........................................................................................................................................
e. Selama sakit, apakah anda dapat menjalankan peran (formal, informal)anda saat ini
dengan baik, jika tidak, konflik apa yang anda rasakan, jelaskan..............apakah
efeknya .....(efek secara sosial-ekonomi)
........................................................................................................................................
........................................................................................................................................
f. Apakah mempunyai pengasuh, kedekatan orang terdekat/pengasuh, kesehatan orang

terdekat/pengasuh
........................................................................................................................................
........................................................................................................................................
DATA OBYEKTIF
a. Hubungan dengan Pengunjung, jumlah
........................................................................................................................................
........................................................................................................................................
b. Komunikasi antar anggota keluarga/teman satu ruangan/teman sebaya

........................................................................................................................................
........................................................................................................................................
c. Gambar-gambar di ruangan
........................................................................................................................................
........................................................................................................................................
d. Interaksi dengan orang lain (perawat, dokter, tenaga kesehatan lain, pasien-pasien
lain)
........................................................................................................................................
........................................................................................................................................

e. Perilaku bonding attachment (keperawatan anak – maternitas)
............................................................................................................
..............................................................
f. Kedekatan orang tua / orang terdekat dengan bayi

............................................................................................................
..............................................................
g. Ketrampilan sebagai orang tua (mengganti popok, memandikan,

membuat susu, memberi makan, dll)
............................................................................................................
..............................................................
8. SEKSUALITAS
DATA SUBYEKTIF
a. Riwayat menstruasi : umur menarche, durasi, frekuensi, keteraturan,
masalah/gangguan menstruasi
........................................................................................................................................
........................................................................................................................................
b. Perkembangan pemeriksaan payudara sendiri dan testis sendiri

........................................................................................................................................
........................................................................................................................................
c. Usia disunat, mimpi basah

........................................................................................................................................
........................................................................................................................................
d. Hubungan seksual yang dilakukan pasien, adakah keterbatasannya terkait dengan
kondisi saat ini
........................................................................................................................................
e. Keluhan-keluhan kaitannnya dengan reproduksi

........................................................................................................................................
........................................................................................................................................
f. Metode KB yang digunakan

........................................................................................................................................
........................................................................................................................................
g. Pengetahuan pasien tentang seksualitas dan reproduksi

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

DATA OBYEKTIF
a. Sunat, testis sudah turun/belum, dircharge vagina,
pembengkakan
..........................................................................................
..........................................................................................
..........................................................................................
..
b. Pemeriksaan fisik : cairan yang keluar dari vagina/lokhea,

perdarahan diantara menstruasi, benjolan di payudara,
..........................................................................................
..........................................................................................
..........................................................................................
..
c. Tinggi fundus uteri

..........................................................................................
..........................................................................................
..........................................................................................
..
9. KOPING/TOLERANSI STRESS
DATA SUBYEKTIF
a. Apakah perubahan kesehatan saat ini menyebabkan anda stress? Jika ya, apa
alasannya.....(adanya perubahan konsep diri, perubahan status sosial, ekonomi,
lingkungan, ancaman kematian, ancaman konsep diri, kebutuhan yang tidak
terpenuhi, mengalami proses menjelang ajal, ragu/tidak percaya pada prognosis)
........................................................................................................................................
........................................................................................................................................
b. Penggunaan obat atau alkohol untuk koping stress (tuliskan penggunaan lain kalau
ada)
........................................................................................................................................
........................................................................................................................................
c. Apa yang anda rasakan saat mengalami stress (pada anak : enuresis)
........................................................................................................................................
........................................................................................................................................
d. Apa mekanisme strategi koping saat menghadapi stress : ketakutan, kesedihan, rasa
berduka (mekanisme pertahanan ego : proyeksi, retraksi, regresi)
........................................................................................................................................
........................................................................................................................................
e. Apakah upaya yang anda lakukan selama ini dapat mengurangi/mengatasi stress
........................................................................................................................................
........................................................................................................................................
f. Persepsi tentang status keamanan di rumah, misal kekerasan fisik/emosional pada

anak dalam keluarga
........................................................................................................................................
........................................................................................................................................

g. Adakah rencana orang tua terhadap masalah-masalah yang sering muncul pada
anak-anak, jika ada uraikan......
........................................................................................................................................
........................................................................................................................................
DATA OBYEKTIF
Catat perilaku atau manifestasi psikologis dari mood, afek, kecemasan dan stress (suara
bergetar, tremor, peningkatan keringat, gemetar, peningkatan kewaspadaan
pendengaran/penglihatan/sensasi, bingung, khawatir, gelisah, ragu, tidak percaya diri,
perubahan tanda-tanda vital : tekanan darah, suhu, nadi, pernafasan) ---lihat batasan
karakteristik DOMAIN 9
Level Stress (1 s.d 6)
...............................................................................................................................................
...............................................................................................................................................
10. PRINSIP HIDUP

Data Subyektif
a. Bagaimana pandangan anda terhadap kesehatan sesuai keyakinan anda
........................................................................................................................................
........................................................................................................................................
b. Apa yang anda hargai dalam hidup ini (pusat kehidupan : keluarga, pekerjaan, harta,
agama)
........................................................................................................................................
........................................................................................................................................
c. Bagaimana kepatuhan anda dengan pola diit dan pengobatan yang berkaitan dengan
keyakinan hidup anda
........................................................................................................................................
........................................................................................................................................
d. Apakah kebiasaan/adat istiadat dan tradisi yang dianut? Jelaskan......, apakah hal
tersebut mendukung/menghambat kesehatan...
........................................................................................................................................
........................................................................................................................................
e. Apakah status kesehatan saat ini mempengaruhi aktifitas spiritualitas anda

........................................................................................................................................
........................................................................................................................................
f. Kegiataan keagamaan yang sering diikuti, peran dalam kegiatan keagamaan tersebut
........................................................................................................................................
........................................................................................................................................
g. Bagaimana kesadaran anda akan perintah Tuhan

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

Data Obyektif
a. Perilaku beribadah klien
........................................................................................................................................
........................................................................................................................................
b. Amati perilaku kepatuhan terhadap program terapi

........................................................................................................................................
........................................................................................................................................
11. KEAMANAN/PROTEKSI
DATA SUBYEKTIF
a. Adakah riwayat cedera, kecelakaan risiko jatuh,
........................................................................................................................................
........................................................................................................................................
b. Adakah keluhan nyeri, (bila ada kaji keluhan nyeri dengan PQRST)
........................................................................................................................................
........................................................................................................................................
c. Adakah keluhan sesag napas, batuk (produktif/tidak produktif), perubahan suhu

badan (hipotermi/hipertermi)
........................................................................................................................................
........................................................................................................................................
d. Riwayat terpapar dengan bahaya saat di rumah atau tempat kerja atau di rumah sakit
(x-ray/radiologi, bahan kimia, mesin, polutan, asap rokok, binatang)
........................................................................................................................................
........................................................................................................................................
e. Kemungkinan terpapar penyakit menular dan patogen (tranfusi darah, gigitan

binatang/serangga, terpapar dengan orang terinfeksi)
........................................................................................................................................
........................................................................................................................................
f. Riwayat penggunaan obat-obatan imunosupresan ( kemoterapi, kortikosteroid, dll)

........................................................................................................................................
........................................................................................................................................
g. Riwayat alergi, penyakit menular, imunisasi, defisiensi imun atau penyakit autoimun
........................................................................................................................................
........................................................................................................................................
h. Bayi : rhesus, ABO incompatibility, Comb test, jarak rupture membrane amnion,
adanya mekonium
........................................................................................................................................
........................................................................................................................................

i. Pediatrik – lingkungan aman untuk anak, imunisasi lengkap
........................................................................................................................................
........................................................................................................................................
DATA OBYEKTIF
a. Keadaan umum: letih, lemah, gelissah, kesadaran
........................................................................................................................................
........................................................................................................................................
b. Periksa Vital sign : S, N,R

........................................................................................................................................
........................................................................................................................................
c. Adakah tanda-tanda infeksi (rubor, dolor, kalor, tumor, fungsio laesa)

........................................................................................................................................
........................................................................................................................................
d. Amati adanya edema dan luka (jenis luka : terbuka/tertutup, ukuran, warna,
drainage, bau)
........................................................................................................................................
........................................................................................................................................
e. Observasi pemasangan /tindakan invasif : jenis, waktu, kondisi

........................................................................................................................................
........................................................................................................................................
f. Observasi suara napas (ronchi , wezing, crakkles, friction rub, stridor)

........................................................................................................................................
........................................................................................................................................
g. Observasi adanya batuk, jenis batuk,

........................................................................................................................................
........................................................................................................................................
h. Faktor lingkungan yang membahayakan : lantai licin, tangga, tinggi tempat tidur,
pengaman tempat tidur). Barang –barang yang membahayakan bagi anak
........................................................................................................................................
........................................................................................................................................
i. Periksa keadaan Kondisi gigi : caries, gigi goyah, gigi palsu, gigi tidak sejajar,
pengikisan email, plak yang berlebihan, karang gigi
........................................................................................................................................
........................................................................................................................................
j. Hasil pemeriksaaan lab : WBC, HB, RBC, Trombosit, albumin, kultur, sensitifitas,
Imunoglobulin
........................................................................................................................................
........................................................................................................................................

k. Penggunaan protese
........................................................................................................................................
........................................................................................................................................
12. KENYAMANAN
DATA SUBYEKTIF
a. Bagaimana perasaan anda terhadap keadaan saat ini (cemas, takut, gangguan pola
tidur, kurang privasi, kurang puas
........................................................................................................................................
........................................................................................................................................
b. Bagaimana perasaan anda selama dirawat di RS?

........................................................................................................................................
........................................................................................................................................
c. Bagaimana hubungan anda dengan keluarga, teman, petugas kesehatan?

........................................................................................................................................
........................................................................................................................................
d. Apa saja yang menyebabkan anda merasa tidak nyaman?

........................................................................................................................................
........................................................................................................................................
e. Adakah peningkatan produksi saliva(hipersalivasi)?

........................................................................................................................................
........................................................................................................................................
f. Apakah anda merasa mual?

........................................................................................................................................
........................................................................................................................................
g. Adakah nyeri, jika ya kaji PQRST

........................................................................................................................................
........................................................................................................................................
h. Apa tindakan yang anda lakukan ketika nyeri, bagaimana efektifitas dari tindakan
tersebut
........................................................................................................................................
........................................................................................................................................
DATA OBYEKTIF
a. Amati respon pasien terhadap ketidaknyamanan : emesis, insomnia, kurang
konsentrasi, cemas, iritabel, ekspresi wajah, perubahan vital sign, posisi antalgik,
........................................................................................................................................
........................................................................................................................................
b. Amati respon pasien terhadap nyeri

........................................................................................................................................
........................................................................................................................................
c. Observasi adanya perubahan nafsu makan

........................................................................................................................................
........................................................................................................................................
d. Observasi interaksi pasien dengan orang lain

........................................................................................................................................
........................................................................................................................................
e. Observasi Respon pasien terhadap pemberian analgetik

........................................................................................................................................
........................................................................................................................................
13. PERTUMBUHAN/PERKEMBANGAN
DATA SUBYEKTIF
a. Perubahan kondisi mood
........................................................................................................................................
........................................................................................................................................
b. Penurunan kognitif
........................................................................................................................................
........................................................................................................................................
c. Penurunan partisipasi dalam aktifitas hidup sehari-hari

........................................................................................................................................
........................................................................................................................................
d. Penurunan ketrampilan sosial

........................................................................................................................................
........................................................................................................................................
e. Ungkapan kehilangan minat pada hal-hal yang menyenangkan

........................................................................................................................................
........................................................................................................................................
f. Asupan nutrisi tidak adekuat

........................................................................................................................................
........................................................................................................................................
g. Mengabaikan lingkungan rumah

........................................................................................................................................
........................................................................................................................................
h. Mengabaikan tanggung jawab finansial

........................................................................................................................................
........................................................................................................................................
i. Penurunan kondisi fisik

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

j. Defisit perawatan diri
........................................................................................................................................
........................................................................................................................................
k. Menarik diri dari lingkungan sosial

........................................................................................................................................
........................................................................................................................................
l. Mengatakan keinginan untuk mati

........................................................................................................................................
........................................................................................................................................
m. Riwayat pre natal (gangguan kongenital, genetik, infeksi maternal, gangguan

endokrin, penyalahgunaan zat, kehamilan kembar, pemajanan teratogen, kehamilan
tidak diinginkan, usia ibu < 15 tahun, usia ibu >35 tahun)
........................................................................................................................................
........................................................................................................................................
n. Bagaimana ketrampilan umum sesuai kelompok usia (anak usia sekolah dan remaja).
........................................................................................................................................
........................................................................................................................................
Pada anak-anak, tambahkan pengkajian tentang :

a. Ungkapan orang tua tentang pertumbuhan perkembangan klien saat ini
(tahap perkembangan erik erikson: kepercayaan Vs kecurigaan, otonomi vs
malu dan ragu, inisiatif vs rasa bersalah, rasa mampu , rajin vs rendah diri,
identitas vs kebingungan identitas, intiminitas vs isolasi, generatifitas vs
stagnasi, integritas ego vs putus harapan)
........................................................................................................................................
........................................................................................................................................
b. Kemampuan melakukan aktifitas perawatan diri yang sesuai dengan usianya

........................................................................................................................................
........................................................................................................................................
c. Aktifitas pengendalian diri

........................................................................................................................................
........................................................................................................................................
d. Riwayat penganiayaan (child abuse) fisik/psikologis

........................................................................................................................................
........................................................................................................................................
e. Kaji kesulitan belajar

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

DATA OBYEKTIF
a. Berat badan (penurunan BB 5 % dalam 1 bulan, 10 % dalam 6 bulan)
........................................................................................................................................
........................................................................................................................................
b. Apatis
........................................................................................................................................
........................................................................................................................................
c. Penyakit mental
........................................................................................................................................
........................................................................................................................................
Pada anak-anak :
Untuk usia 0 – 5 tahun, lakukan Denver Development Screening Tes II (DDST II)
a. Motorik kasar
.......................................................................................................................
.................
b. Motorik Halus
.......................................................................................................................
.................
c. Personal Sosial
.......................................................................................................................
.................
d. Bahasa
.......................................................................................................................
.................
e. Observasi pertumbuhan fisik (lihat grafik pertumbuhan anak) dan

gangguan/ketunadayaan fisik
.......................................................................................................................
.................
DATA PENUNJANG
1. Hasil Pemeriksaan Laboratorium, radiologi, tindakan yang sudah dilakukan untuk pasien dan
program terapi

ANALISA DATA
NO DATA SENJANG ETIOLOGI PROBLEM

B. Urutan Diagnosa Keperawatan Berdasarkan Priorita

p. Rencana Tindakan Keperapan/Nursing Care Plan
NO HARI/TANGGAL DIAGNOSA KEP TUJUAN INTERVENSI IMPLEMENTASI EVALUASI

Rencana Tindakan Keperapan/Nursing Care Plan




1. Rencana Tindakan Keperapan/Nursing Care Plan

Catatan perkembangan
NO HARI/TGL SOAPIE

NO HARI/TGL SOAPIE

NO HARI/TGL SOAPIE

NO HARI/TGL SOAPIE


Format Pengkjian 13 Domain

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Format Pengkjian 13 Domain

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FORMAT ASUHAN KEPERAWATAN (MA : ..................

II. Identitas Penanggung Jawab/Orang Tua/Wali

III. Keluhan Utama

IV. Riwayat Penyakit Sekarang (alasan masuk Rumah Sakit)

semakin lemes dan panas, kmdian di bawa ke RS mondok di bangsala bakung.

Format pengkajian 13 domain NANDA

e. Upaya-upaya penyembuhan yang dilakukan saat ini (terapi, obat-obatan, suplemen

f. Riwayat alergi obat/makanan/lainnya

g. Rencana antisipasi untuk pulang (Discharge Planning) atau perawatan selanjutnya

h. Perilaku-perilaku yang berresiko terhadap gangguan kesehatan di antaranya : riwayat

i. Riwayat kehamilan dan persalinan (untuk anak & maternitas)

j. Riwayat Immunisasi (jenis immunisasi, jumlah pemberian, waktu pemberian,

Format pengkajian 13 domain NANDA

k. Riwayat alergi dan riwayat sensitifitas

b. Observasi perilaku kepatuhan terhadap program terapi yang diberikan

c. Pengobatan saat ini (Obat, herbal, vitamin)

Obat Dosis Frekuensi

Format pengkajian 13 domain NANDA

f. Makanan dan minuman yang disukai dan yang tidak disukai

g. Penggunaan alat makan (sendok, piring khusus)

h. Pembatasan diet atau makanan yang dianjurkan

i. Penggunaan suplemen, vitamin, makanan energi

j. Penggunaan alat bantu nutrisi (misal : NGT)

k. Riwayat alergi makanan

n. Riwayat makan kaji sesuai usia anak (untuk Keperawatan Anak)

Format pengkajian 13 domain NANDA

b. Body Mass Index/BMI (kurus, sedang, gemuk, obesitas)

e. Tinggi badan, berat badan

f. Kondisi mulut, bibir, membran mukosa, sclera, konjunctiva

h. Kondisi gigi, gusi, perdarahan gusi

i. Kondisi luka atau bekas-bekas luka

j. Kondisi rambut, kulit dan kuku (integritas, warna)

k. Intake oral dan cairan intravena

Format pengkajian 13 domain NANDA

b. Kapan BAB dan BAK terakhir

c. Penggunaan laxative atau diuretik

Format pengkajian 13 domain NANDA

b. Aktifitas yang dilakukan di rumah/di tempat kerja

c. Perasaan/persepsi respon terhadap aktifitas (pusing, lemah, dll)

e. Aktifitas-aktifitas pada saat waktu luang (hobi)

f. Kemampuan untuk makan, mandi, toileting, mobilitas di tempat tidur, berpakaian,

Format pengkajian 13 domain NANDA

h. Riwayat masalah sendi dan tulang belakang atau kelemahan

i. Riwayat merokok, berapa banyak dan berapa lama

j. Riwayat penyakit individu/keluarga : jantung, hipertensi, Asma, TB

k. Riwayat bisa melakukan motorik kasar dan motorik halus

l. Jumlah jam tidur dalam 24 jam

m. Frekuensi periode istirahat

n. Jam berapa tidur malam

o. Waktu terbangun siang hari

p. Masalah yang dirasakan, kesulitan tidur, sering terbangun lebih awal

q. Kebiasaan tidur/istirahat yang terbalik (siang tidur, malam istirahat)

r. Keluhan saat bangun tidur

Format pengkajian 13 domain NANDA

t. Penggunaan bantuan tidur (seperti obat)

v. Rutinitas dan ritual pengantar waktu tidur, item keamanan

b. Postur gaya berjalan

c. Tes range of motion (ROM) sendi

d. Tes kekuatan, tonus dan massa otot

f. Palpasi nadi : teraba atau tidak, rate, irama dan kualitas

Format pengkajian 13 domain NANDA

i. Auskultasi bunyi nafas, catat adanya suara nafas tambahan

j. Catat jumlah dan karakter pernafasan, adanya kesulitan/kelainan (retraksi, batuk,