JURUSAN KEPERAWATAN P

FAKULTAS KESEHATAN A
UNIVERSITAS TRIBHUWANA TUNGGADEWI G
E

PENGKAJIAN DASAR KEPERAWATAN 1

Nama Mahasiswa : Tempat Praktik :

NIM : Tgl. Praktik :

A. IdentitasKlien
Nama : .......................................... No. RM : ....................................
Usia : ............. tahun Tgl. Masuk : ....................................
Jeniskelamin : .......................................... Tgl. Pengkajian : ....................................
Alamat : .......................................... Sumberinformasi : ....................................
No. telepon : .......................................... Namaklg. dekatygbisadihubungi:...............
Status pernikahan : .......................................... .....................................
Agama : .......................................... Status : ....................................
Suku : .......................................... Alamat : ....................................
Pendidikan : .......................................... No. telepon : ....................................
Pekerjaan : .......................................... Pendidikan : ....................................
Lama berkerja : .......................................... Pekerjaan : ....................................

B. StatuskesehatanSaatIni
1. Keluhan Utama
a. Saat MRS :......... ...................................................................................................
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b. Saat Pengkajian :.......... .………………………………………………………………………..
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2. Riwayat Kesehatan Saat ini
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C. RiwayatKesehatanTerdahulu
1. Penyakitygpernahdialami:
a. Kecelakaan (jenis&waktu) : ..............................................................................................
b. Operasi (jenis&waktu) : ..............................................................................................
c. Penyakit:
 Kronis : .......................................................................................................................
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 Akut : .......................................................................................................................
d. Terakhirmasuki RS : ..............................................................................................
2. Alergi (obat, makanan, plester, dll):
Tipe Reaksi Tindakan
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3. Imunisasi:
( )BCG ( ) Hepatitis
( ) Polio ( ) Campak
( ) DPT ( ) ................
4. Kebiasaan:
Jenis Frekuensi Jumlah Lamanya
Merokok .................................. ....................................... ................................
Kopi .................................. ....................................... ................................
Alkohol .................................. ....................................... ................................

5. Obat-obatanygdigunakan:
Jenis Lamanya Dosis
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D. RiwayatKeluarga
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 GENOGRAM P
A
G
E

E. RiwayatLingkungan
Jenis Rumah Pekerjaan
 Kebersihan ...................................................... ...............................................
 Bahayakecelakaan ...................................................... ...............................................
 Polusi ...................................................... ...............................................
 Ventilasi ...................................................... ...............................................
 Pencahayaan ...................................................... ...............................................

F. PolaAktifitas-Latihan
Rumah RumahSakit
 Makan/minum .................................................. ............................................
 Mandi .................................................. ............................................
 Berpakaian/berdandan .................................................. ............................................
 Toileting .................................................. ............................................
 Mobilitas di tempattidur .................................................. ............................................
 Berpindah .................................................. ............................................
 Berjalan .................................................. ............................................
 Naiktangga .................................................. ............................................
PemberianSkor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang lain, 4 = tidakmampu

G. PolaNutrisiMetabolik
Rumah RumahSakit
 Jenisdiit/makanan ............................................. .........................................
 Frekuensi/pola ............................................. .........................................
 Porsiygdihabiskan ............................................. .........................................
 Komposisi menu ............................................. .........................................
 Pantangan ............................................. .........................................
 Napsumakan ............................................. .........................................
 Fluktuasi BB 6 bln. terakhir ............................................. .........................................
 Jenisminuman ............................................. .........................................
 Frekuensi/polaminum ............................................. .........................................
 Gelasygdihabiskan ............................................. .........................................
  Sukarmenelan (padat/cair) ............................................. ......................................... P
A
 Pemakaiangigipalsu (area) ............................................. ......................................... G
E
 Riw. masalahpenyembuhanluka ............................................. .........................................
1
H. PolaEliminasi
Rumah RumahSakit
 BAB:
- Frekuensi/pola ................................................... ..........................................
- Konsistensi ................................................... ..........................................
- Warna&bau ................................................... ..........................................
- Kesulitan ................................................... ..........................................
- Upayamengatasi ................................................... ..........................................
 BAK:
- Frekuensi/pola ................................................... ..........................................
- Warna&bau ................................................... ..........................................
- Kesulitan ................................................... ..........................................
- Upayamengatasi ................................................... ..........................................

I. PolaTidur-Istirahat
 Tidursiang:Lamanya
- Jam …s/d…
- Kenyamananstlh. tidur
 Tidurmalam: Lamanya
- Jam …s/d…
- Kenyamananstlh. tidur
- Kebiasaansblm. tidur
- Kesulitan
- Upayamengatasi
Rumah
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RumahSakit
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J. PolaKebersihanDiri
 Mandi:Frekuensi
- Penggunaansabun
 Keramas: Frekuensi
- Penggunaan shampoo
 Gosokgigi: Frekuensi
- Penggunaan pasta gigi
 Gantibaju:Frekuensi
 Memotong kuku: Frekuensi
 Kesulitan
 Upayaygdilakukan
Rumah
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RumahSakit
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K. PolaToleransi-KopingStres P
A
1. Pengambilankeputusan: ( ) sendiri ( ) dibantu orang lain, sebutkan, ............................... G
E
2. Masalahutamaterkaitdenganperawatan di RS ataupenyakit (biaya, perawatandiri, dll): ............
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3. Yang biasadilakukanapabila stress/mengalamimasalah: ..........................................................
4. Harapansetelahmenjalaniperawatan: .......................................................................................
5. Perubahan yang dirasa setelah sakit:.......................................................................................

L. KonsepDiri
1. Gambarandiri: ..........................................................................................................................
2. Ideal diri: ..................................................................................................................................
3. Hargadiri: .................................................................................................................................
4. Peran: ......................................................................................................................................
5. Identitasdiri...............................................................................................................................

M. PolaPeran&Hubungan
1. Perandalamkeluarga ................................................................................................................
2. Sistem pendukung:suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain, sebutkan: .....
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3. Kesulitan dalam keluarga:( ) Hub. dengan orang tua ()Hub.dengan pasangan
( )Hub. dengan sanak saudara ( ) Hub.dengan anak
( ) Lain-lain sebutkan, ................................................................
4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS: ........................
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5. Upaya yg dilakukan untuk mengatasi: ......................................................................................
N. PolaKomunikasi
1. Bicara: () Normal ( )Bahasautama: .............................
( ) Tidakjelas ( ) Bahasadaerah: ...........................
( ) Bicaraberputar-putar ( ) Rentangperhatian: ......................
( ) Mampumengertipembicaraan orang lain( ) Afek: ...........................................
2. Tempattinggal: ( ) Sendiri
( ) Kos/asrama
( ) Bersama orang lain, yaitu: .......................................................................
3. Kehidupankeluarga
a. Adatistiadatygdianut: ...........................................................................................................
b. Pantangan& agama ygdianut:..............................................................................................
c. Penghasilan keluarga: ( ) < Rp. 250.000 ( ) Rp. 1 juta – 1.5 juta
( ) Rp. 250.000 – 500.000 ( ) Rp. 1.5 juta – 2 juta
( ) Rp. 500.000 – 1 juta ( ) > 2 juta
O. PolaSeksualitas P
A
1. Masalahdalamhubungan seksual selama sakit: ( ) tidak ada ( ) ada G
E
2. Upaya yang dilakukanpasangan:
( ) perhatian ( ) sentuhan ( ) lain-lain, seperti, .................................................... 1

P. PolaNilai&Kepercayaan
1. ApakahTuhan, agama, kepercayaanpentinguntukAnda, Ya/Tidak
2. Kegiatan agama/kepercayaanygdilakukandirumah (jenis&frekuensi): ......................................
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3. Kegiatan agama/kepercayaantidakdapatdilakukan di RS: ........................................................
4. Harapanklienterhadapperawatuntukmelaksanakanibadahnya: .................................................

Q. PemeriksaanFisik

1. KeadaanUmum: .......................................................................................................................
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 Kesadaran: ..........................................................................................................................
 Tanda-tanda vital: - Tekanandarah :……… mmHg - Suhu :………oC
- Nadi :……...x/menit - RR :……… x/menit
 Tinggibadan: ..................................... cm BeratBadan: ........................ kg
2. Kepala&Leher
a. Kepala:
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b. Mata:
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c. Hidung:
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d. Mulut&tenggorokan:
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E
e. Telinga:
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f. Leher:
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3. Thorak& Dada:
 Jantung
- Inspeksi:..........................................................................................................................
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- Palpasi: ...........................................................................................................................
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- Perkusi: ...........................................................................................................................
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- Auskultasi:.......................................................................................................................
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 Paru
- Inspeksi:..........................................................................................................................
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- Palpasi: ...........................................................................................................................
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- Perkusi: ...........................................................................................................................
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- Auskultasi:.......................................................................................................................
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4. Payudara&Ketiak
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5. Punggung&TulangBelakang
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6. Abdomen P
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 Inspeksi: .............................................................................................................................. G
E
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 Palpasi:................................................................................................................................
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 Perkusi: ...............................................................................................................................
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 Auskultasi: ...........................................................................................................................
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7. Genetalia& Anus
 Inspeksi: ..............................................................................................................................
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 Palpasi:................................................................................................................................
8. Ekstermitas
 Atas: ....................................................................................................................................
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 Bawah: ................................................................................................................................
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9. SistemNeorologi
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10. Kulit& Kuku
 Kulit: ....................................................................................................................................
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 Kuku:…………………………………………………………………………………………………
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R. HasilPemeriksaanPenunjang P
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PersepsiKlienTerhadapPenyakitnya
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