PROGRAM STUDI S1 KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN (STIKES)

BHAKTI HUSADA MULIA MADIUN

FORMAT PENGKAJIAN

A. Identitas Klien
Nama :.........................................................No. Reg :.......................................................
Usia :.................. tahun Tgl. Masuk :.......................................................
Jenis kelamin :.........................................................Tgl. Pengkajian :.......................................................
Alamat :.........................................................Sumber informasi :.......................................................
Nama klg. dekat yg bisa dihubungi:.....................................................
Status pernikahan :......................................................... ........................................................
Agama :.........................................................Status :.......................................................
Suku :.........................................................Alamat :.......................................................

B. RIWAYAT KEPERAWATAN
a. RIWAYAT KESEHATAN PASIEN
Keluhan Utama : .....................................................................................................................
Riwayat Kesehatan Saat Ini
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Riwayat Kesehatan Terdahulu

1. Penyakit yg pernah dialami:
2. Alergi (obat, makanan, plester, dll):

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 3. Kebiasaan:

4. Obat-obatan yg digunakan:

Riwayat Kesehatan Keluarga

Dengan siapa klien tinggal dan berapa jumah keluarga?
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Apakah ada anggota keluarga yang menderita penyakit serupa?
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Apakah ada keluarga yang mempunyai penyakit menular atau menurun?
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Bagaimana efek yang terjadi pada keluarga bila salah satu anggota keluarga
sakit?
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GENOGRAM

C. Riwayat Lingkungan
Jenis Rumah
Pekerjaan
 Kebersihan .......................................................................... .......................................
 Bahaya kecelakaan .......................................................................... .......................................
 Polusi .......................................................................... .......................................
 Ventilasi .......................................................................... .......................................
 Pencahayaan .......................................................................... .......................................

D. Pola Aktifitas-Latihan
Rumah Rumah
Sakit
 Makan/minum ...................................................................... ...................................

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  Mandi ...................................................................... ...................................
 Berpakaian/berdandan ...................................................................... ...................................
 Toileting ...................................................................... ...................................
 Mobilitas di tempat tidur ......................................................................
 Berpindah ...................................................................... ...................................
 Berjalan ...................................................................... ...................................
 Naik tangga ...................................................................... ...................................
Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang
lain, 4 = tidak mampu

E. Pola Nutrisi Metabolik

Rumah Rumah
Sakit
 Jenis diit/makanan .............................................................. ...............................
 Frekuensi/pola .............................................................. ...............................
 Porsi yg dihabiskan .............................................................. ...............................
 Komposisi menu .............................................................. ...............................
 Pantangan .............................................................. ...............................
 Nafsu makan .............................................................. ...............................
 Jenis minuman .............................................................. ...............................
 Frekuensi/pola minum .............................................................. ...............................
 Sukar menelan (padat/cair) .............................................................. ...............................

F. Pola Eliminasi
Rumah Rumah
Sakit
 BAB:
- Frekuensi/pola ...................................................................... .................................
- Warna & bau ...................................................................... .................................
- Kesulitan ...................................................................... .................................
- Upaya mengatasi ...................................................................... .................................

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  BAK:
- Frekuensi/pola ...................................................................... .................................
- Warna & bau ...................................................................... .................................
- Kesulitan ...................................................................... .................................
- Upaya mengatasi ...................................................................... .................................

G. Pola Tidur-Istirahat
Rumah Rumah
Sakit
 Tidur siang:Lamanya ............................................................. ...........................
 Tidur malam: Lamanya ............................................................. ..............................
- Kebiasaan sebelum tidur .............................................................. .............................
- Kesulitan .............................................................. .............................
- Upaya mengatasi .............................................................. .............................

H. Pola Kebersihan Diri

Rumah Rumah
Sakit
 Mandi:Frekuensi .................................................................. ...............................
- Penggunaan sabun ................................................................ ..............................
 Keramas: Frekuensi .................................................................. ...............................
- Penggunaan shampoo ................................................................ ..............................
 Gosok gigi: Frekuensi .................................................................. ...............................
- Penggunaan odol .................................................................... ..............................
 Kesulitan .................................................................. ...............................
 Upaya yg dilakukan .................................................................. ...............................

I. Pola Toleransi-Koping Stres

1. Pengambilan keputusan: ( ) sendiri ( ) dibantu orang lain, sebutkan,........................
2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri,
dll):

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 3. Harapan setelah menjalani perawatan:..............................................................................................

J. Pola Peran & Hubungan

1. Peran dalam keluarga................................................................................................................................
2. Sistem pendukung:suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain,
sebutkan:........................................................................................................................................................
3. Kesulitan dalam keluarga: ( ) Hub. dengan orang tua
( ) Hub.dengan
( ) Hub. dengan sanak saudara
( ) Hub.dengan anak

K. Pola Komunikasi
1. Bicara: ( ) Normal ( ) Bahasa utama:........................
( ) Tidak jelas ( ) Bahasa daerah:.......................
( ) Bicara berputar-putar ( ) Rentang perhatian:...............
( ) Mampu mengerti pembicaraan ( ) Afek:............................................
2. Kehidupan keluarga
a. Adat istiadat yg dianut:.......................................................................................................................
b. Pantangan & agama yg dianut:........................................................................................................

L. Pola Seksualitas
1. Masalah dalam hubungan seksual selama sakit: ( ) tidak ada ( ) ada
2. Upaya yang dilakukan pasangan:
( ) perhatian ( ) sentuhan ( ) lain-lain, seperti, ...............................................

M. Pola Nilai & Kepercayaan

1. Apakah Tuhan, agama, kepercayaan penting untuk Anda, Ya/Tidak
2. Kegiatan agama/kepercayaan yg dilakukan dirumah (jenis & frekuensi):..........................

N. Pemeriksaan Fisik
1. Keadaan umum :
a. Kesadaran :
b. Tanda-tanda vital : - Tekanan Darah : Suhu :
- Nadi : Pernafasan :

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 c. Tinggi Badan : Berat Badan :
2. Kepala dan Leher
a. Kepala : Bentuk Massa
Distribusi rambut Warna kulit kepala
b.Mata : Bentuk Konjungtiva
Pupil : ( ) reaksi terhadap cahaya ( ) isokor ( )Miosis
Tanda-tanda radang :
Funsi penglihatan : ( ) Baik ( ) Kabur
Penggunaan alat bantu : ( ) Ya( ) Tidak
c. Hidung : Bentuk ………….. Warna ………….Pembengkakan …………
Nyeri tekan …….. Perdarahan …………..
Riw. Alergi ……… Cara mengatasinya ……………………………..

d. Mulut dan Tenggorokan :

Warna bibir ……… Mukosa …………… Ulkus …………………...
Lesi ……………… Massa …………….. Warna Lidah
……………
Perdarahan gusi …………………………. Karies …………………..
Kesulitan menelan ………………………
Sakit tenggorok …………………………. Gangguan bicara ………
e. Telinga : Bentuk …………… Warna ……………. Lesi ……………………
Massa ……………. Nyeri …………………………………………..
Fs. Pendengaran…………….Alat bantu pendengaran……………….
f. Leher : Kekakuan………………..Nyeri/Nyeri tekan…………………………
Benjolan/massa……………Keterbatasan gerak…………………….
Vena jugularis……………
3.Dada : Bentuk ………………… Pergerakan Dada ……………………
Nyeri/nyeri tekan ……… Massa …………. Peradangan ……
Pola nafas ………………………………
Jantung : Inspeksi
Perkusi
Auskultasi …………………………………………………..
Paru : Inspeksi
Perkusi
Auskultasi …………………………………………………
4. Payudara dan Ketiak :
Benjolan/massa ……………….. Nyeri/nyeri tekan ……………..
Bengkak ………………………… Kesimetrisan ………………….
5.Abdomen :
Inspeksi ……………………………………………………………….
Auskultasi …………………………………………………………….
Palpasi ………………………………………………………………..
Perkusi ……………………………………………………………….
6. Genetalia :
Inspeksi ………………………………………………………………
Palpasi ………………………………………………………………..

7. Ekstremitas : Kekuatan otot ………………………………………………………

Kontraktur …………………………… Pergerakan ……………….

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 Deformitas ……………………………Pembengkakan …………….
Nyeri/nyeri tekan ……………….
Pus/luka …………………………
8. Kulit Kulit : Warna …………………… Lesi ………………
Turgor ……………
Pengisian kapiler ……………….

O. Hasil Pemeriksaan Penunjang

Laboratorium
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Radiologi
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P. Terapi Pengobatan

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Q. Kesimpulan

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.........................., ......-.......-20......

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 ANALISA DATA

Tanggal Data Etiologi Masalah

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 PRIORITAS DIAGNOSA KEPERAWATAN

1. ................................................................................................................................................
2. ................................................................................................................................................
3. ................................................................................................................................................
4. ................................................................................................................................................

INTERVENSI KEPERAWATAN

HARI/ DIAGNOSA KEPERAWATAN

NO. INTERVENSI
TANGGAL (tujuan dan kriteria hasil)

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 IMPLEMENTASI DAN EVALUASI KEPERAWATAN

Hari pertama, ..........................................

Hari/ Diagnosa
Shift Jam Implementasi Jam Evaluasi (Soap) Paraf
Tanggal Keperawatan

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