Format Pengkajian Keperawatan

STIKes Maharani Malang

Jl. Akordion Selatan 8B Malang
www.stikesmaharani.ac.id

Nama Mahasiswa: Tempat Praktek:

NIM : Tgl. Praktek :

A. Identitas Klien
Nama :......................................... No.RM :.......................................
Usia :......................................... Tgl. Masuk :.......................................
Jenis Kelamin :......................................... Tgl. Pengkajian :.......................................
Alamat :......................................... Sumber Informasi :.......................................
No. Telepon :......................................... Nama klg. Dekat yng bisa dihubungi:................
Status Pernikahan:......................................... ...........................................................................
Agama :......................................... Status :.......................................
Suku :.......................................... Alamat :.......................................
Pendidikan :......................................... No. Telepon :.......................................
Pekerjaan :......................................... Pendidikan :.......................................
Lama Bekerja :......................................... Pekerjaan :.......................................

B. Status Kesehatan Saat Ini

1. Keluhan utama :
a. Saat MRS : ........................................................................................................
b. Saat Pengkajian : ........................................................................................................
2. Lama Keluhan : …………………………………………………………………………….
3. Kualitas Keluhan : …………………………………………………………………………….
4. Faktor Pencetus : …………………………………………………………………………….
5. Faktor Pemberat : …………………………………………………………………………….
6. Upaya yg telah dilakukan: …………………………………………………………………………
7. Diagnosa Medis :
1. ..................................................................... tanggal...................................................
2. ..................................................................... tanggal...................................................
3. ..................................................................... tanggal...................................................

C. Riwayat Kesehatan Saat Ini

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D. Riwayat Kesehatan Terdahulu
1. Penyakit yang pernah dialami :
1. Kecelakaan (jenis & waktu) :.................................................................................................
2. Operasi (jenis & waktu) : .................................................................................................
3. Penyakit:
 Akut : ........................................................................................................................
 Kronis : ........................................................................................................................
2. Alergi (obat, makanan, plester, dll):
Tipe Reaksi Lamanya
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3. Kebiasaan
Jenis Frekuensi Jumlah Lamanya
Merokok ............................................ ................................... ...................................
Kopi ............................................ ................................... ...................................
Alkohol ............................................ ................................... ...................................
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4. Obat-obatan yang digunakan

Jenis
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Lamanya
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Dosis
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E. Riwayat Keluarga
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GENOGRAM

Keterangan:
: Laki-laki
: Perempuan
: Garis keturunan
: Hubungan pernikahan
: Klien
: Tinggal dalam satu rumah

: Meninggal dunia
F. Riwayat Lingkungan
Jenis Rumah Pekerjaan
 Kebersihan .................................................... ...................................................
 Bahaya kecelakaan ................................................... ...................................................
 Polusi ................................................... ...................................................
 Ventilasi ................................................... ...................................................
 Pencahayaan ................................................... ...................................................

G. Pola Aktivitas-Latihan
Jenis Rumah Rumah Sakit
 Makan/Minum ........................................................ ................................................................
 Mandi ....................................................... ...............................................................
 Berpakaian ....................................................... ..............................................................
 Toiletting ....................................................... ...............................................................
 Mobilitas ....................................................... ..............................................................
 Berpindah ...................................................... ................................................................
 Berjalan ....................................................... ...............................................................
 Naik tangga ....................................................... ................................................................
Pemberian Skor: 0=mandiri, 1=alat bantu, 2=dibantu orang lain (1 orang), 3=dibantu orang lain (>1 orang),
4=tidak mampu

Masalah kep : ____________________________________________________________

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H. Pola Nutrisi
Jenis Rumah Rumah Sakit
Makan
 Jenis diit/makanan .................................................... ...................................................
 Frekuensi/pola ................................................... ...................................................
 Porsi yang dihabiskan ................................................... ...................................................
 Komposisi menu ................................................... ...................................................
 Pantangan ................................................... ...................................................
 Nafsu makan ................................................... ...................................................
 Fluktuasi BB 6 bl trhr ................................................... ...................................................
Minum
 Jenis minuman ................................................... ...................................................
 Frekuensi/pola minum ................................................... ...................................................
 Gelas yang dihabiskan ................................................... ...................................................
 Sukar menelan ................................................... ...................................................
 Pemakaian gigi palsu ................................................... ...................................................
 Riw.masalah
penyembuhan luka ................................................... ...................................................

I. Pola Eliminasi
Jenis Rumah Rumah Sakit
BAB
 Frekuensi/pola .................................................... ...................................................
 Konsistensi .................................................... ...................................................
 Warna & bau .................................................... ...................................................
 Kesulitan .................................................... ...................................................
  Upaya mengetasi .................................................... ...................................................
BAK
 Frekuensi/pola .................................................... ...................................................
 Konsistensi .................................................... ...................................................
 Warna & bau .................................................... ...................................................
 Kesulitan .................................................... ...................................................
 Upaya mengetasi .................................................... ...................................................

J. Pola Tidur-Istirahat
Rumah Rumah Sakit
 Tidur siang: Lamanya ........................................... ..................................................
- Jam .....s/d...... ........................................... ...................................................
- Kenyamanan stl tidur ........................................... ...................................................
 Tidur malam: Lamanya ........................................... ...................................................
- Jam .....s/d...... ........................................... ...................................................
- Kenyamanan stl tidur ........................................... ...................................................
- Kebiasaan sbl tidur ........................................... ...................................................
- Kesulitan ........................................... ...................................................
- Upaya mengatasi ........................................... ...................................................

K. Pola Kebersihan Diri

Rumah
 Mandi: Frekuensi ...........................................
- Penggunaan sabun ...........................................
 Keramas: Frekuensi ...........................................
- Penggunaan Shampo ...........................................
 Gosok gigi: Frekuensi ...........................................
- Penggunaan odol ...........................................
 Ganti baju: Frekuensi ...........................................
 Memotong kuku: Frekuensi.....................................
 Kesulitan ...........................................
 Upaya yang dilakuan ...........................................
Rumah Sakit
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L. Pola Toleransi Koping Stress

1. Pengembilan keputusan: ( ) sendiri, ( ) dibantu orang lain, ........................................................
2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri, dll).......
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3. Yang biasa dilakukan apabila stres/mengalami masalah ..........................................................
4. Harapan setelah menjalani perawatan.......................................................................................
5. Perubahan yang dirasa setelah sakit.........................................................................................

M. Pola peran & Hubungan

1. Peran dalam keluarga................................................................................................................
2. Sistem pendukung: suami/istri/tetangga/teman/keluarga/tidak ada, sebutkan ..........................
3. Kesulitan dalam keluarga ( ) Hub. dgn orang tua ( ) Hub.dgn pasangan
( ) Hub. dgn sanak saudara ( ) Hub. dgn anak
( ) Lain-lain sebutkan
4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS .........................
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5. Upaya yang dilakukan untuk mengatasi.....................................................................................
N. Pola Komunikasi
1. Bicara: ( ) Normal Bahasa utama:
( ) Tidak Jelas ( ) Bahasa daerah ( ) Bahasa Indonesia
( ) Bicara berputar-putar ( ) Rentang perhatian
( ) Mampu mengerti pembicaraan orang lain ( ) Afek........................................
2. Tempat tinggal: ( ) Sendiri
( ) Kos/asrama
( ) Bersama orang lain, yaitu: ...............................................................
3. Kehidupan Keluarga
a. Adat istiadat yag dianut: ......................................................................................................
b. Pantangan adat dan agama yang dianut: ...........................................................................
c. Penghasilan Keluarga: ( ) < Rp 500.000 ( ) Rp 2 juta – 3 juta
( ) Rp 500.000 – 1 juta ( ) Rp 3 juta – 4 juta
( ) Rp 1 juta – 2 juta ( ) > 4 juta

O. Pola Seksualitas
1. Masalah dalam hubungan seksual selama sakit: ( ) Tidak ada ( ) Ada
2. Upaya yang dilakukan pasangan: ( ) Perhatian ( ) Sentuhan
( ) Lain-lain, seperti ...................................................................................................................

P. Pola Nilai & Kepercayaan

1. Apakah Tuhan dan agama penting untuk anda: ( ) Ya ( ) Tidak
2. Kegiatan keagamaan yang dilakukan di rumah (jenis dan frekuensi):.....................................
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3. Kegiatan keagamaan yang tidak dapat dilakukan di RS: ........................................................
4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya: .........................................

Q. Konsep Diri
a. Citra tubuh : ………………………………………………………………………………..........
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b. Identitas : ………………………………………………………………………....………......
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c. Peran : …………………………………………………………………………....……......
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d. Ideal diri : …………………………………………………………....……………………......
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e. Hargadiri : ……………………………………………………….......…………………………
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R. Pemeriksaan fisik
1. Keadaan umum:.......................................................................................................................
a. Kesadaran: ........................................................................................................................
b. Tanda tanda vital: Tek.darah : ..........mmHg Suhu : ..............oC
Nadi : ..........x/m Pernapasan : ..............x/m
2. Kepala dan leher
a. Kepala:
 Bentuk.......... Massa..........Distribusi Rambut ...................Warna kulit kepala............
 Keluhan: pusing/sakit kepala/migren/lainnya, sebutkan .............................................
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 b. Mata
 Bentuk ................................. Konjungtiva ........................................
 Pupil: ( ) Reaksi terhadap cahaya ( ) Isokor ( ) Meiosis ( ) Pin Point ( ) Midriasis
 Tanda radang:...............................................................................................................
 Fungsi penglihatan: ( ) Baik ( ) Kabur
 Penggunaan alat bantu: ( ) ya ( ) tidak
Apabila ya: ( ) kaca mata ( ) lensa kontak
( ) minus.....ka/ki ( ) plus....ka/ki
 Pemeriksaan mata terakhir: .........................................................................................
 Riwayat operasi: .........................................................................................................
c. Hidung
 Bentuk......................... Warna ............................... Pembengkakan...........Nyeri
tekan........ Pendarahan......... Sinus ...............
 Riwayat Alergi......... Cara mengatasi .........................................................................
 Penyakit yang pernah terjadi ......................................................................................
 Frekuensi.......................................... Cara mengatasi ................................................
d. Mulut dan tenggorokan
 Warna bibir ...................... Mukosa.................. Ulkus.........Lesi............ Massa...........
Warna lidah............................Perdarahan gusi .............Karies...................................
Gangg bicara................................................
 Pemeriksaan gigi terakhir.............................................................................................
e. Telinga
 Bentuk .............................Warna ......................Lesi......... Massa ......... Nyeri..........
Nyeri Tekan...........
 Fungsi Pendengaran ......... ....Alat bantu pendengaran ..............................................
 Masalah Yang Pernah Terjadi: ...................................................................................
f. Leher
 Kekakuan.......... .....................Nyeri/nyeri tekan...................................
 Benjolan/ Massa........ ............Keterbatasan gerak........................
 Vena jugularis : ..................Tiroid...............Limfe................. Trakea........................
Keluhan: ......................................................................................................................
 Upaya untuk mengatasi ...............................................................................................
3. Dada
 Bentuk .......................................... Pergerakan Dada ..........................................................
 Nyeri/nyeri tekan......Massa.........Peradangan......Taktil Fremitus ........................................
Pola Nafas .................................................................
 Jantung
Inspeksi................................................................................................................................
Palpasi .................................................................................................................................
Perkusi .................................................................................................................................
Auskultasi .............................................................................................................................
 Paru:
Inspeksi................................................................................................................................
Palpasi ..................................................................................................................................
Perkusi ................................................................................................................................
Auskultasi ............................................................................................................................
4. Payudara dan ketiak
 Benjolan/Massa: .........................Nyeri/nyeri tekan ..............................................
 Bengkak ....................... ...Kesimetrisan: ................................................................
5. Abdomen
  Inspeksi: .............................................................................................................................
 Palpasi: ...............................................................................................................................
 Perkusi: ..............................................................................................................................
 Auskultasi: ............................................................................................................................
6. Genitalia
 Inspeksi : ...........................................................................................
 Palpasi : ...........................................................................................
 Perempuan: Siklus Menstruasi ..........................................................................
 Kontrasepsi ........................................................................................................
 Kehamilan ..........................................................................................................
 Keluhan ..............................................................................................................
 Pria: Keluhan ......................................................................................................
7. Ekstremitas
 Kekuatan otot: .............................................................................................................
Kontraktur ..............Pergerakan .........................Deformitas .......... Pembengkakan ...........
Edema ............... Nyeri/nyeri tekan ..............Pus/luka ........................................................
8. Kulit dan Kuku
 Kulit : Warna .................Jaringan parut: .............
Lesi........... Suhu........... Tekstur .............
Turgor.......................................................
 Kuku : Warna ..................................... Bentuk .................................................
Lesi ........................................ Pengisian Kapiler ..................................
Hasil pemeriksaan penunjang
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S. Pengobatan
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T. Perencanaan Pulang
 Tujuan Pulang: .....................................................................................................................
 Transportasi Pulang: ..............................................................................................................
 Dukungan Keluarga: ..............................................................................................................
 Antisipasi bantuan biaya setelah pulang: ...............................................................................
 Antisipasi masalah perawatan diri setalah pulang: .................................................................
 Pengobatan: ..........................................................................................................................
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 Hal-hal yang perlu diperhatikan di rumah: .............................................................................

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 Keterangan lain: ....................................................................................................................