Program S1 Reguler Program Studi Ilmu Keperawatan

Fakultas Kedokteran Unsrat Manado

FORMAT PENGKAJIAN KEPERAWATAN
(Pengorganisasian Berdasarkan Pola Fungsi Kesehatan dari Gordon)

Tanggal pengkajian : Waktu Pengkajian :

Tgl masuk RS : Ruangan/kamar :

A. IDENTIFIKASI
I. KLIEN
Nama (Inisial) : ………………………………………................................
Tempat / Tgl Lahir : ……………………………………....................................
Jenis Kelamin : Laki-laki Perempuan
Status Perkawinan : ………………………………………................................
Jumlah Anak : ............................................................................................
Agama/Suku : ............................................................................................
Warga Negara : Indonesia Asing
Bahasa yang Digunakan : Indonesia.
Daerah.
Asing
Pendidikan : .............................................................................................
Pekerjaan : .............................................................................................
Alamat Rumah : .............................................................................................

II. PENANGGUNG JAWAB

Nama : ................................................................................
Alamat : ................................................................................
Hubungan dengan Klien : ................................................................................

B. DATA MEDIK
I. Dikirim oleh : UGD Dokter Praktek
II. Diagnosa Medik : ................................................................................................
- Saat Masuk : ...........................................................................................
- Saat Pengkajian : ...........................................................................................

C. KEADAAN UMUM
I. Keadaan Sakit : Klien tampak sakit ringan / sedang / berat / tidak tampak sakit
Alasan : Tak Bereaksi / Baring Lemah / Duduk / Aktif / Gelisah / Posisi
Tubuh ........................../ Pucat / Cyanosis / Sesak Napas
Penggunaan Alat Medik: .............................................................................................
Lain-lain : ................................................................................................

II. TANDA – TANDA VITAL :

a. Kesadaran
- Kualitatif : Compos Mentis Somnolens Coma
Apatis Soporocomatous
- Kuantitatif :
Skala Coma Glasgow : Respon Motorik .......... jumlah
Respon Bicara ..........
Respon Membuka Mata ........
Kesimpulan :..........................................................................................
b. Tekanan darah ......................... mmHg
c. Suhu ............°C Oral Axillar Rectal
d. Nadi ............ x / menit

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Program S1 Reguler Program Studi Ilmu Keperawatan
Fakultas Kedokteran Unsrat Manado
e. Pernapasan : frekuensi ............x / menit
Irama : Teratur Kusmaul Cheynes-Stokes
Jenis : Dada Perut

III. PENGUKURAN :
a. Tinggi Badan : ..................cm Berat Badan :..........kg
b. I.M.T (Indeks Massa Tubuh): kg/m2
c. Kesimpulan : ..............................................................................
f. Catatan : ..............................................................................

GENOGRAM :

D. PENGKAJIAN POLA KESEHATAN

I. KAJIAN PERSEPSI KESEHATAN-MANAJEMEN KESEHATAN
Riwayat penyakit yang perna dialami :
(sakit berat, dirawat, kecelakaan, operasi, gangguan kehamilan/persalinan, abortus, trasfusi,
reaksi alergi)
Kapan Catatan
....................................................
.....................................................
Kapan Catatan
.....................................................
.....................................................
a. Data Subjektif
o Keadaan Sebelum Sakit : .....................................................................................................
..............................................................................................................................................
..............................................................................................................................................
o Keadaan Saat Sakit : ...........................................................................................................
..............................................................................................................................................
..............................................................................................................................................
b. Data Objektif
o Observasi
- Kebersihan rambut : .............................................................................
- Kulit kepala : .............................................................................
- Kebersihan kulit : .............................................................................
- Higiene rongga mulut : .............................................................................
- Kebersihan genitalia : .............................................................................
- Kebersihan anus : ..............................................................................

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Program S1 Reguler Program Studi Ilmu Keperawatan
Fakultas Kedokteran Unsrat Manado
II. KAJIAN NUTRISI METABOLIK
a. Data Subjektif
o Keadaan Sebelum Sakit : ............................................................................................
.....................................................................................................................................
.....................................................................................................................................
o Keadaan Saat Sakit : ..................................................................................................
.....................................................................................................................................
.....................................................................................................................................
b. Data Objektif
o Observasi
o Pemeriksaan Fisik
- Keadaan rambut ..........................................................................................
- Hidrasi kulit ..........................................................................................
- Palpebra ..........................................................................................
- Sclera ..........................................................................................
- Hidung ..........................................................................................
- Rongga mulut ..........................................................................................
- Gigi geligi ..........................................................................................
- Kemampuan mengunya keras ..................................................................
- Lidah ......................................................................................................
- Abdomen
 Inspeksi : Bentuk ..........................................................
 Auskultasi : Peristaltik ................x / menit
 Palpasi : Tanda nyeri umum ........................................
Massa ...........................................................
Hidrasi kulit ................................................
Nyeri tekan : R. Epigastrica Titik Mc. Burney
R.Suprapublika R. Illiaca
 Perkusi : .......................................................................
Ascites Negatif
Positif, lingkar perut ......... cm
 Spider neavi Negatif Positif
 Uremik Frost Negatif Positif
 Edema Negatif Positif, lokasi
 Icterik Negatif Positif
 Tanda-tanda radang ................................................................
o Pemeriksaan diagnostik
- Laboratorium : - Lain-lain :

o Terapi : ........................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
III. KAJIAN POLA ELIMINASI
a. Data Subjektif
o Keadaan Sebelum Sakit : ............................................................................................
.....................................................................................................................................
.....................................................................................................................................
o Keadaan Saat Sakit : ..................................................................................................
.....................................................................................................................................
.....................................................................................................................................
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Program S1 Reguler Program Studi Ilmu Keperawatan
Fakultas Kedokteran Unsrat Manado
b. Data Objektif
o Observasi : ..................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
o Pemeriksaan fisik :
 Palpasi suprapubika : Kandung kemih Penuh Kosong
 Nyeri ketuk ginjal :
 Mulut Uretra :
Kiri : Negatif Positif
Kanan : Negatif Positif
 Anus :
- Peradangan : Negatif Positif
- Fisura : Negatif Positif
- Hemoroid : Negatif Positif
- Prolapsus recti : Negatif Positif
o Pemeriksaan diagnostik
- Laboratorium : - Lain-lain :

o Terapi : ........................................................................................................................
.....................................................................................................................................

IV. KAJIAN POLA AKTIVITAS DAN LATIHAN

a. Data Subjektif
o Keadaan Sebelum Sakit : ............................................................................................
.....................................................................................................................................
.....................................................................................................................................
o Keadaan Saat Sakit : ..................................................................................................
.....................................................................................................................................
.....................................................................................................................................
b. Data Objektif
o Observasi : ..................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
 Aktivitas harian :
1. Makan :
2. Mandi : 0 : Mandiri
3. Berpakaian : 1 : Bantuan dengan alat
4. Kerapian : 2 : Bantuan orang
5. Buang air besar : 3 : Bantuan orang dan alat
6. Buang air kecil : 4 : Bantuan penuh
7. Mobilisasi tempat tidur :
8. Ambulasi :
o Pemeriksaan fisik :
 Perfusi darah perifer kuku : …………………………………
 Thorax dan pernapasan :
1. Inspeksi :
Bentik thoraks : .........................................................
Stridor : Negatif Positif
Dyspnea d’Efford : Negatif Positif
Sianosis : Negatif Positif
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Program S1 Reguler Program Studi Ilmu Keperawatan
Fakultas Kedokteran Unsrat Manado
2. Palpasi : Vokal fremitus ...............................
3. Perkusi : Sonor Redup Pekak
4. Auskultasi : Suara napas : ...........................
 Jantung
1. Inspeksi : Ictrus cordis : ....................................
Klien menggunakan alat pacu jantung : Negatif Psitif
2. Palpasi : Ictrus cordis : ...................................
3. Perkusi : Batas atas jantung : ...........................
Batas kanan jantung : .........................................................
Batas kiri jantung : .........................................................
4. Auskultasi : Bunyi jantung II A : .................................
Bunyi jantung II P : .................................
Bunyi jantung I T : .................................
Bunyi jantung I M : .................................
Bunyi jantung III Irama Gallop : Negatif Positif
Murmur : Negatif
Positif : Tempat : .................................
Grade : .................................
HR ..............x / menit
 Lengan dan Tungkai :
Atrofi otot : Negatif Positif, tempat:.....................
Rentang gerak : ............................................................................
Mati sendi : .......................................................
Kaku sendi : .......................................................
Uji kekuatan otot : Kiri : 0 1 2 3 4 5 0 1 2 3 4 5
Kanan : 0 1 2 3 4 5 0 1 2 3 4 5
Reflex Fisiologik : ..........................................................................
Reflex Patologik : Babinski, Kiri Negatif Positif
Kanan Negatif Positif
Clubing jari-jari : Negatif Positif
Varices tungkai : Negatif Positif
 Columna Vertebralis
Inspeksi : Kelainan bentuk : .......................................................
Palpasi : Nyeri tekan : Negatif Positif

o Pemeriksaan diagnostik
- Laboratorium : - Lain-lain :

o Terapi : ..........................................................................................................................
........................................................................................................................................
........................................................................................................................................

V. KAJIAN POLA ISTIRAHAT DAN TIDUR

a. Data Subjektif
o Keadaan Sebelum Sakit : ...........................................................................................
.....................................................................................................................................
.....................................................................................................................................
o Keadaan Saat Sakit : ..................................................................................................
.....................................................................................................................................
.....................................................................................................................................

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Program S1 Reguler Program Studi Ilmu Keperawatan
Fakultas Kedokteran Unsrat Manado
b. Data Objektif
o Observasi :
Expresi wajah mengantuk : Negatif Positif
Banyak menguap : Negatif Positif
o Terapi : ........................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

VI. KAJIAN POLA KOGNITIF PERSEPTUAL

a. Data Subjektif
o Keadaan Sebelum Sakit : ............................................................................................
.....................................................................................................................................
.....................................................................................................................................
o Keadaan Saat Sakit : ..................................................................................................
.....................................................................................................................................
.....................................................................................................................................
b. Data Objektif
o Observasi : ..................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
o Pemeriksaan fisik
 Penglihatan
Cornea : ...................................................................
Visus : ...................................................................
Pupil : ....................................................................
Lensa mata : ...................................................................
 Pendengaran
Canalis : ...................................................................
Membran tympani : ........................................................
Tes pendengaran : ........................................................

VII. KAJIAN POLA PERSEPSI DAN KONSEP DIRI

a. Data Subjektif
o Keadaan Sebelum Sakit : ............................................................................................
.....................................................................................................................................
.....................................................................................................................................
Keadaan Saat Sakit : .................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Data Objektif
o Observasi :
Kontak mata : ........................................................................................
Rentang penglihatan : .........................................................................................
Suara dan cara bicara : ........................................................................................
o Pemeriksaan Fisik
Kelainan bawaan yang nyata : ...........................................................
Abdomen : Bentuk : .......................................................................
Bayangan vena : .............................................................
Benjolan massa : . ...........................................................
Kulit : lesi kulit : ............................................................

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Program S1 Reguler Program Studi Ilmu Keperawatan
Fakultas Kedokteran Unsrat Manado
VIII. KAJIAN POLA PERAN DAN HUBUNGAN DENGAN SESAMA (KOPING)
a. Data Subjektif
o Keadaan Sebelum Sakit : ............................................................................................
.....................................................................................................................................
.....................................................................................................................................
o Keadaan Saat Sakit : ..................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Data Objektif
o Observasi : ..................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

IX. KAJIAN POLA REPRODUKSI – SEKSUALITAS

a. Data Subjektif
o Keadaan Sebelum Sakit : ............................................................................................
.....................................................................................................................................
.....................................................................................................................................
o Keadaan Saat Sakit : ..................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Data Objektif
o Observasi : .................................................................................................................
.....................................................................................................................................
o Pemeriksaan fisik
.....................................................................................................................................

X. KAJIAN POLA MEKANISME KOPING DAN TOLERANSI TERHADAP SRESS

a. Data Subjektif
o Keadaan Sebelum Sakit : ............................................................................................
.....................................................................................................................................
.....................................................................................................................................
Keadaan Saat Sakit : ..................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Data Objektif
o Observasi : ..................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
o Pemeriksaan fisik
Tekanan darah : Berbaring :...............mmHg
Duduk : ...............mmHg
Berdiri : ...............mmHg
Kesimpulan : Hipotensi ortostatik : Negatif Positif
HR : ................X / menit
Terapi : ........................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

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Program S1 Reguler Program Studi Ilmu Keperawatan
Fakultas Kedokteran Unsrat Manado
XI. KAJIAN POLA SISTEM NILAI KEPERCAYAAN
a. Data Subjektif
o Keadaan Sebelum Sakit :.............................................................................................
.....................................................................................................................................
.....................................................................................................................................
Keadaan Saat Sakit :...................................................................................................
.....................................................................................................................................
.....................................................................................................................................
Data Objektif
o Observasi : ..................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

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