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JURUSAN KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN


Nama Mahasiswa : Rizky Dwi Aryani Departement : KMB
NIM : 175070200111017 Trigger :

A. Identitas Klien
Nama :Ny. F.................................. No. RM : 4249xx............................
Usia :65 ........ tahun Tgl. Masuk :15 Mei 2015.....................
Jenis kelamin :Perempuan........................ Tgl. Pengkajian :23 Mei 2015.....................
Alamat :Bangsalan Teras, Boyolali. Sumber informasi :Keluarga px......................
No. telepon :tidak terkaji........................ Nama klg. dekat yg bisa dihubungi: tidak terkaji
Status pernikahan :Menikah............................. ..........................................
Agama :Islam.................................. Status :tidak terkaji.......................
Suku :Jawa.................................. Alamat :tidak terkaji.......................
Pendidikan :SD..................................... No. telepon :tidak terkaji.......................
Pekerjaan :Petani................................ Pendidikan :tidak terkaji.......................
Lama berkerja :tidak terkaji........................ Pekerjaan :tidak terkaji.......................

B. Status kesehatan Saat Ini


1. Keluhan utama : tangan dan kaki kanan tidak bisa digerakkan...........................................
2. Lama keluhan : 8 hari yang lalu.........................................................................................
3. Kualitas keluhan : tidak bisa bergerak...................................................................................
4. Faktor pencetus : pusing, bicara pelo, tubuh lemas..............................................................
5. Faktor pemberat : hipertensi.................................................................................................
6. Upaya yg. telah dilakukan : tidak terkaji................................................................................
7. Diagnosa medis :
a. Stroke non Hemoragik................................................ Tanggal 15 Mei 2015...................
b. .................................................................................... Tanggal.......................................
c. .................................................................................... Tanggal.......................................

C. Riwayat Kesehatan Saat Ini


Px dibawa ke UGD RS oleh keluarganya dengan keluhan pusing, sulit bicara, lemas, dan juga tubuh
bagian kanan sulit untuk digerakkan. Kaluarga mengatakan setelah px pulang kerja sekitar pukul 13.00.
tiba-tiba klien merasa bagian tubuh sebelah kanan tidak bisa digerakkan dan juga merasa kesulitan
berbicara. ..........................................................................................................................................
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D. Riwayat Kesehatan Terdahulu


1. Penyakit yg pernah dialami:
a. Kecelakaan (jenis & waktu) :tidak terkaji ......................................................................
b. Operasi (jenis & waktu) :tidak terkaji.......................................................................
c. Penyakit:
 Kronis :Hipertensi...............................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
 Akut :...............................................................................................................
d. Terakhir masuki RS :5 tahun yang lalu..............................................................
2. Alergi (obat, makanan, plester, dll): tidak terkaji
Tipe Reaksi Tindakan
.................................................... .............................................. .................................................
.................................................... .............................................. .................................................
3. Imunisasi: tidak terkaji
( ) BCG ( ) Hepatitis
( ) Polio ( ) Campak
( ) DPT ( ) .................
4. Kebiasaan:tidak terkaji
Jenis Frekuensi Jumlah Lamanya
Merokok .................................. ........................................ ........................................
Kopi .................................. ........................................ ........................................
Alkohol .................................. ........................................ ........................................

5. Obat-obatan yg digunakan:tidak terkaji


Jenis Lamanya Dosis
.................................................... .............................................. .................................................
.................................................... .............................................. .................................................

E. Riwayat Keluarga
Keluarga mengatakan tidak ada riwayat stoke, hipertensi dan juga penyakit menurut atau menular
dalam keluarga..........................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
GENOGRAM
(keluarga tidak dijelaskan secara detail)
F. Riwayat Lingkungan tidak terkaji
Jenis Rumah Pekerjaan
 Kebersihan ....................................................... .......................................................

 Bahaya kecelakaan ....................................................... .......................................................

 Polusi ....................................................... .......................................................

 Ventilasi ....................................................... .......................................................

 Pencahayaan ....................................................... .......................................................


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

G. Pola Aktifitas-Latihan
Rumah Rumah Sakit
 Makan/minum 0.................................................. 3..................................................

 Mandi 0.................................................. 3..................................................

 Berpakaian/berdandan 0.................................................. 3..................................................

 Toileting 0.................................................. 3..................................................

 Mobilitas di tempat tidur 0.................................................. 3..................................................

 Berpindah 0.................................................. 3..................................................

 Berjalan 0.................................................. tidak terkaji..................................

 Naik tangga 0.................................................. tidak terkaji..................................


Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang lain, 4 = tidak mampu

H. Pola Nutrisi Metabolik tidak terkaji


Rumah Rumah Sakit
 Jenis diit/makanan .............................................. .................................................

 Frekuensi/pola .............................................. .................................................

 Porsi yg dihabiskan .............................................. .................................................

 Komposisi menu .............................................. .................................................

 Pantangan .............................................. .................................................

 Napsu makan .............................................. .................................................

 Fluktuasi BB 6 bln. terakhir .............................................. .................................................

 Jenis minuman .............................................. .................................................

 Frekuensi/pola minum .............................................. .................................................

 Gelas yg dihabiskan .............................................. .................................................

 Sukar menelan (padat/cair) .............................................. .................................................

 Pemakaian gigi palsu (area) .............................................. .................................................

 Riw. masalah penyembuhan luka .............................................. .................................................

I. Pola Eliminasi
Rumah Rumah Sakit
 BAB:
- Frekuensi/pola tidak terkaji.................................. tidak terkaji...............................
- Konsistensi tidak terkaji.................................. tidak terkaji...............................
- Warna & bau tidak terkaji.................................. tidak terkaji...............................
- Kesulitan tidak ada..................................... butuh bantuan...........................
- Upaya mengatasi tidak terkaji.................................. tidak terkaji...............................
 BAK:
- Frekuensi/pola tidak terkaji.................................. tidak terkaji...............................
- Konsistensi tidak terkaji.................................. tidak terkaji...............................
- Warna & bau tidak terkaji.................................. tidak terkaji...............................
- Kesulitan tidak ada..................................... butuh bantuan ..........................
- Upaya mengatasi tidak terkaji.................................. tidak terkaji...............................

J. Pola Tidur-Istirahat
Rumah Rumah Sakit
 Tidur siang:Lamanya 1-2 jam.................................. 4 jam...........................................

- Jam …s/d… tidak terkaji........................... tidak terkaji................................


- Kenyamanan stlh. tidur tidak terkaji........................... tidak terkaji................................
 Tidur malam: Lamanya 7 jam..................................... 10 jam.........................................

- Jam …s/d… tidak terkaji........................... tidak terkaji................................


- Kenyamanan stlh. tidur tidak terkaji........................... tidak terkaji................................
- Kebiasaan sblm. tidur tidak terkaji........................... tidak terkaji................................
- Kesulitan tidak terkaji........................... tidak terkaji................................
- Upaya mengatasi tidak terkaji........................... tidak terkaji................................

K. Pola Kebersihan Diri


Rumah Rumah Sakit
 Mandi:Frekuensi tidak terkaji............................... tidak terkaji...............................

- Penggunaan sabun tidak terkaji.............................. tidak terkaji..............................


 Keramas: Frekuensi tidak terkaji............................... tidak terkaji...............................

- Penggunaan shampoo tidak terkaji.............................. tidak terkaji..............................


 Gososok gigi: Frekuensi tidak terkaji............................... tidak terkaji...............................

- Penggunaan odol tidak terkaji.............................. tidak terkaji..............................


 Ganti baju:Frekuensi tidak terkaji............................... tidak terkaji...............................

 Memotong kuku: Frekuensi tidak terkaji............................... tidak terkaji...............................

 Kesulitan tidak ada.................................. butuh bantuan..........................

 Upaya yg dilakukan tidak ada.................................. tidak terkaji...............................

L. Pola Toleransi-Koping Stres tidak terkaji


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

3. Yang biasa dilakukan apabila stress/mengalami masalah:.................................................................


4. Harapan setelah menjalani perawatan:..............................................................................................
5. Perubahan yang dirasa setelah sakit:.................................................................................................

M. Konsep Diri tidak terkaji


1. Gambaran diri:....................................................................................................................................
2. Ideal diri:.............................................................................................................................................
3. Harga diri:...........................................................................................................................................
4. Peran:.................................................................................................................................................
5. Identitas diri........................................................................................................................................

N. Pola Peran & Hubungan


1. Peran dalam keluarga px sebagai ibu dan juga istri...........................................................................
2. Sistem pendukung:suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain, sebutkan:.............
3. Kesulitan dalam keluarga: ( ) Hub. dengan orang tua ( ) Hub.dengan pasangan
( ) Hub. dengan sanak saudara ( ) Hub.dengan anak
(√) Lain-lain sebutkan, tidak terkaji..............................................
4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS:tidak terkaji................
......................................................................................................................................................... ..
5. Upaya yg dilakukan untuk mengatasi:tidak terkaji..............................................................................
O. Pola Komunikasi
1. Bicara: ( ) Normal ( )Bahasa utama:.....................................
(√) Tidak jelas ( ) Bahasa daerah:..................................
( ) Bicara berputar-putar ( ) Rentang perhatian:............................
( ) Mampu mengerti pembicaraan orang lain( ) Afek:..................................................
2. Tempat tinggal:tidak terkaji ( ) Sendiri
( ) Kos/asrama
( ) Bersama orang lain, yaitu:.................................................................................
3. Kehidupan keluarga: tidak terkaji
a. Adat istiadat yg dianut:................................................................................................................
b. Pantangan & agama yg dianut:...................................................................................................
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

P. Pola Seksualitas tidak terkaji


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

Q. Pola Nilai & Kepercayaan tidak terkaji


1. Apakah Tuhan, agama, kepercayaan penting untuk Anda, Ya/Tidak
2. Kegiatan agama/kepercayaan yg dilakukan dirumah (jenis & frekuensi):.........................................
....................................................................................................................................................
3. Kegiatan agama/kepercayaan tidak dapat dilakukan di RS:...............................................................
4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya:.....................................................
R. Pemeriksaan Fisik
1. Keadaan Umum: px tampak lemah, komunikasi px tidak jelas. Dan px hanya membuka mata
apabila diberi rangsang nyeri.............................................................................................................
......................................................................................................................................................
 Kesadaran: sopor..........................................................................................................................
 Tanda-tanda vital: - Tekanan darah :170/110… mmHg - Suhu :36…oC
- Nadi :90….. x/meni - RR :24… x/menit
 Tinggi badan: tidak terkaji..................cm Berat Badan:tidak terkaji......kg
2. Kepala & Leher
a. Kepala:
Rambut terlihat acak-acakan.........................................................................................
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b. Mata:
Px hanya membuka mata saat ada rangsang nyeri. .....................................................
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c. Hidung:Tidak terkaji
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d. Mulut & tenggorokan:
Px bisa menelan dan menggunyah................................................................................
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e. Telinga:Tidak terkaji
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f. Leher:Tidak terkaji
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3. Thorak & Dada: Tidak terkaji

 Jantung
- Inspeksi:..................................................................................................................................
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- Palpasi:...................................................................................................................................
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- Perkusi:...................................................................................................................................
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- Auskultasi:..............................................................................................................................
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 Paru
- Inspeksi:..................................................................................................................................
................................................................................................................................................
- Palpasi:...................................................................................................................................
................................................................................................................................................
- Perkusi:...................................................................................................................................
................................................................................................................................................
- Auskultasi:.................................................................................................................................
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4. Payudara & Ketiak


Tidak terkaji...............................................................................................................................
5. Punggung & Tulang Belakang
Tidak terkaji...............................................................................................................................

6. Abdomen Tidak terkaji


 Inspeksi:........................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
 Palpasi:..........................................................................................................................................
....................................................................................................................................................
 Perkusi:..........................................................................................................................................
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 Auskultasi:.....................................................................................................................................
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7. Genetalia & Anus Tidak terkaji
 Inspeksi:........................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
 Palpasi:.......................................................................................................................................
8. Ekstermitas
 Atas: uji kekuatan oto tangan kiri adalah derajat 2 sedangkan tangan kanan derajat 0..............
...........................................................................................................................................
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 Bawah: uji kekuatan ekstrimitan kiri adalah derajat 2 dan sebelah kanan adalah derajat 0.........
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9. Sistem Neorologi
Px mengalami hambatan pada saraf kranial nervus I, II, V, VII, VIII, XI.......................................
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10. Kulit & Kuku Tidak terkaji
 Kulit:

 Kuku:

S. Hasil Pemeriksaan Penunjang

Pemeriksaan darah pada tanggal 23 April: hemoglobin 11.0 g/dL (N : 12-16 g/dL), LED : 25/mm (N :
0-20 mm). Hitung jenis sel, eosinofil : 0 % (N : 1-3 %), limfosit : 19,1 % (N : 20-40 %), hematokrit :
34.6 % (N : 37-47 %), eritrosit : 3.99 uL (N : 4.2-5.4 uL)
Pemeriksaan CT Scan tanggal 25 April 2013 dengan hasil : lesi hipodens intraserebral fronto
temporal kiri (08-09), struktur mediana di tengah, sistema ventrikel baik, sulci gyri tak prominent,
slices interval 10 mm. Kesan : infark serebri fronto temporal kiri ..........................................................
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T. Terapi
Tidak terkaji..........................................................................................................................................
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U. Persepsi Klien Terhadap Penyakitnya
Tidak terkaji..........................................................................................................................................
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V. Kesimpulan
Ny.F berjenis kelamin perempuan dengan usia 65 tahun terdiagnosis medis SNH atau stroke
non Hemoragik, dengan keluhan saat ini pusing, lemas, sulit berbicara, dan juga tidak bisa
menggerakkan tubuh bagian kanannya. px memiliki riwayat penyakit hipertensi dan pernah MRS 5
tahun yang lalu. Keluarga mengatakan tidak ada riwayat stroke atau hipertensi dan penyakit menular.
Sebelum sakit px tidur malam dengan durasi 7 jam dengan nyeyak, dan tidur siang selama 1-2 jam.
Selama di RS pc lebih banyak tidur dalam sehari bisa tidur hingga 14 jam. Sebelum masuk RS px
melakukan aktifitasnya secara mandiri, sedangkan di RS harus dibantu oleh keluarga atau tenaga
kesehatan perawat di atas tempat tidur dikarenakan kedasaran pasien sopor. Pendengaran baik
telinga kanan atau kiri mengalami gangguan. Sensori pasien masih mampu membedakan sensori
tajam maupun tumpul walaupun harus ditekan dengan kuat pada ekstrimitas kiri sedangkan
ekstrimitas kanan tidak ada respon. Px hanya membuka mata ketika mendapat rangsangan nyeri.
tekanan darah 170/110 mmHg, nadi 90x/menit, suhu 368 C, pernafasan 24x/menit. Pemeriksaaan
laboratorium tanggal 23 April 2013, dengan hasil : pemeriksaan darah, hemoglobin : 11.0 g/dL (N :
12-16 g/dL), LED : 25/mm (N : 0-20 mm). Hitung jenis sel, eosinofil : 0 % (N : 1-3 %), limfosit : 19,1 %
(N : 20-40 %), hematokrit : 34.6 % (N : 37-47 %), eritrosit : 3.99 uL (N : 4.2-5.4 uL). Pemeriksaan CT
Scan tanggal 25 April 2013 dengan hasil : lesi hipodens intraserebral fronto temporal kiri (08-09),
struktur mediana di tengah, sistema ventrikel baik, sulci gyri tak prominent, slices interval 10 mm.
Kesan : infark serebri fronto temporal kiri. Uji kekuatan otot px ektrimitas kiri memiliki derajat 2
sedangkan kanan memiliki derjat 0.
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W. Perencanaan Pulang
 Tujuan pulang:rumah..........................................................................................................................
 Transportasi pulang:kendaraan keluarga...........................................................................................
 Dukungan keluarga:keluarga bergantian menunggu px di RS ...........................................................
 Antisipasi bantuan biaya setelah pulang:tidak tekaji...........................................................................
 Antisipasi masalah perawatan diri setalah pulang:bantuan untuk membersikkan diri.........................
 Pengobatan: ......................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
 Rawat jalan ke: belum ada rencana...................................................................................................
....................................................................................................................................................
 Hal-hal yang perlu diperhatikan di rumah: menjaga pola makan dan juga px diharapkan untuk
istirahat yang cukup. Minum obat dengan tepat waktu. Dan perlu dilakukan terapi untuk
memperbaiki kondisi bagian tubuh px.
 Keterangan lain:tidak terkaji...............................................................................................................