PROGRAM STUDI PENDIDIKAN NERS

STIKES BHAKTI HUSADA MULIA MADIUN

FORMAT PENGKAJIAN KEPERAWATAN

A. Identitas Klien
Nama :......................................... No.RM :.......................................
Usia :......................................... Tgl. Masuk :.......................................
Jenis Kelamin :......................................... Tgl. Pengkajian :.......................................
Alamat :......................................... Sumber Informasi :.......................................
No. Telepon :......................................... Status Pernikahan :.........................................
Nama keluarga dekat yang bisa dihubungi:................
Agama :......................................... Status :.......................................
Suku :.......................................... Alamat :.......................................
Pendidikan :......................................... No. Telepon :.......................................
Pekerjaan :......................................... Pendidikan :.......................................
Lama Bekerja :......................................... Pekerjaan :.......................................
B. Status Kesehatan Saat Ini
1. Keluhan utama :.............................................................................................................
2. Diagnosa Medis :
a. ..................................................................... Tanggal .........................................................
b. ..................................................................... Tanggal .........................................................
Riwayat Kesehatan Saat Ini
Saat MRS:....................................................................................................................................................
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Keluhan Saat pengkajian :
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Riwayat Kesehatan Terdahulu
3. Penyakit yang pernah dialami :
a. Kecelakaan (jenis & waktu) :.................................................................................................
b. Operasi (jenis & waktu) : .................................................................................................
c. Penyakit:
 Akut : ........................................................................................................................
 Kronis : ........................................................................................................................
4. Alergi (obat, makanan, plester, dll):
Tipe Reaksi Lamanya
........................................... .................................................. ..........................................
5. Imunisasi ( ) BCG ( ) Hepatitis
( ) Polio ( ) Campak
( ) DPT ( ) ....................
6. Kebiasaan
Jenis Frekuensi Jumlah Lamanya
Merokok ............................................ ................................... ...................................
 Kopi ............................................ ................................... ...................................
Alkohol ............................................ ................................... ...................................
7. Obat-obatan yang digunakan
Jenis Lamanya Dosis
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C. Riwayat Kesehatan Keluarga
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GENOGRAM

D. Riwayat Lingkungan
Jenis Rumah Pekerjaan
 Kebersihan .................................................... ...................................................
 Bahaya kecelakaan .................................................... ...................................................
 Polusi .................................................... ...................................................
 Ventilasi ................................................... ...................................................
 Pencahayaan ................................................... ...................................................
 .......................... ................................................... ...................................................
E. 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
F. Pola Nutrisi
Jenis Rumah Rumah Sakit
Makan
 Jenis diit/makanan .................................................... ...................................................
 Frekuensi/pola ................................................... ...................................................
  Porsi yang dihabiskan ...................................................
 Komposisi menu ...................................................
 Pantangan ...................................................
 Nafsu makan ...................................................
 Fluktuasi BB 6 bulan terakhir ...................................................
Minum
 Jenis minuman ...................................................
 Frekuensi/pola minum ...................................................
 Gelas yang dihabiskan ...................................................
 Sukar menelan ...................................................
 Pemakaian gigi palsu ...................................................
 Riw.masalah
penyembuhan luka ...................................................
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G. Pola Eliminasi
Jenis Rumah Rumah Sakit
BAB
 Frekuensi/pola .................................................... ...................................................
 Konsistensi .................................................... ...................................................
 Warna & bau .................................................... ...................................................
 Kesulitan .................................................... ...................................................
 Upaya mengatasi .................................................... ...................................................
BAK
 Frekuensi/pola .................................................... ...................................................
 Konsistensi .................................................... ...................................................
 Warna & bau .................................................... ...................................................
 Kesulitan .................................................... ...................................................
 Upaya mengatasi .................................................... ...................................................
H. 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 ........................................... ...................................................

I. Pola Kebersihan Diri

Rumah Rumah Sakit
 Mandi: Frekuensi ........................................... ..................................................
- Penggunaan sabun ........................................... ...................................................
 Keramas: Frekuensi ........................................... ...................................................
 - Penggunaan Shampo...........................................
 Gosok gigi: Frekuensi ...........................................
- Penggunaan pasta gigi...........................................
 Ganti baju: Frekuensi ...........................................
 Memotong kuku: Frekuensi.....................................
 Kesulitan ...........................................
 Upaya yang dilakuan ...........................................
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J. 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.........................................................................................
K. 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.....................................................................................
L. Pola Komunikasi
1. Bicara: ( ) Normal ( ) Bahasa utama: jawa
( ) Tidak Jelas ( ) Bahasa daerah
( ) 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 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
M. Pola Seksualitas
1. Masalah dalam hubungan seksual selama sakit: ( ) Tidak ada ( ) Ada
2. Upaya yang dilakukan pasangan: ( ) Perhatian ( ) Sentuhan ( ) Lain-lain, seperti .....................
N. 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: .........................................
O. Pemeriksaan fisik
1. Keadaan umum:.......................................................................................................................
a. Kesadaran: ........................................................................................................................
b. Tanda tanda vital: TD : ..........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 .............................................
b. Mata
 Bentuk ................................. Konjungtiva ........................................
 Pupil: ( ) Reaksi terhadap cahaya ( ) Isokor ( ) Meiosis ( ) Pin Point ( ) Midriasis
 Tanda radang:......................... Lensa........................... Sclera.......................
 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.........
 Penyakit yang pernah
dialami ....................................................................................................
d. Mulut dan tenggorokan
 Warna bibir ...................... Mukosa.................. Ulkus.........Lesi............ Massa......................
Warna lidah....................... Perdarahan gusi .............Karies...................................
Gangguan 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: ......................................................................................................................
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: ..............................................................................................................................
……………………………………………………………………………………………
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 Auskultasi : ..........................................................................................................................
 Perkusi: ...............................................................................................................................
 Palpasi: ...............................................................................................................................
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6. Genitalia
Inspeksi : ............................................................................................................
Palpasi : ............................................................................................................
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 ..................................
P. Terapi
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Q. Hasil pemeriksaan laboratorium

No. Jenis Pemeriksaan Hasil Nilai Normal

R. Hasil pemeriksaan penunjang lain (X-Ray, USG, EKG, CT-Scan, MRI, dll)

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