I. Pengkajian
A. Identitas
1. Klien
Nama Klien : ...................
Umur : .......... tahun
Agama : .....................................
Suku/Bangsa : .....................................
Daerah : ................
Asing : ................
Pendidikan : .....................................
Pekerjaan : .....................................
Alamat Rumah : .................................................................................
2. Penanggung Jawab
Nama : ...................
Alamat Rumah : .................................................................................
Hubungan dengan klien : ...................
B. Data Medik
Diagnosa Medis
▪ Saat masuk : ...........................................................
▪ Saat pengkajian : ...........................................................
C. Alasan masuk rumah sakit
..................................................................................................................
Keluhan utama saat pengkajian : .......................................................................
G. Kebiasaan sehari-hari
1. Nutrisi - Cairan
a. Keadaan sejak sakit :
▪ Napsu makan : .............................................
▪ Frekuensi makan : .............................................
▪ Jumlah makan yang masuk
Kurang satu porsi
▪ Diet : .............................................
▪ Ketaatan terhadap diet tertentu : .............................................
▪ Mual/enek : .............................................
▪ Muntah : .............................................
▪ Nyeri ulu hati : .............................................
▪ Jumlah minum/24 jam : .............................................
▪ Jenis minum : .............................................
▪ Keluhan makan dan minum : .............................................
Masalah Keperawatan:.............................................................................................
2. Eliminasi
a. Keadaan sejak sakit :
▪ Frekuensi BAB/24 jam : .............................................
▪ Waktu BAB : .............................................
▪ Warna feses : .............................................
▪ Konsistensi : .............................................
Disuria
Urine menetes
Hematuri
Masalah Keperawatan:.............................................................................................
3. Aktivitas - latihan
a. Keadaan sejak sakit :
▪ Aktivitas perawatan diri
✓ Makan :
✓ Mandi :
✓ Kerapian :
✓ Ambulasi :
Keterangan :
0 : mandiri
1 : bantuan dengan alat
2 : bantuan orang
3 : bantuan orang dan alat
4 : bantuan penuh
✓ Kesimpulan :.......................................................................................
4. Tidur - istirahat
a. Keadaan sejak sakit :
▪ Tidur siang : ya tidak
bila ya, berapa jam : ............ jam
▪ Tidur malam : ............ jam
▪ Kebiasaan sebelum tidur : .............................................
▪ Keluhan tidur : .............................................
▪ Ekspresi wajah mengantuk : Negatif Positif
Masalah Keperawatan:.............................................................................................
J. Data spritual
Agama yang dianut : .............................................
Apakah agama sangat penting bagi anda : .............................................
Jika ya, dalam hal apa : .............................................
Kegiatan keagamaan selama dirawat : .............................................
Apakah selalu berdoa untuk kesembuhan : .............................................
Masalah Keperawatan:.............................................................................................
K. Pemeriksaan Fisik
1. Keadaan sakit : Klien tampak sakit ringan/ sedang/ berat/ tidak tampak sakit
Alasan : ...............................................................................................
...............................................................................................
2. Tanda-tanda vital
a. Kesadaran
1) Kualitatif : Kompos mentis (alert) Lethargi
Semicoma Coma
2) Kuantitatif :
▪ Glasgow Coma Scale : Respon motorik (M) : .......
Respon bicara (V) : .......
Respon membuka mata (E) : .......
▪ Jumlah : ..........
▪ Kesimpulan : ...................................
Kusmaul Cheyness-stokes
Masalah Keperawatan:...........................................................................................
3. Antropometri
a. Lingkar lengan atas : ............ cm
b. Lipat kulit triceps : ............ cm
c. Tinggi badan : ............ cm
d. Berat badan : ............ cm
e. IMT (Indeks Massa Tubuh : .................. kg/m2
Masalah Keperawatan:...........................................................................................
4. Kepala
a. Bentuk kepala : Simetris tidak simetris
Ukuran : .............................................................................
Fontanel : .............................................................................
Pirang Perak
Tumbuh subur
Ketombe Bersih
e. Bengkak/benjolan : .............................................................................
f. Nyeri/pusing : .............................................................................
g. Keluhan lain : .............................................................................
Masalah Keperawatan:...........................................................................................
5. Mata/Penglihatan
a. Ketajaman penglihatan : ...................................................................
d. Simetris : ya tidak
Kuning/ikterik
kebiruan
f. Pupil
mengecil
melebar
g. Palpebra :
edema
peradangan
Ptosis
lagopthalmus
baik/normal
h. Konjungtiva : .............................................................................
i. Bola mata : .............................................................................
j. Gerakan bola mata : .............................................................................
k. Lapang pandang : .............................................................................
kaca mata
kontak lensal
Masalah Keperawatan:...........................................................................................
6. Hidung/Penciuman
a. Struktur luar :
▪ Ukuran : ..............................................................................
▪ Bentuk : ..............................................................................
▪ Kesimetrisan : ..............................................................................
b. Struktur dalam :
Masalah Keperawatan:...........................................................................................
7. Telinga/pendengaran
a. Struktur luar :
Warna : ...................................................................
Lesi : ...................................................................
Cerumen : ...................................................................
Membran timpani : ...................................................................
b. Fungsi pendengaran :
Test Rinne : ...................................................................
Test Weber : ...................................................................
c. Nyeri : ...................................................................
d. Alat bantu : ...................................................................
e. Keseimbangan : ...................................................................
f. Lain-lain : ...................................................................
Masalah Keperawatan:...........................................................................................
8. Mulut/Pengecapan
a. Bibir
Warna : ...................................................................
Kesimetrisan : ...................................................................
Kelembaban : ...................................................................
Biru/sianosis
Pucat
Bengkak
b. Mukosa mulut
Warna : ...................................................................
Kelembaban : ...................................................................
Lesi : ...................................................................
c. Gigi :
Masalah Keperawatan:...........................................................................................
9. Leher
a. Kelenjar getah bening : ...................................................................
b. Kelenjar thyroid : ...................................................................
c. Kelenjar sub mandibulalis : ...................................................................
d. JVP : ...................................................................
e. Kaku kuduk : ...................................................................
f. Sulit menelan : ...................................................................
g. Lain-lain : ...................................................................
Masalah Keperawatan:...........................................................................................
10. Dada
a. Bentuk : Simetris tidak simetris
lambat
dalam
dangkal
c. Suara napas :
Vesiculer
Broncho vesiculer
Bronchial/tracheal
Ronchi
Wheezing
d. Perkusi dada :
Redup/dullness
Resonan
Tympani
Masalah Keperawatan:.............................................................................................
11. Kardiovaskuler/SIrkulasi
a. Batas jantung : ...................................................................
b. Heart rate : ...................................................................
c. Bunyi jantung I : ...................................................................
d. Bunyi jantung II : ...................................................................
e. Bunyi jantung tambahan : ...................................................................
f. Nyeri dada : ...................................................................
g. Palpitasi : ...................................................................
h. Edema : ...................................................................
i. Cyanosis : ...................................................................
j. Jari-jari tabuh : ...................................................................
k. Lain-lain : ...................................................................
Masalah Keperawatan:.............................................................................................
12. Abdomen/pencernaan
Masalah Keperawatan:.............................................................................................
Masalah Keperawatan:.............................................................................................
14. Genitourinaria
Laki-laki :
a. Penis/skrotum : ...................................................................
b. Testis : ...................................................................
c. Fungsi seksual : ...................................................................
d. Pertumbuhan rambut : ...................................................................
e. Pembengkakan : ...................................................................
f. Nyeri daerah perineal : ...................................................................
g. Kebersihan genitalia : ...................................................................
h. Kebersihan anus : ...................................................................
i. Lain-lain : ...................................................................
Perempuan :
a. Menstruasi : ...................................................................
b. Kehamilan : ...................................................................
c. Konstrasepsi yang digunakan : ...................................................................
d. Pemeriksaan usap vagina : ...................................................................
e. Pertumbuhan rambut : ...................................................................
Masalah Keperawatan:.............................................................................................
Masalah Keperawatan:.............................................................................................
Masalah Keperawatan:.............................................................................................
17. Integumen/Kulit
a. Warna
cyanosis
biru kemerahan
Joundice/ikterus
Pallor (pucat)
b. Tekstur
halus/licin
lunak
fleksibel
keriput
c. Turgor : ...................................................................
d. Kelembaban : ...................................................................
e. Suhu kulit :
Hangat
Dingin
Normal/alamiah
f. Lesi
hipo pigmentasi
hiperpigmentasi
normal/alamiah
j. Edema
+1
+2
+3
+4
l. Lain-lain : ...................................................................
Masalah Keperawatan:...........................................................................................
L. Pemeriksaan diagnostik :
1. Laboratorium :
a. Darah : ..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................
b. Feses : ..............................................................................................
..............................................................................................
..............................................................................................
d. Sputum : ..............................................................................................
..............................................................................................
e. Lain-lain : ..............................................................................................
..............................................................................................
2. Radiologi : ..................................................................................
..................................................................................
..................................................................................
3. EKG : ..................................................................................
..................................................................................
4. EEG : ..................................................................................
..................................................................................
5. USG : ..................................................................................
..................................................................................
M. Program terapi :
1. Obat-obatan
................................................. .................................................
................................................. .................................................
................................................. .................................................
................................................. .................................................
2. Fisioterapi : ...........................................................................
Medan,............................................
( )
NIM:
UMUR : ...............
DATA ETIOLOGI MASALAH