POLITEKNIK KESEHATAN RS dr.

SOEPRAOEN
PROGRAM STUDI KEPERAWATAN

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Tempat Praktik :
NIM : Tgl Praktik :

A. Identitas Klien
Nama : No. RM :
Usia : Tanggal Masuk :
Jenis kelamin : Tanggal Pengkajian :
Alamat : Sumber Informasi :
No. Telepon : Nama klg. dekat yang bisa dihubungi:
Status pernikahan :
Agama : Status :
Suku : Alamat :
Pendidikan : No. telepon :
Pekerjaan : Pendidikan :
Lama bekerja : Pekerjaan :

B. Status Kesehatan Saat Ini

1. Keluhan utama :
2. Lama keluhan :
3. Kualitas keluhan:
4. Faktor pencetus :
5. Faktor pemberat:
6. Upaya yang telah dilakukan:
7. Keluhan saat pengkajian:

Diagnosa Medis:

C. Riwayat Kesehatan Saat Ini

D. Riwayat Kesehatan Dahulu
1. Penyakit Yang Pernah Dialami
a. Kecelakaan (Jenis &waktu)
b. Operasi (Jenis &waktu)
c. Penyakit :
 Kronis :
 Akut :
d. Terakhir masuk RS:
2. Alergi (obat, makanan, plester, dll) :
3. Imunisasi
( )BCG ( )Hepatitis
( )Polio ( )Campak
( )DPT ( )……………
4. Kebiasaan
Jenis Frekuensi Jumlah Lamanya

5. Obat-obatan yang digunakan

E. Riwayat Kesehatan Keluarga

F. Genogram
G. Riwayat Lingkungan
Jenis Rumah Pekerjaan
 Kebersihan
 Bahaya Kecelakaan
 Polusi
 Ventilasi
 Pencahayaan

H. Pola Aktivitas – Latihan

Jenis Rumah Rumah sakit
Sebelum sakit Sesudah sakit
 Makan minum
 Mandi
 Berpakaian/berdandan
 Toileting
 Mobilitas di tempat tidur
 Berpindah
 Berjalan
 Naik tangga
Pemberian skor : 0 = mandiri, 1 = alat bantu, 2 = dibantu 1 orang, 3 = dibantu>1 orang, 4 =
tidak mampu
I. Pola Nutrisi Metabolik
Jenis Rumah Rumah sakit
 Jenis diet
 Frekuensi/pola
 Porsi yng dihabiskan
 Komposisi menu
 Pantangan
 Nafsu makan
 Fluktuasi BB 6 bulan terakhir
 Jenis minuman
 Frekuensi/pola
J. Pola Eliminasi
Rumah Rumah sakit
BAB
 Frekuensi/pola
 Konsistensi
 Warna & bau
 Kesulitan
 Upaya mengatasi
BAK
 Frekuensi/pola
 Konsistensi
 Warna & bau
 Kesulitan
 Upaya mengatasi
K. Pola Tidur – Istirahat
Rumah Rumah sakit
Tidur siang : lamanya
 Jam….s/d…..
 Kenyamanan stlh tidur
Tidur malam : lamanya
 Jam….s/d…..
 Kenyamanan stlh tidur
 Kebiasaan sblm tidur
 Kesulitan
 Upaya mengatasi

L. Pola Kebersihan Diri

Rumah Rumah sakit
 Mandi : frekuensi
Penggunaan sabun
 Keramas : frekuensi
Penggunaan sampo
 Gosok gigi : frekuensi
Penggunaan odol
 Ganti baju : frekuensi
 Potong kuku : frekuensi
 Kesulitan
 Upaya yg dilakukan

M. Pola Toleransi Koping-Stress

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:
N. Konsep Diri
1. Gambaran
2. Ideal diri
3. Harga diri
4. Peran
5. Identitas diri
O. Pola Peran dan Hubungan
1. Peran dalam keluarga: kepala keluarga
2. Sistem pendukung: suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain, sebutkan:
3. Kesulitan dalam keluarga: -
 ( ) hubungan dengan orang tua ( ) hubungan dengan pasangan
( ) hubungan dengan sanak saudara ( ) hubungan dengan anak
( ) lain-lain sebutkan,
4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS:
5. Upaya yang dilakukan untuk mengatasi
P. Pola Komunikasi
1. Bicara ( ) Normal ( ) bahasa utama
( ) Tidak jelas ( ) bahasa daerah
( ) bicara berputar putar ( ) rentang perhatian
( ) Mampu mengerti pembicaraan orang lain ( ) afek
Q. Pola Seksualitas
1. Masalah dalam hubungan seksual selama sakit: ( ) tidak ada ( ) ada
2. Upaya yang dilakukan pasangan:
( ) perhatian ( ) sentuhan ( ) lain-lain, seperti
R. Pola Nilai dan Kepercayaan
1. Apakah Tuhan, agama, dan kepercayaan penting untuk Anda, Ya/Tidak
2. Kegiatan agama/kepercayaan yang dilakukan di rumah (jenis dan frekuensi)
3. Kegiatan agama/kepercayaan tidak dapat dilakukan di RS
4. Harapan klien terhadap perawat untuk melakukan ibadahnya
S. Pemeriksaan Fisik
1. Keadaan umum :
 Kesadaran :
 Tanda tanda vital :
Tekanan Darah : Suhu :
Nadi : RR :
 Tinggi Badan : cm Berat Badan : kg

2. Kepala & Leher

a. Kepala
 Bentuk:
 Massa:
 Distribusi rambut:
 Warna kulit kepala:
 Keluhan: pusing/sakit kepala/migraine, lainnya:
b. Mata
 Bentuk:
 Konjungtiva:
 Pupil: ( ) reaksi terhadap cahaya ( ) isokor ( ) miosis ( ) pin point ( ) midriasis
 Tanda radang:
 Fungsi penglihatan:
 Penggunaan alat bantu:
c. Hidung
 Bentuk :
 Warna :
  Pembengkakan :
 Nyeri tekan :
 Perdarahan :
 Sinus :
d. Mulut & Tenggorokan
 Warna bibir :
 Mukosa :
 Ulkus :
 Lesi :
 Massa :
 Warna lidah :
 Perdarahan gusi :
 Karies :
 Gangguan bicara :
e. Telinga
 Bentuk :
 Warna :
 Lesi :
 Massa :
 Nyeri :
 Nyeri tekan :
f. Leher
 Kekakuan :
 Benjolan/massa :
 Vena jugularis :
 Nyeri :
 Nyeri tekan :
 Keterbatasan gerak :
 Keluhan lain :
3. Thorak & Dada
 Jantung
- Inspeksi :

Palpasi : ....................................................................................................................................
-
. .................................................................................................................................................
- Perkusi : ....................................................................................................................................
. .................................................................................................................................................
- Auskultasi : ...............................................................................................................................
. .................................................................................................................................................
 Paru
- Inspeksi . ...................................................................................................................................
. .................................................................................................................................................
- Palpasi : . ...................................................................................................................................
. .................................................................................................................................................
- Perkusi : . ..................................................................................................................................
. .................................................................................................................................................
- Auskultasi : ...............................................................................................................................
. .................................................................................................................................................
4. Payudara & Ketiak
 Benjolan/massa : . ...........................................................................................................................
 Bengkak : . .......................................................................................................................................
 Nyeri : . ............................................................................................................................................
  Nyeri tekan : . .................................................................................................................................
 Kesimetrisan : .................................................................................................................................
5. Punggung & Tulang Belakang
...............................................................................................................................................................
. ..............................................................................................................................................................
6. Abdomen
 Inspeksi . .............................................................................................................................................
. ...........................................................................................................................................................
 Palpasi. ...............................................................................................................................................
. ...........................................................................................................................................................
 Perkusi. ...............................................................................................................................................
. ...........................................................................................................................................................
 Auskultasi. ..........................................................................................................................................
. ...........................................................................................................................................................

7. Genitalia & Anus

 Inspeksi : . ...........................................................................................................................................
. ...........................................................................................................................................................
 Palpasi. ...............................................................................................................................................
. ...........................................................................................................................................................
8. Ekstremitas (kekuatan otot, kontraktur, deformitas, edema, luka, nyeri/nyeri tekan, pergerakan)
 Atas : . .................................................................................................................................................
. ...........................................................................................................................................................
. ...........................................................................................................................................................
. ...........................................................................................................................................................
. ...........................................................................................................................................................
 Bawah . ...............................................................................................................................................
. ...........................................................................................................................................................
. ...........................................................................................................................................................
. ...........................................................................................................................................................
. ...........................................................................................................................................................
9. Sistem Neurologi 9SSP : I-XII, reflek, motorik, sensorik)
. ..............................................................................................................................................................
. ..............................................................................................................................................................
. ..............................................................................................................................................................
. ..............................................................................................................................................................
. ..............................................................................................................................................................
10. Kulit & Kuku
 Kulit : (warna, lesi, turgor, jaringan parut, suhu, tekstur, diaphoresis)
. .......................................................................................................................................................
. .......................................................................................................................................................
 Kuku : (warna, lesi, bentuk, CRT)
. .......................................................................................................................................................
.
T. Hasil Pemeriksaan Penunjang (Laboratorium, USG, Rontgen, MRI)
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
U. Terapi (Medis, RehabMedik, Nutrisi)
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................

. ....................................................................................................................................................................
V. Persepsi Klien Terhadap Penyakitnya
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................

. ....................................................................................................................................................................
W. Kesimpulan
. ....................................................................................................................................................................
. ....................................................................................................................................................................
. ....................................................................................................................................................................
X. Perencanaan Pulang
 Tujuan Pulang. .......................................................................................................................................
 Transportasi pulang. ..............................................................................................................................
 Dukungan keluarga. ...............................................................................................................................
 Antisipasi bantuan biaya setelah pulang. ..............................................................................................
 Antisipasi masalah perawatan diri setelah pulang. ...............................................................................
 Pengobatan. ..........................................................................................................................................
 Rawat jalan ke. ......................................................................................................................................
 Hal hal yang perlu diperhatikan di rumah. ............................................................................................
 Keterangan lain......................................................................................................................................

Malang,
Pengkaji

__________________
 ANALISA DATA

No. Data Etiologi Masalah keperawatan

 ANALISA DATA

No. Data Etiologi Masalah keperawatan

 DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

NAMA KLIEN :
NO.REG :

NO TANGGAL DIAGNOSA TANGGAL TANDA

MUNCUL KEPERAWATAN TERATASI TANGAN
 RENCANA ASUHAN KEPERAWATAN

Nama / Usia : Dx / No.Reg :

No Tgl Dx Keperawatan Tujuan & Kriteria Hasil Intervensi Rasional

 RENCANA ASUHAN KEPERAWATAN

Nama / Usia : Dx / No.Reg :

No Tgl Dx Keperawatan Tujuan & Kriteria Hasil Intervensi Rasional

 IMPLEMENTASI DAN EVALUASI

Nama : __________________ Ruangan : ______________________ RM No. : _____________________Dx medis : _____________________

No. Tanggal/
IMPLEMENTASI KEPERAWATAN EVALUASI
Dx Jam