FORMAT PENGKAJIAN

PRAKTIK LAPANGAN MATA KULIAH KEPERAWATAN DASAR II

PSIK STIKes HANG TUAH

Nama mahasiswa : Tanggal praktik :

NIM : Ruangan/Lokasi :
A. INFORMASI UMUM PASIEN

Tanggal Pengkajian : 05 juni 2018 Suku Bangsa : melayu

Nama Lengkap : ny. R Agama : islam
Umur : 45 Tahun Tanggal Masuk :
Tanggal lahir : 31 Desember 1973 Hari rawat ke :
Jenis Kelamin : perempuan Dari/Rujukan :
No. MR : Penanggung Jawab Biaya :
Diagnosa Medik :

B. KELUHAN UTAMA
Pasien mengeluh susah untuk memulai tidur, tidur kurang nyenyak, sering merasa ngantuk
saat bekerja
C. RIWAYAT PENYAKIT YANG DIDERITA SAAT INI
Insomnia
D. RIWAYAT KESEHATAN SEBELUMNYA
Alergi pada debu
E. RIWAYAT KESEHATAN KELUARGA
TERSERAHHHH EJAKKKKK
F. KEADAAN UMUM

 Kesadaran :

 Tanda-tanda vital (Pukul: WIB)

TD : 110/70 mmHg , N : 74 x/menit
RR : 18 x/menit S : 36,8 °C,
 BB/TB: TERSERAHHH EJAK
IMT :
G. PENGKAJIAN HEAD TO TOE

1. Kulit
Inspeksi: warna kulit sawo matang, kulit terlihat bersih, tidak ada lesi
Palpasi: kulit kering, tidak ada lesi, turgor kulit kembali setelah 2 detik.
Masalah Keperawatan Tidak ada masalah
 2. Kepala
a. Rambut & Kulit Kepala:
Inspeksi: bentuk kepala simetris, kulit kepala bersih, tidak ada ketombe, warna rambut
hitam, kepala tidak berminyak, tidak ada luka dan benjolan
Palpasi: saat diraba dan ditekan tekstur rambut lembut, tidak ada luka, tidak ada nyeri
dikepala.
Masalah Keperawatan: tidak ada masalah

b. Mata:
Inspeksi: pucat , seclera putih, kelopal mata terdapat lingkaran hitam, konjungtiva anemis
TAMBAHKAN LAGI JAK
Palpasi:
Masalah Keperawatan...........................................................................................................

c. Telinga:
Inspeksi: Telinga tampak simetris, tidak ada serumen, tidak ada lesi
Palpasi: saat ditekan dan diraba tidak nyeri dan tidak ada benjolan
Masalah Keperawatan: tidak ada masalah
Hidung:
Inspeksi: hidung simetris kiri dan kanan, tidak ada gangguan saat bernapas.
Palpasi: saat diraba dan ditekan rambut keras dan tidak ada benjolan
Masalah Keperawatan: tidak ada masalah

d. Mulut:
Inspeksi: bibir simetris, bibir terlihat pucat, tidak ada lesi, mukosa mulut kering
Palpasi:. Saat diraba dan ditekan tidak adanya benjolan, tidak ada nyeri ssat ditekan
Masalah Keperawatan:

2. Leher:
Inspeksi: simetris, tidak ada luka dan benjolan pada leher
Palpasi: tidak ada benjolan ssat diraba, tidak ada nyeri saat ditekan
Masalah Keperawatan.........................................................................................................
3. Dada
a. Paru-Paru
Inspeksi:..................................................................................................................................
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Palpasi:..................................................................................................................................
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Perkusi:...................................................................................................................................
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Auskultasi:............................................................................................................................
Masalah Keperawatan.........................................................................................................

b. (Jantung)
Inspeksi:..................................................................................................................................
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Palpasi:..................................................................................................................................
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Perkusi:...................................................................................................................................
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Auskultasi:............................................................................................................................
Masalah Keperawatan.........................................................................................................

4. Payudara dan Aksila:

Inspeksi:..................................................................................................................................
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Palpasi:..................................................................................................................................
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Masalah Keperawatan...........................................................................................................

5. Tangan:

Inspeksi: terlihat simetris kiri dan kanan, tidak ada lesi

 Palpasi: saat diraba dan ditekan tidak ada benjolan pembengkakan serta nyeri
Masalah Keperawatan.........................................................................................................

6. Abdomen

Inspeksi:..................................................................................................................................
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Auskultasi:............................................................................................................................
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Perkusi:...................................................................................................................................
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Palpasi:.................................................................................................................................
Masalah Keperawatan.........................................................................................................

7. Genitalia dan Perkemihan:

Inspeksi:..................................................................................................................................
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Palpasi:..................................................................................................................................
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Masalah Keperawatan...........................................................................................................

8. Rektum dan Anus:

Inspeksi:..................................................................................................................................
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Palpasi:..................................................................................................................................
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Masalah Keperawatan...........................................................................................................

9. Kaki:

Inspeksi: simetris kiri dan kanan, tidak ada lesi atau luka,
Palpasi: saat diraba dan ditekan tidak ada benjolan dan nyeri
 Masalah Keperawatan..........................................................................................................

10. Punggung:
Inspeksi: simetris, tidak ada lesi
Palpasi: tidak ada benjolan dan nyeri
Masalah Keperawatan: tidak ada masalah

H. POLA ISTIRAHAT DAN TIDUR

Tidur tidak teratur
I. POLA AKTIVITAS HARIAN (ADL)
Makan tidak teratur, konsentrasi terganggu saat bekerja

J. CAIRAN, NUTRISI ELIMINASI

1. Intake Oral/Enteral
(mencakup jumlah, jenis dan frekuensi makan berat, makan selingan dan konsumsi air
dan terapi parenteral)
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Masalah Keperawatan....................................................................................................

2. Eliminasi
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Masalah Keperawatan...........................................................................................................

H. PSIKO-SOSIAL-SPIRITUAL
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Masalah Keperawatan...........................................................................................................

K. PEMERIKSAAN REFLEKS FISIOLOGIS DAN PATOLOGIS

a. Bisep
b. Trisep
c. Brakioradialis
d. Patela
e. Achilles
f. Babinski

L. HASIL PEMERIKSAAN LABORATORIUM DAN DIAGNOSTIK

(Mencakup tanggal pemeriksaan, hasil dan rentang normal)
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M. MEDIKASI/OBAT-OBATAN YANG DIBERIKAN SAAT INI

No Nama Obat Rute Dosis Indikasi Kontra Indikasi

N. DIAGNOSA KEPERAWATAN
1. …………………………………………………………………………………………
2. …………………………………………………………………………………………
3. …………………………………………………………………………………………
4. …………………………………………………………………………………………
5. …………………………………………………………………………………………

Pekanbaru, ……………………………..
Mahasiswa

( )
 ANALISA MASALAH

Masalah Keperawatan
No Data Etiologi
 FORMAT RENCANA ASUHAN KEPERAWATAN

Nama Pasien: Nama Mahasiswa:

Ruang: NIM :
No.MR:
No Diagnosa Keperawatan Nursing Outcome Classification (NOC) Nursing Intervention Clasification (NIC)
 CATATAN PERKEMBANGAN

Nama Klien :
Diagnosa Medis:
Ruang Rawat :
Hari/Tgl/Jam Diagnosa IMPLEMENTASI SOAP Ttd