FORMAT PENGKAJIAN BERDASARKAN TEORI CALISTA ROY

Mata Kuliah : Keperawatan Medikal Bedah

Dosen Pembimbing : Ns. Chrisyen Damanik, S.Kep. M.Kep

Kelompok 1
NAMA : NIM
1. ALAMSYAH B1735713901
2. ALFI SYAHRIN B1735814001
3. ANITA BERLIN B1735914101
4. ANTONIA FILDERITA PETRASEA B1736014201
5. AYU DEWI SUWANTI B1736114301
6. CAHAYANI KURNIAWATI B1736214401
7. CHRISONIA FEBERIA B1736314501
8. EKA FITRI B1736414601
9. EKA SEPTIANI RINAI B1736514701
10. ERMA YULITA B1736614801
11. ERNI SUSANTI B1736714901

PROGRAM STUDI ILMU KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN WIYATA HUSADA
SAMARINDA
2017
 HALAMAN PENGESAHAN

JUDUL : Format Pengkajian Berdasarkan Teori Calista Roy

NAMA ANGGOTA :
No Nama
1. ALAMSYAH
2. ALFI SYAHRIN
3. ANITA BERLIN
4. ANTONIA FILDERITA PETRASEA
5. AYU DEWI SUWANTI
6. CAHAYANI KURNIAWATI
7. CHRISONIA FEBERIA
8. EKA FITRI
9. EKA SEPTIANI RINAI
10. ERMA YULITA
11. ERNI SUSANTI

PROGRAM STUDI : S1 KEPERAWATAN

Makalah ini telah diperkenankan di hadapan dosen pembimbing

Pada tanggal 02 November 2017

Fasilitator Tutorial : Ns. Chrisyen Damanik, S.Kep. M.Kep ..........................................................

FORMAT PENGKAJIAN
APLIKASI TEORI MODEL KONSEP ADAPTASI CALISTA ROY

A. PENGKAJIAN
1. Identitas Klien
a. Nama : ........................................................................................................................
b. Jenis kelamin : L/P
c. Umur : .......... tahun
d. Agama : ........................................................................................................................
e. Pendidikan : ........................................................................................................................
f. Pekerjaan : ........................................................................................................................
g. Suku : ........................................................................................................................
h. Alamat : ........................................................................................................................

Kondisi saat ini :...........................................................................................................................................................

.....................................................................................................................................................................................................
.....................................................................................................................................................................................................
Riwayat Keperawatan : :...........................................................................................................................................................
.......................................................................................................................................................................................................
........................................................................................................................................................................................................
Riwayat Keluarga : :...........................................................................................................................................................
.....................................................................................................................................................................................................
......................................................................................................................................................................................................

2. Pengkajian Tahap Pertama

I. Fisiologi
a. Oksigenasi
1) Ventilasi :
a) Respirasi :
b) Irama :
c) Kedalaman :
i.  Hyperpnea
ii.  Hypopnea
iii.  Kusmaul
iv.  Normal
d) Bunyi nafas :
i.  Normal
ii.  Stridor
iii.  Wheezing
iv.  Ronchi

e) Reflek :
1)  Reflek batuk
i. Volume sekret.............................
ii. Konsistensi..................................
iii. Bau...............................................
iv. Warna..........................................
 Reflek Bersin
2) Pertukaran gas
AGD
a)  Asidosis respiratori
 b)  Alkalosis respiratori
c)  Asidosis metabolik
d)  Alkalosis metabolik

3) Transportasi Gas
a) Nadi.......x/menit
i.  Reguler
ii.  Irreguler
iii.  Aritmia

b) Kuku
i.  Tidak sianosis
ii.  Sianosis
iii.  Aritmia

c) Pemeriksaan penunjang
i. Hb : ...............................
ii. Ht : ...............................
iii. Eritrosit : .......................
iv. AGD :
a. PaCO2 :............................
b. PaO2 :............................
c. HCO3 :.............................
d. H2CO3:............................
e. PH :.............................

v. EKG :.................................

b. Nutrisi
1) Nafsu makan :..........................................................................................
2) Intake nutrisi :..........................................................................................
3) Tipe nutrisi :..........................................................................................
4) TB dan BB :...............cm ....................kg
5) Pola makan :..........................................................................................
6) Riwayat alergi terhadap makanan :..........................................................................................
7) Kondisi rongga mulut :..........................................................................................
8) Gangguan pencernaan :..........................................................................................
9) Saraf pengecapan dan penciuman :..........................................................................................

c. Eliminasi
1) BAK :..................................................................................................................
2) BAB :...................................................................................................................

d. Aktivitas dan Istirahat

1) Qualitas istirahat :..........................................................................................
2) Quantitas istirahat :.......................................................................................
3) Pola tidur (frekuensi dan durasi) :............................................................
 4) Gangguan tidur (insomnia/narkolepsi) :...................................................
5) Riwayat tidur sebelumnya yang berhubungan dengan pola saat ini :........................................
6) Tanda – tanda gangguan tidur (psikologis/fisik) :..............................................................................
7) Perasaan subyektif yang berhubungan dengan istirahat/tidur :....................................................

e. Proteksi
1) Kulit (warna, tekstur, kelembaban, turgor,distribusi pigmen) :.....................................................
2) Rambut :.............................................................................................................................................................
3) Kuku (pertumbuhan, tekstur) :....................................................................................................................
4) Kemampuan tubuh untuk sembuh dari infeksi : ................................................................................

f. Indera Perasa
1) Penglihatan :............................................................................................
2) Pendengaran :........................................................................................
3) Pengecap :...............................................................................................
4) Peraba :....................................................................................................
5) Penciuman :............................................................................................

g. Cairan dan Elektrolit

1) Intake : ..................................ltr/hari
2) Output : ................................ltr/hari
a)  Dehidrasi
b)  Edema

Keseimbangan elektrolit
1) Na :....................................................................
2) Ca :...................................................................
3) K :...................................................................
Keseimbangan asam basa
1) Asidosis respiratorik 
2) Alkalosis respiratorik 
3) Asidosis metabolik 
4) Alkalosis metabolik 

h. Fungsi neurologis
1) Tingkat kesadaran
a) Compos mentis 
b) Apatis 
c) Sopor 
d) Coma 
e) GCS :.....................

i. Fungsi Endokrin
1) Oksigenasi
a) Status mental :..............................................................................
b) Fungsi sirkulasi dan pernafasan : ................ TTV :........................
 2) Nutrisi :
a) Jumlah :.............................................................
b) Penurunan BB :..............................................................
c) Penambahan BB :...........................................................

3) Laboratorium :..............................................................................

II. Konsep diri

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III. Fungsi peran
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IV. Ketergantungan
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....................................................................................................................................................................................................
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3. Pengkajian Tahap Kedua

Stimuli
Perilaku Focal Kontekstual residual

A. Pengkajian mode konsep diri

1. Pengkajian perilaku :
a. Body sensation : Bagaimana ia merasakan bagian dari dirinya.
b. Body image : Bagaimana dia cara memandang bagian dirinya.
c. Self consistency : Bagaimana menanggapi situasi dirinya.
d. Self idea :
e. Moral etik dan spiritual :

2. Pengkajian stimuli
a. Tumbuh kembang :...............................................................................................
b. Belajar : ...............................................................................................
c. Reaksi lain : ...............................................................................................
 d. Persepsi : ...............................................................................................
e. Krisis maturasi : ...............................................................................................
f. Strategi koping : ...............................................................................................

3. Pengkajian mode fungsi peran

a. Usia : ...............................................................................................
b. Jenis Kelamin : ...............................................................................................
c. Peran sebagai orang tua : .........................................................................................
d. Penghargaan bila peran dapat dijalankan : .........................................................

4. Pengkajian mode interdependensi

a. Inisiatif untuk memberi sesuatu kepada orang lain 
b. Respon ketika menerima sesuatu dari orang lain 

B. DIAGNOSA KEPERAWATAN
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C. RENCANA DAN TINDAKAN KEPERAWATAN

No. DX Tujuan Intervensi
D. IMPLEMENTASI DAN EVALUASI

No. DX Implementasi Evaluasi