FORMAT PENGKAJIAN

Sekolah Tinggi Ilmu Kesehatan Stella Maris

Jl. MAIPA NO.19 MAKASSAR

KAJIAN KEPERAWATAN

Nama Mahasiswa Yang Mengkaji: NIM:

Unit : …………………………… Autoanamnese: …………………

Kamar : …………………………… Alloanamnese : …………………
Tanggal masuk RS : ……………………………
Tanggal pengkajian : …………………………....
I. IDENTIFIKASI
A. PASIEN
Nama initial : …………………………………………………………………........
Umur : …………………………………………………………………........
Jenis kelamin : ………………………………………………………………………
Status perkawinan : ………………………………………………………………………
Jumlah anak : ………………………………………………………………………
Agama/ suku : ………………………………………………………………………
Warga negara : ………………………………………………………………………
Bahasa yang digunakan : ……………………………………………………………….......
Pendidikan : ………………………………………………………………………
Pekerjaan : ………………………………………………………………………
Alamat rumah : ………………………………………………………………………
B. PENANGGUNG JAWAB
Nama : …………………………………………………………………. …..
Umur : ………………………………………………………………………
Alamat : ………………………………………………………………………
Hubungan dengan pasien : ………………………………………………………………….
II. DATA MEDIK
Diagnosa medik
Saat masuk : ……………………………………………………………………...
Saat pengkajian : ……………………………………………………………………...
III. KEADAAN UMUM
A. KEADAAN SAKIT
Pasien tampak sakit ringan/ sedang / berat / tidak tampak sakit
Alasan:
………............................................................................................................................ ..................................................
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B. TANDA-TANDA VITAL
1. Kesadaran (kualitatif): …………………………………………………………………
Skala koma Glasgow (kuantitatif)
a) Respon motorik : …………………………..
b) Respon bicara : …………………………..
c) Respon membuka mata : ………………………….
Jumlah:
Kesimpulan : ………………………………………………………………………...
 2. Tekanan darah :……………………..mmHg
MAP :………………………..mmHg
Kesimpulan : …………………………………………………………………………….
3. Suhu :………..0C di Oral Axilla Rectal
4. Pernapasan: ……….x/menit
Irama : Teratur Bradipnea Takipnea Kusmaul Cheynes-stokes
Jenis : Dada Perut
5. Nadi : ………..x/menit
Irama : Teratur Bradikardi Takikardi
Kuat Lemah
C. PENGUKURAN
1. Lingkar lengan atas : …………….cm
2. Tinggi badan : …………….cm
3. Berat badan : …………….kg
4. IMT (Indeks Massa Tubuh : …………...
Kesimpulan : …………………………………………………………………………….
D. GENOGRAM

IV. PENGKAJIAN POLA KESEHATAN

A. POLA PERSEPSI KESEHATAN DAN PEMELIHARAAN KESEHATAN
1. Keadaan sebelum sakit:
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2. Riwayat penyakit saat ini :
a) Keluhan utama :
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b) Riwayat keluhan utama :
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Riwayat penyakit yang pernah dialami :
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Riwayat kesehatan keluarga :
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Pemeriksaan fisik :
c) Kebersihan rambut : .....................................................................................
d) Kulit kepala : .....................................................................................
e) Kebersihan kulit : .....................................................................................
f) Higiene rongga mulut : .....................................................................................
g) Kebersihan genetalia : .....................................................................................
h) Kebersihan anus : .....................................................................................

B. POLA NUTRISI DAN METABOLIK

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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Observasi :
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3. Pemeriksaan fisik :
a) Keadaan rambut : ......................................................................................
b) Hidrasi kulit : ......................................................................................
c) Palpebra/conjungtiva : ......................................................................................
d) Sclera : ......................................................................................
e) Hidung : ......................................................................................
f) Rongga mulut : ............................................ gusi :...............................
g) Gigi : ............................................ gigi palsu :.......................
h) Kemampuan mengunyah keras : .......................................................................
i) Lidah : ......................................................................................
j) Pharing : .....................................................................................
k) Kelenjar getah bening : .....................................................................................
l) Kelenjar parotis : ...................................................................................
m) Abdomen :
 Inspeksi : ………………………………………………………………………
 Auskultasi : ………………………………………………………………………
 Palpasi : ………………………………………………………………………
 Perkusi : ………………………………………………………………………

n) Kulit :
 Edema : Positif Negatif
 Icterik : Positif Negatif
 Tanda-tanda radang : …………………………………………………………..
o) Lesi : …………………………………………………………………………………

C. POLA ELIMINASI
1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :
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4. Pemeriksaan fisik :
a) Peristaltik usus : …………….x/menit
b) Palpasi kandung kemih : Penuh Kosong
c) Nyeri ketuk ginjal : Positif Negatif
d) Mulut uretra : ………………………………………………………………………...
e) Anus :
 Peradangan : ………………………………………………………………
 Hemoroid : ………………………………………………………………
 Fistula : ………………………………………………………………
D. POLA AKTIVITAS DAN LATIHAN
1. Keadaan sebelum sakit :
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Keadaan sejak sakit :
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2. Observasi :
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a) Aktivitas harian : 0 : mandiri
 Makan : ……. 1 : bantuan dengan alat
 Mandi : …….
2 : bantuan orang
3 : bantuan alat dan
 Pakaian : …….
orang
 Kerapihan : …….
4 : bantuan penuh
 Buang air besar : …….
 Buang air kecil : …….
 Mobilisasi di tempat tidur : …….
b) Postur tubuh : ………………………………………………………………………
c) Gaya jalan : ………………………………………………………………………
d) Anggota gerak yang cacat : ……………………………………………………….....
e) Fiksasi: : ………………………………………………………………………
f) Tracheostomi : ………………………………………………………………………
3. Pemeriksaan fisik
a) Tekanan darah
Berbaring : ………………..mmHg
Duduk : ………………..mmHg
Berdiri : ………………..mmHg
Kesimpulan : Hipotensi ortostatik : Positif Negatif
b) HR : …………………x/menit
c) Kulit :
Keringat dingin : ………………………………………………………
Basah : ………………………………………………………
d) JVP : ……………………..cmH2O
Kesimpulan : ………………………………………………………………………...
e) Perfusi pembuluh kapiler kuku : ……………………………………………………
f) Thorax dan pernapasan
 Inspeksi:
Bentuk thorax : ………………………………………………………………
Retraksi interkostal : ……………………………………………………….
Sianosis : ………………………………………………………………
Stridor : ………………………………………………………………
 Palpasi :
Vocal premitus: ……………………………………………………………...
Krepitasi : ………………………………………………………………
 Perkusi :
Sonor Redup Pekak
Lokasi : ……………………………………………………………………………
 Auskultasi :
Suara napas : ……………………………………………………………..
 Suara ucapan : ……………………………………………………………..
Suara tambahan : …………………………………………………………
g) Jantung
 Inspeksi :
Ictus cordis : ………………………………………………………………....
 Palpasi :
Ictus cordis : ………………………………………………………………....
 Perkusi :
Batas atas jantung : ……………………………………………………
Batas bawah jantung : ……………………………………………………
Batas kanan jantung : ……………………………………………………
Batas kiri jantung : ……………………………………………………
 Auskultasi :
Bunyi jantung II A : ……………………………………………………
Bunyi jantung II P : ……………………………………………………
Bunyi jantung I T : ……………………………………………………
Bunyi jantung I M : ……………………………………………………
Bunyi jantung III irama gallop : …………………………………………….
Murmur : ………………………………………………………………
Bruit : Aorta : ……………………………………………………
A.Renalis : ……………………………………………………
A. Femoralis : ……………………………………………………
h) Lengan dan tungkai
 Atrofi otot : Positif Negatif
 Rentang gerak : ………………………………………………………………
Kaku sendi : ………………………………………………………………
Nyeri sendi : ………………………………………………………………
Fraktur : ………………………………………………………………
Parese : ………………………………………………………………
Paralisis : ………………………………………………………………
 Uji kekuatan otot
Kanan Kiri
Tangan

Kaki
Keterangan :
Nilai 5: kekuatan penuh
Nilai 4: kekuatan kurang dibandingkan sisi yang lain
Nilai 3: mampu menahan tegak tapi tidak mampu melawan tekanan
Nilai 2: mampu menahan gaya gravitasi tapi dengan sentuhan akan jatuh
Nilai 1: tampak kontraksi otot, ada sedikit gerakan
Nilai 0: tidak ada kontraksi otot, tidak mampu bergerak
 Refleks fisiologi : ………………………………………………………………..
 Refleks patologi : ………………………………………………………………..
Babinski, Kiri : Positif Negatif
Kanan : Positif Negatif
 Clubing jari-jari: ………………………………………………………………
 Varises tungkai : ………………………………………………………………
i) Columna vetebralis:
 Inspeksi : Lordosis Kiposis Skoliosis
  Palpasi : ………………………………………………………………………
Kaku kuduk : ………………………………………………………………………
E. POLA TIDUR DAN ISTIRAHAT
1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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Observasi :
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Ekspresi wajah mengantuk : Positif Negatif
Banyak menguap : Positif Negatif
Palpebra inferior berwarna gelap : Positif Negatif

F. POLA PERSEPSI KOGNITIF

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :
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4. Pemeriksaan fisik :
a) Penglihatan
 Kornea : ………………………………………………………………………
 Pupil : ………………………………………………………………………
 Lensa mata : ……………………………………………………………………..
 Tekanan intra okuler (TIO) : …………………………………………………....
b) Pendengaran
 Pina : ………………………………………………………………………
 Kanalis : ………………………………………………………………………
 Membran timpani : ………………………………………………………………
c) Pengenalan rasa pada gerakan lengan dan tungkai
………………………………………………………………………………………….
G. POLA PERSEPSI DAN KONSEP DIRI
1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :
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a) Kontak mata : ………………………………………………………………
b) Rentang perhatian : ………………………………………………………………
 c) Suara dan cara bicara : ……………………………………………………..
d) Postur tubuh : ………………………………………………………………
4. Pemeriksaan fisik :
a) Kelainan bawaan yang nyata : ……………………………………………..
b) Bentuk/postur tubuh : ……………………………………………………...
c) Kulit : ……………………………………………………...

H. POLA PERAN DAN HUBUNGAN DENGAN SESAMA

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :
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I. POLA REPRODUKSI DAN SEKSUALITAS

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :
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4. Pemeriksaan fisik :
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J. POLA MEKANISME KOPING DAN TOLERANSI TERHADAP STRES

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :

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3. Observasi :
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K. POLA SISTEM NILAI KEPERCAYAAN

1. Keadaan sebelum sakit :
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2. Keadaan sejak sakit :
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3. Observasi :
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V. UJI SARAF KRANIAL

A. N I : …………………………………………………………………………………………..
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B. N II : ………………………………………………………………………………………....
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C. N III, IV, VI : ……………………………………………………………………………......
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D. NV:
Sensorik : ..…………………………………………………………………………………...
Motorik : ..…………………………………………………………………………………...
E. N VII :
Sensorik : …..………………………………………………………………………………...
Motorik : …..………………………………………………………………………………...
F. N VIII :
Vestibularis : ….……………………………………………………………………………..
Akustikus : …..……………………………………………………………………………..
G. N IX : ……………………………………………………………………………………..….
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H. N X : ………………………………………………………………………………………....
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I. N XI : ………………………………………………………………………………………...
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J. N XII : ……………………………………………………………………………………….
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VI. PEMERIKSAAN PENUNJANG

VII. TERAPI
Tanda Tangan Mahasiswa Yang Mengkaji

( )
 ANALISA DATA
NO DATA ETIOLOGI MASALAH
Ds:
-
 DIAGNOSA KEPERAWATAN
Nama/ Umur :.........................................................
Ruang/ Kamar:...................................................................
NO DIAGNOSA KEPERAWATAN
 RENCANA KEPERAWATAN
Nama/ umur : ..................................................................
Ruang/ kamar : .................................................................
Diagnosa Keperawatan Rencana tindakan (NIC)
Tanggal Hasil Yang Diharapkan (NOC)
(NANDA) Meliputi: Tindakan keperawatan, tindakan observatif, penyuluhan, kolaborasi dokter
 PELAKSANAAN KEPERAWATAN
Nama/ Umur :.........................................................
Ruang/ Kamar:...................................................................
Tgl DP Waktu Pelaksanaan Keperawatan Nama Perawat
 EVALUASI KEPERAWATAN
Nama/ Umur :.........................................................
Ruang/ Kamar:.........................................................................
TANGGAL Evaluasi S O A P Nama Perawat