STIKES MUHAMMADIYAH LAMONGAN

Jl. Plalangan Plosowahyu Lamongan

FORMAT PENGKAJIAN DATA KEPERAWATAN

BIODATA
Nama : ..............................................................................................................................
Jenis Kelamin :...............................................................................................................................
Umur :...............................................................................................................................
Status Perkawinan :...............................................................................................................................
Pekerjaan :...............................................................................................................................
Agama :...............................................................................................................................
Pendidikan Terakhir :...............................................................................................................................
Alamat :...............................................................................................................................
No. Register :...............................................................................................................................
Diagnose Medis :...............................................................................................................................

RIWAYAT KESEHATAN KLIEN

1. Keluhan Utama / Alasan masuk Rumah Sakit :
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2. Riwayat Penyakit Sekarang :
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3. Riwayat Penyakit Yang Lalu :
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4. Riwayat Kesehatan Keluarga :
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5. Riwayat Alergi :
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 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

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6. Riwayat Reproduksi :
a. Menstruasi :
Menarche : …………………………………………………………………………………………………………………………………….
Siklus : ………………………………………………………………………………………………………………………..............
Lama : ……………………………………………………………………………………………………………………………………..
Keluhan : …………………………………………………………………………………………………………………………………….
Bau : ……………………………………………………………………………………………………………………………………..
Konsistensi : ……………………………………………………………………………………………………………………………………..

b. Riwayat kehamilan dan persalinan yang lalu :

kehamilan persalinan Nifas KB

Ana BB Alat keluha
lam penyuli penolon tempa penyuli penyuli lam
k ke bay kontraseps n
a t g t t t a
i i

7. Riwayat Perkawinan :
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POLA AKTIVITAS SEHARI-HARI

A. Pola Tidur / Istirahat :
1. Waktu Tidur :..............................................................................................................................
2. Waktu Bangun :...............................................................................................................................
3. Masalah Tidur :...............................................................................................................................
4. Hal-hal yang mempermudah tidur :...............................................................................................
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5. Hal-hal yang mempermudah terbangun :......................................................................................
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B. Pola Eleminasi :
 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

6. BAK : .............................................................................................................................
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7. BAB : .............................................................................................................................
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8. Kesulitan BAK/BAB : .......................................................................................................................
9. Upaya mengatasi masalah tersebut : .............................................................................................
C. Pola Makan dan Minum :
1. Jumlah dan Jenis makanan :
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2. Waktu pemberian makanan :
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3. Jumlah dan jenis cairan :
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4. Waktu pemberian cairan :
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5. Pantangan :
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6. Masalah makan dan minum :
a. Kesulitan mengunyah :.....................................................................................................
b. Kesulitan menelan :.....................................................................................................
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c. Mual dan muntah:....................................................................................................................
d. Tidak dapat makan sendiri :.....................................................................................................
7. Upaya mengatai masalah tersebut :................................................................................................
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D. Kebersihan Diri / Personal Hygiene :
1. Pemeliharaan badan :
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2. Pemeliharaan gigi dan mulut :
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3. Pemeliharaan kuku :
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E. Pola Kegiatan / Aktifitas Lain

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 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

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DATA PSIKOSOSIAL
A. Pola Komunikasi :
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B. Orang yang paling dekat dengan klien :

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C. Rekreasi :
Hobby :...............................................................................................................................................
Penggunaan waktu senggang : ...................................................................................................................
D. Dampak dirawat di Rumah Sakit :
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E. Hubungan dengan orang lain / Interaksi social :
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F. Keluarga yang dihubungi bila diperlukan :
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DATA SPIRITUAL
1. Ketaatan beribadah :
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2. Keyakinan terhadap sehat / sakit :
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3. Keyakinan terhadap penyembuhan :
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PEMERIKSAAN FISIK
A. Kesan Umum / Keadaan Umum :
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B. Tanda – tanda vital :

TD : ............................................. Suhu : …………………………………………….
RR :............................................... BB : …………………………………….........
Nadi : …………………………………………. TB : ................................................

C. Pemeriksaan kepala dan leher :

 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

1. Kepala dan rambut

a. Bentuk kepala : ..................................................................................................................
Ubun—ubun : ..................................................................................................................
Kulit kepala : ..................................................................................................................
b. Rambut
Penyebaran rambut : .........................................................................................................
Bau dan warna : ..........................................................................................................

c. Wajah
Warna kulit : ..........................................................................................................
Kesimetrisan : ..........................................................................................................

2. Mata
a. Kelengkapan dan kesimetrisan : ........................................................................................
b. Kelopak mata (palpebra) : .......................................................................................
c. Konjungtiva dan sclera : .......................................................................................
d. Pupil dan kornea : .......................................................................................
e. Ketajaman penglihatan / visus : ........................................................................................
f. Tekanan bola mata : .......................................................................................

3. Hidung
a. Tulang hidung dan posisi septum nasi : .............................................................................
b. Lubang hidung : .................................................................................................................

4. Telinga
a. Bentuk dan ukuran telinga : ..............................................................................................
b. Lubang telinga : ..............................................................................................
c. Ketajaman pendengaran : ..............................................................................................

5. Mulut dan faring :

a. Keadaan bibir : ..............................................................................................
b. Keadaan gusi dan gigi : ..............................................................................................
c. Lidah : ..............................................................................................
d. Orofaring : ..............................................................................................
6. Leher
a. Posisi trachea : ........................................................................................................
b. Tiroid : ........................................................................................................
c. Suara : ........................................................................................................
d. Kelenjar limfe : ........................................................................................................
e. Vena jugularis : ........................................................................................................
f. Nadi karotis : ........................................................................................................

D. Pemeriksaa Payudara dan Ketiak

a. Ukuran & bentuk payudara : ...................................................................................................
 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

b. Pigmentasi areola : ...................................................................................................

c. Kelainan payudara : ...................................................................................................
d. Axilla & clavicula : ...................................................................................................

E. Pemeriksaan thoraks / dada

1. Pemeriksaan paru
a. Inspeksi
Bentuk thoraks :.................................................................................................
Jumlah dan irama nafas : ................................................................................................
Tanda kesulitan bernafas : .................................................................................................
b. Palpasi
Vocal fremitus : .................................................................................................
c. Perkusi
Batas paru : .................................................................................................
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d. Auskultasi
Suara nafas : .................................................................................................
Suara ucapan : .................................................................................................
Suara tambahan : .................................................................................................

2. Pemeriksaan jantung
a. Inspeksi dan palpasi
Pulsasi : .................................................................................................
Ictus cordis : .................................................................................................
b. Perkusi
Batas-batas jantung : .................................................................................................
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c. Auskultasi
Bunyi jantung I : .................................................................................................
Bunyi jantung II : .................................................................................................
Bunyi jantung tambahan : .................................................................................................
Bising / murmur : .................................................................................................
Frekuensi denyut jantung : ................................................................................................

F. Pemeriksaan Abdomen
1. Inspeksi
Bentuk abdomen : .................................................................................................
Keadaan abdomen : .................................................................................................
2. Auskultasi
Peristaltik usus : .................................................................................................
3. Palpasi
Nyeri tekan : .................................................................................................
Benjolan / massa : .................................................................................................
Hepar : .................................................................................................
 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

Lien : .................................................................................................
Tanda-tanda asites : .................................................................................................

4. Perkusi
Suara abdomen : .................................................................................................
Pemeriksaan asites : .................................................................................................

G. Pemeriksaan Genetalia dan sekitarnya

1. Genetalia
a. Rambut pubis : .................................................................................................
b. Vulva/vagina : .................................................................................................
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c. Daerah inguinal : .................................................................................................

2. Anus dan perineum

a. Lubang anus : .................................................................................................
b. Perineum : .................................................................................................

H. Pemeriksaan Musculoskeletal
1. Kesimetrisan otot : .................................................................................................
2. Pemeriksaan udema : .................................................................................................
3. Kekuatan dan tonus otot : .................................................................................................
4. Kelainan pada ekstrimitas dan kuku : ......................................................................................
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I. Pemeriksaan Integumen
1. Kebersihan : .................................................................................................
2. Kehangatan : .................................................................................................
3. Warna dan tekstur kulit : .................................................................................................
4. Turgor : .................................................................................................
5. Kelembapan : .................................................................................................
6. Kelaianan pada kulit : .................................................................................................

J. Pemeriksaan Neurologi
1. Tingkat kesadaran : .................................................................................................
2. Tanda-tanda rangsangan otak (meningeal sign) : ....................................................................
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3. Nervus cranialis : .................................................................................................
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 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

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4. Fungsi motorik : .................................................................................................
5. Fungsi sensorik : .................................................................................................
6. Reflek
a. Fisiologis : ................................................................................................
b. Patologis : ................................................................................................

K. Pemeriksaan Status Mental

1. Kondisi emosi dan perasaan : .................................................................................................
2. Orientasi : .................................................................................................
3. Proses berfikir (ingatan, atensi, keputusan,perhitungan): .......................................................
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4. Motivasi : .................................................................................................
5. Persepsi : .................................................................................................
6. Bahasa : .................................................................................................

PEMERIKSAAN PENUNJANG
1. Pemeriksaan Laboratorium : .................................................................................................
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2. Rontgen : .................................................................................................
3. ECG : .................................................................................................
4. USG : .................................................................................................
5. Lain-lain : .................................................................................................
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PENATALAKSANAAN DAN TERAPI

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……………………….., ……………20…..
MAHASISWA

( )
 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

ANALISA DATA

NAMA :
NO. REG. :
NO DATA PENUNJANG MASALAH ETIOLOGI
 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

DAFTAR DIAGNOSA KEPERAWATAN

NAMA :
NO. REG. :
NO TANGGAL DIAGNOSA KEPERAWATAN TANGGAL TTD
MUNCUL TERATASI
 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

CATATAN KEPERAWATAN

NAMA :
NO. REG. :
NO TANGGAL / NO. DX IMPLEMENTASI TTD
JAM
 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

CATATAN PERKEMBANGAN

NAMA :
NO. REG. :
NO TANGGAL / NO. DX EVALUASI TTD
JAM
STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

FORMAT PENGKAJIAN KEPERAWATAN

ASUHAN KEPERAWATAN PADA Tn/Ny…………………….

DENGAN KASUS……………………………..
DIRUANG………………………..
RUMAH SAKIT…………………………………………..
STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

NAMA : ……………………………………………………
NIM : …………………………………………………..

SEKOLAH TINGGI ILMU KESEHATAN

MUHAMMADIYAH LAMONGAN
2012/2013
 STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

RENCANA ASUHAN KEPERAWATAN

NAMA :
NO. REG. :
NO TGL DX KEP TUJUAN DAN RENCANA INTERVENSI RASIONAL TTD
KRITERIA HASIL
STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan
STIKES MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan