UNIVERSITAS 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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6. Riwayat Reproduksi :
a. Menstruasi :
Menarche : …………………………………………………………………………………………………………………………………….
Siklus : ………………………………………………………………………………………………………………………..............
Lama : ……………………………………………………………………………………………………………………………………..

Keluhan : …………………………………………………………………………………………………………………………………….
Bau : ……………………………………………………………………………………………………………………………………..
 UNIVERSITAS MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

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 :
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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 UNIVERSITAS MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

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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 :..........................................................................................
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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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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 UNIVERSITAS MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

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 :

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 : ........................................................................................
UNIVERSITAS MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

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............................................................................................:

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
UNIVERSITAS MUHAMMADIYAH LAMONGAN
Jl. Plalangan Plosowahyu Lamongan

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

3. Nervus cranialis : ...........................................................................................

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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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Lamongan 2020
MAHASISWA

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 ANALISA DATA

NO Tgl DATA ETIOLOGI MASALAH

PRIORITAS DIAGNOSA KEPERAWATAN

1.

2.

3.
 RENCANA KEPERAWATAN

Dx No SLKI SIKI
 IMPLEMENTASI

Dx. Paraf
Tgl/jam Implementasi Respon Pasien
Kep No Perawat
 EVALUASI

Tgl/ jam Dx. Evaluasi Paraf

Kep No Perawat