FORMAT PENGKAJIAN

KEPERAWATAN PALIATIF
DOSEN PENGAMPU : NAZARUDDIN ,S.KEP., NS., M.KEP

Oleh :

Wiwin : P201801077
L2 Keperawatan

PROGRAM STUDI S1 KEPERAWATAN

FAKULTAS ILMU-ILMU KESEHATAN
UNIVERSITAS MANDALA WALUYA
KENDARI
2021

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 FORMAT PENGKAJIAN
KEPERAWATAN PALIATIF

Nama Mahasiswa : ....................................... Ruangan : .......................................

Waktu Praktik : ....................................... Pembimbing : .......................................

A. IDENTITAS KLIEN
Nama : ............................... Pendidikan : ...............................
Umur : ............................... Pekerjaan : ...........................................
Jenis Kelamin : ............................... Dx Medis : ...........................................
Alamat : ............................... Tgl MRS : ...........................................
Status Perkawinan : ............................... No. RM : ...........................................
Agama : ............................... Tgl Pengkajian : ...............................
Suku Bangsa : ............................... Jam Pengkajian : ...............................
B. IDENTITIAS PENANGGUNG JAWAB
Nama :...........................................................................................
Usia :...........................................................................................
Hubungan dengan pasien :..........................................................................................
Alamat rumah :..........................................................................................
C. RIWAYAT PENYAKIT
1. Riwayat Penyakit Sekarang
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2. Riwayat Kesehatan Dahulu

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3. Riwayat Kesehatan Keluarga
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4. Riwayat Alergi
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D. PENGKAJIAN KEPERAWATAN
1. Persepsi dan Pemeliharaan Kesehatan
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2. Pola Nutrisi / Metabolik
Intake Makanan :
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Intake Cairan :
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3. Pola Eliminasi
a. Buang air besar :
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b. Buang air kecil :
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4. Pola Aktivitas dan Latihan
Kemampuan perawatan diri 0 1 2 3 4 Keterangan:
Makan/minum 0: Mandiri;
Mandi 1: Alat bantu;
Toileting 2:dibantu orang
Berpakaian lain;
Mobilitas di tempat tidur 3:Dibantu orang
Berpindah lain dan alat;
Ambulasi/ROM 4:Ketergantungan
Oksigenasi total
: ......................................................................................................................................
......................................................................................................................................................................
..
5. Pola Tidur dan Istirahat (lama tidur, gangguan tidur, perasaan saat bangun tidur):
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6. Pola Perceptual (penglihatan, pendengaran, pengecap, sensasi):
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7. Pola Persepsi Diri (pandangan klien tentang sakitnya, kecemasan, konsep diri):

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 ......................................................................................................................................................................
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8. Pola Seksualitas dan Reproduksi (fertilitas, libido, menstruasi, kontrasepsi, dll):
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9. Pola Peran-Hubungan (komunikasi, hubungan dengan orang lain, kemampuan
keuangan):
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10. Pola Managemen Koping-Stress (perubahan terbesar dalam hidup akhir-akhir ini,
dll):
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11. Sistem Nilai dan Keyakinan (pandangan klien tentang agama, kegiatan keagamaan,
dll):
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E. PEMERIKSAAN FISIK
1. Cephalocaudal
a. Keluhan yang dirasakan saat ini:
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b. TD: / mmHgP: x/menit N: x/menit S: o
C
c. BB / TB : ........... Kg / ........... cm
d. Kepala :...........................................................................................................................
e. Leher : ..........................................................................................................................
f. Thoraks : ..........................................................................................................................
g. Ingunal : ..........................................................................................................................
h. Ekstremitas (termasuk keadaan kulit, kakuatan)
: ..................................................................................................................................................

2. Penanganan Kasus :
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F. TERAPI
1. Terapi Obat

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2. Terapi Suportif
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 ANALISA DATA
Nama Pasien : .......................................... Dx. Medis : .........................................
No. RM : ..........................................
Data
No Tgl/jam Etiologi Problem
(Subyektif dan Obyektif)

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 ASUHAN KEPERAWATAN
Nama Pasien : .......................................... Dx. Medis : ..........................................
No. RM : ..........................................

No Dx. Kep Nursing Ooutcome Nursing Intervention Implementasi