PENGKAJIAN

STASE KEPERAWATAN DASAR PROFESI

I. IDENTITAS KLIEN
Nama : …………………… Suku : …………………………
Tanggal lahir/Umur : …………………… Tgl masuk : …………………………
Jenis kelamin : …………………… Tgl dikaji : …………………………
Alamat : …………………… Ruang perawatan: …………………...
Pendidikan : …………………… Diagnosa medis : ……………………
Agama : …………………… No. Rekam Medis : ………………….

Identitas Penanggung jawab

Nama : …………………… Alamat : …………………………
Umur : …………………… Pendidikan : …………………………
Jenis kelamin : …………………… Pekerjaan : …………………………
Suku/bangsa : …………………… Hubungan : …………………………

II. PENGKAJIAN
a. Keluhan Utama:
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b. Riwayat Penyakit Dahulu:
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c. Riwayat Penyakit Sekarang:
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d. Riwayat Keluarga: Genogram:

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e. Keadaan umum :
f. Tingkat
kesadaran:
g. Antropometrik : TB : .................................. cm BMI: ..................................
BB : .................. T................ cm
h. TTV : RR ............ x/m SpO2 .................. %
HR ............ x/m Suhu .................. 0C
TD ............ mmHg MAP .................. mmHg
i. Kebutuhan O2 : Via:
j. Pemeriksaan fisik :
1. Kulit, ......................................................................................................................
Kuku ......................................................................................................................
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2. Rambut ......................................................................................................................
, Kepala, Mata, ......................................................................................................................
Telinga ......................................................................................................................
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3. Hidung, ......................................................................................................................
Mulut/ ......................................................................................................................
Tenggorokan ......................................................................................................................
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4. Leher, ......................................................................................................................
Thorax/dada, ......................................................................................................................
Abdomen ......................................................................................................................
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5. Ekstre ......................................................................................................................
mitas, ......................................................................................................................
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6. Genitali ......................................................................................................................
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7. Refleks ......................................................................................................................
neurologis ......................................................................................................................
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8. Nervus ......................................................................................................................
Cranial ......................................................................................................................
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k. Kebutuhan Cairan :
l. Intake cairan : Output Cairan :

m. Balance Cairan :

n. Nutrisi : Sebelum di RS Sesudah di RS

Frekuensi : .............................. ................................................................
Porsi makan/minum: ................ ................................................................
Keterangan: .............................. ................................................................

o. Pola tidur : Sebelum di RS Sesudah di RS

Siang/ malam : .....jam/ ... jam Siang/ malam : .....jam/ .......jam
Kebiasaan tidur: ....................... Kebiasaan tidur: ........................

p. Kebersihan diri : Sebelum di RS Sesudah di RS

Mandi : ................ x/hari Mandi : ................ x/hari
Sikat gigi : ................ x/hari Sikat gigi : ................ x/hari
Potong kuku: ................ x/hari Potong kuku: ................ x/hari

q. Eliminasi : Sebelum di RS Sesudah di RS

BAB: ........ x/hari BAB: ........ x/hari
BAK: ........ x/hari BAK: ........ x/hari

r. Spiritualitas : Apa aktivitas spiritualitas Anda sebelum masuk RS?

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Selama di RS, apakah Anda masih bisa melakukan aktivitas spiritualitas?
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Jika, tidak. Apakah hal tersebut menjadi kekhawatiran Anda?
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s. ADL (Indeks Barthel)

Item penilaian Skor Hasil

Makan (Feeding) 0 = tidak mampu
1 = butuh bantuan
2 = mandiri
Mandi (Bathing) 0 = butuh bantuan
1 = mandiri
Perawatan diri 0 = butuh bantuan
(Grooming) 1 = mandiri
Berpakaian (Dressing) 0 = butuh bantuan total
1 = sebagian dibantu
2 = mandiri
Buang air kecil (Bowel) 0 = inkontinensia/ pakai kateter
1 = kadang inkontinensia (1x/ minggu)
2 = kontinensia
Buang air besar (Bladder) 0 = inkontinensia/ perlu enema
1 = kadang inkontinensia (1x/ minggu)
2 = kontinensia
Penggunaan toilet 0 = butuh bantuan total
1 = sebagian dibantu
2 = mandiri
Transfer 0 = tidak mampu
1 = butuh bantuan (2 orang)
2 = butuh bantuan (1 orang)
3 = mandiri
Mobilitas 0 = immobile
1 = menggunakan kursi roda
2 = berjalan dengan bantuan 1 orang
3 = mandiri
Naik turun tangga 0 = tidak mampu
1 = butuh bantuan
2 = mandiri
Total Skor

Keterangan: Skor 20 : mandiri

Skor 12-19 : ketergantungan ringan
Skor 9-11 : ketergantungan sedang
Skor 5-8 : ketergantungan berat
Skor 0-4 : ketergantungan total
t. Nyeri :
Pengkajian nyeri pada dewasa (PQRST)

P :

Q :

R :

S :

T :

u. Resiko Jatuh :
MORSE FALL SCALE (MFS)/ SKALA JATUH DARI MORSE

No. PENGKAJIAN SKALA NILAI KET.

Riwayat jatuh: Tidak 0
1. Apakah pasien pernah jatuh dalam 3 bulan
Ya 25
terakhir?
Diagnosa sekunder: Tidak 0
2. Apakah pasien memiliki lebih dari satu
Ya 25
penyakit?
3. Alat bantu jalan:
0
 Bed rest/dibantu perawat?
 Kruk/tongkat/walker 15
 Berpegangan pada benda-benda
30
disekitar (kursi, lemari, meja)
Terapi Intravena: Tidak 0
4.
Apakah pasien saat ini terpasang infus? Ya 20
Gaya berjalan/cara berpindah:
5.  Normal/bed rest/ immobile (tidak dapat 0
bergerak sendiri)
 Lemah (tidak bertenaga) 10
 Gangguan/ tidak normal
20
(pincang/diseret)
Status Mental:
6. 0
 Pasien menyadari kondisi dirinya
 Pasien mengalami keterbatasan daya
15
ingat
TOTAL
Nilai 0-24 : tidak beresiko
Nilai 25-50 : risiko rendah
Nilai > 51 : risiko tinggi
 SKALA RESIKO JATUH ONTARIO MODIFIED STRTIFY – SYDNEY SCORING UNTUK
GERIATRI
Keterangan
No. Parameter Skrining Jawaban Skor
Nilai
1. Riwayat Jatuh Apakah pasien datang kerumah sakit Salah satu
Ya/Tidak
karena jatuh? jawaban
Jika tidak, apakah pasien mengalami Ya=6
Ya/Tidak
jatuh dalam 2 bulan terakhir ini?
2. Status Mental Apakah pasien delirium? (tidak dapat Salah satu
membuat keputusan, pola pikir tidak Ya/Tidak jawaban
terorganisir, gangguan daya ingat) Ya=14
Apakah pasien disorientasi? (salah
Ya/Tidak
menyebutkan waktu, tempat atau orang)
Apakah pasien mengalami agitasi?
Ya/Tidak
(ketakutan, gelisah, dan cemas)
3. Penglihatan Apakah pasien memakai kacamata? Ya/Tidak Salah satu
Apakah pasien mengeluh adanya jawaban
Ya/Tidak
penglihatan buram? Ya=1
Apakah pasien mempunyai
Ya/Tidak
Glaukoma/Katarak/ Degenerasi Makula?
Kebiasaan Apakah terdapat perubahan perilaku
4. berkemih berkemih? (frekuensi, urgensi, Ya/Tidak Ya=2
inkontinensia, nokturia)
5. Transfer (dari Mandiri (boleh memakai alat bantu jalan) 0
tempat tidur Memerlukan sedikit bantuan (1 orang)
1 Jumlah nilai
ke kursi dan /dalam pegawasan
kembali lagi Memerlukan bantuan yang nyata (2 transfer dan
2 mobilitas.
ke tempat orang)
tidur) Tidak dapat duduk dengan seimbang, Jika nilai total
3
perlu bantuan total 0 – 3 maka
6 Mobilitas Mandiri (boleh menggunakan alat bantu skor = 0
0
jalan) Jika nilai total
Berjalan dengan bantuan 1 orang 4 – 6, maka
1
(verbal/fisik) skor = 7
Menggunakan kursi roda 2
Immobilisasi 3
TOTAL
Keterangan skor:
0 – 5: resiko rendah 6 – 16 : resiko sedang 17 – 30 : resiko tinggi
v. Skala Cemas (Hamilton Rating Scale for Anxiety/ HARS) :

Skor
No Pertanyaan
0 1 2 3 4
1 Perasaan Ansietas
- Cemas
- Firasat Buruk
- Takut Akan Pikiran Sendiri
- Mudah Tersinggung
2 Ketegangan
- Merasa Tegang
- Lesu
- Tak Bisa Istirahat Tenang
- Mudah Terkejut
- Mudah Menangis
- Gemetar
- Gelisah
3 Ketakutan
- Pada Gelap
- Pada Orang Asing
- Ditinggal Sendiri
- Pada Binatang Besar
- Pada Keramaian Lalu Lintas
- Pada Kerumunan Orang Banyak
4 Gangguan Tidur
- Sukar Masuk Tidur
- Terbangun Malam Hari
- Tidak Nyenyak
- Bangun dengan Lesu
- Banyak Mimpi-Mimpi
- Mimpi Buruk
- Mimpi Menakutkan
5 Gangguan Kecerdasan
- Sukar Konsentrasi
- Daya Ingat Buruk
6 Perasaan Depresi
- Hilangnya Minat
- Berkurangnya Kesenangan Pada Hobi
- Sedih
- Bangun Dini Hari
- Perasaan Berubah-Ubah Sepanjang Hari
7 Gejala Somatik (Otot)
- Sakit dan Nyeri di Otot-Otot
- Kaku
- Kedutan Otot
- Gigi Gemerutuk
- Suara Tidak Stabil
8 Gejala Somatik (Sensorik)
- Tinitus
- Penglihatan Kabur
- Muka Merah atau Pucat
- Merasa Lemah
- Perasaan ditusuk-Tusuk
9 Gejala Kardiovaskuler
- Takhikardia
- Berdebar
- Nyeri di Dada
 - Denyut Nadi Mengeras
- Perasaan Lesu/Lemas Seperti Mau Pingsan
- Detak Jantung Menghilang (Berhenti
Sekejap)
10 Gejala Respiratori
- Rasa Tertekan atau Sempit Di Dada
- Perasaan Tercekik
- Sering Menarik Napas
- Napas Pendek/Sesak
11 Gejala Gastrointestinal
- Sulit Menelan
- Perut Melilit
- Gangguan Pencernaan
- Nyeri Sebelum dan Sesudah Makan
- Perasaan Terbakar di Perut
- Rasa Penuh atau Kembung
- Mual
- Muntah
- Buang Air Besar Lembek
- Kehilangan Berat Badan
- Sukar Buang Air Besar (Konstipasi)
12 Gejala Urogenital
- Sering Buang Air Kecil
- Tidak Dapat Menahan Air Seni
- Amenorrhoe
- Menorrhagia
- Menjadi Dingin (Frigid)
- Ejakulasi Praecocks
- Ereksi Hilang
- Impotensi
13 Gejala Otonom
- Mulut Kering
- Muka Merah
- Mudah Berkeringat
- Pusing, Sakit Kepala
- Bulu-Bulu Berdiri
14 Tingkah Laku Pada Wawancara
- Gelisah
- Tidak Tenang
- Jari Gemetar
- Kerut Kening
- Muka Tegang
- Tonus Otot Meningkat
- Napas Pendek dan Cepat
- Muka Merah
Total Skor

Keterangan:
Skor: 0 = tidak ada Total Skor:
1 = ringan kurang dari 14 = tidak ada kecemasan
2 = sedang 14 – 20 = kecemasan ringan
3 = berat 21 – 27 = kecemasan sedang
4 = berat sekali 28 – 41 = kecemasan berat
42 – 56 = kecemasan berat sekali
w. Hasil laboratorium
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x. Foto thoraks, dll (Hasil pembacaan)

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y. Terapi Farmakologi
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III. Data Fokus

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IV. Analisis Data

DATA KLIEN MASALAH
No ETIOLOGI
(Data Subjektif & Data Objektif) KEPERAWATAN
V. Diagnosa Keperawatan
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VI. Rencana Keperawatan

Diagnosa Perencanaan
No
Keperawatan Tujuan Keperawatan & NOC Intervensi Keperawatan (NIC)
VII. Implementasi dan Evaluasi

Hari/ Nomor Dx Implementasi Evaluasi

Jam TTD
Tgl Keperawatan Keperawatan Keperawatan

S:

O:

A:

P:

I:

E: