Pengkajian Stikes Maharani
Pengkajian Stikes Maharani
A. Identitas Klien
Nama :......................................... No.RM
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Usia :......................................... Tgl. Masuk
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Jenis Kelamin :......................................... Tgl. Pengkajian
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Alamat :......................................... Sumber Informasi
:.......................................
No. Telepon :......................................... Nama klg. Dekat yng bisa dihubungi:................
Status Pernikahan:......................................... ...........................................................................
Agama :......................................... Status
:.......................................
Suku :.......................................... Alamat
:.......................................
Pendidikan :......................................... No. Telepon
:.......................................
Pekerjaan :......................................... Pendidikan
:.......................................
Lama Bekerja :......................................... Pekerjaan
:.......................................
3. Kebiasaan
Jenis Frekuensi Jumlah Lamanya
Merokok ............................................ ................................... ...................................
Kopi ............................................ ................................... ...................................
Alkohol ............................................ ................................... ...................................
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E. Riwayat Keluarga
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GENOGRAM
Keterangan:
: Laki-laki
: Perempuan
: Garis keturunan
: Hubungan pernikahan
: Klien
: Tinggal dalam satu rumah
: Meninggal dunia
F. Riwayat Lingkungan
Jenis Rumah Pekerjaan
Kebersihan .................................................... ...................................................
Bahaya kecelakaan ................................................... ...................................................
Polusi ................................................... ...................................................
Ventilasi ................................................... ...................................................
Pencahayaan ................................................... ...................................................
G. Pola Aktivitas-Latihan
Jenis Rumah Rumah Sakit
Makan/Minum ........................................................ ...............................................................
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Mandi ....................................................... ...............................................................
Berpakaian ....................................................... ..............................................................
Toiletting ....................................................... ...............................................................
Mobilitas ....................................................... ..............................................................
Berpindah ...................................................... ...............................................................
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Berjalan ....................................................... ...............................................................
Naik tangga .......................................................
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Pemberian Skor: 0=mandiri, 1=alat bantu, 2=dibantu orang lain (1 orang), 3=dibantu orang lain (>1
orang), 4=tidak mampu
H. Pola Nutrisi
Jenis Rumah Rumah Sakit
Makan
Jenis diit/makanan .................................................... ...................................................
Frekuensi/pola ................................................... ...................................................
Porsi yang dihabiskan ................................................... ...................................................
Komposisi menu ................................................... ...................................................
Pantangan ................................................... ...................................................
Nafsu makan ................................................... ...................................................
Fluktuasi BB 6 bl trhr ................................................... ...................................................
Minum
Jenis minuman ................................................... ...................................................
Frekuensi/pola minum ................................................... ...................................................
Gelas yang dihabiskan ................................................... ...................................................
Sukar menelan ................................................... ...................................................
Pemakaian gigi palsu ................................................... ...................................................
Riw.masalah
penyembuhan luka ................................................... ...................................................
I. Pola Eliminasi
Jenis Rumah Rumah Sakit
BAB
Frekuensi/pola .................................................... ...................................................
Konsistensi .................................................... ...................................................
Warna & bau .................................................... ...................................................
Kesulitan .................................................... ...................................................
Upaya mengetasi .................................................... ...................................................
BAK
Frekuensi/pola .................................................... ...................................................
Konsistensi .................................................... ...................................................
Warna & bau .................................................... ...................................................
Kesulitan .................................................... ...................................................
Upaya mengetasi .................................................... ...................................................
J. Pola Tidur-Istirahat
Rumah Rumah Sakit
Tidur siang: Lamanya ........................................... ..................................................
- Jam .....s/d...... ........................................... ...................................................
- Kenyamanan stl tidur ........................................... ...................................................
Tidur malam: Lamanya ........................................... ...................................................
- Jam .....s/d...... ........................................... ...................................................
- Kenyamanan stl tidur ........................................... ...................................................
- Kebiasaan sbl tidur ........................................... ...................................................
- Kesulitan ........................................... ...................................................
- Upaya mengatasi ........................................... ...................................................
N. Pola Komunikasi
1. Bicara: ( ) Normal Bahasa utama:
( ) Tidak Jelas ( ) Bahasa daerah ( ) Bahasa Indonesia
( ) Bicara berputar-putar ( ) Rentang perhatian
( ) Mampu mengerti pembicaraan orang lain ( ) Afek........................................
2. Tempat tinggal: ( ) Sendiri
( ) Kos/asrama
( ) Bersama orang lain, yaitu: ...............................................................
3. Kehidupan Keluarga
a. Adat istiadat yag dianut: ......................................................................................................
b. Pantangan adat dan agama yang dianut: ...........................................................................
c. Penghasilan Keluarga: ( ) < Rp 500.000 ( ) Rp 2 juta – 3 juta
( ) Rp 500.000 – 1 juta ( ) Rp 3 juta – 4 juta
( ) Rp 1 juta – 2 juta ( ) > 4 juta
O. Pola Seksualitas
1. Masalah dalam hubungan seksual selama sakit: ( ) Tidak ada ( ) Ada
2. Upaya yang dilakukan pasangan: ( ) Perhatian ( ) Sentuhan
( ) Lain-lain,
seperti ...................................................................................................................
Q. Konsep Diri
a. Citra tubuh : ………………………………………………………………………………..........
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b. Identitas : ………………………………………………………………………....………......
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c. Peran : …………………………………………………………………………....……......
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d. Ideal diri : …………………………………………………………....……………………......
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e. Hargadiri : ……………………………………………………….......
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R. Pemeriksaan fisik
1. Keadaan umum:.......................................................................................................................
a. Kesadaran: ........................................................................................................................
b. Tanda tanda vital: Tek.darah : ..........mmHg Suhu
: ..............oC
Nadi : ..........x/m Pernapasan : ..............x/m
2. Kepala dan leher
a. Kepala:
Bentuk.......... Massa..........Distribusi Rambut ...................Warna kulit kepala............
Keluhan: pusing/sakit kepala/migren/lainnya, sebutkan .............................................
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b. Mata
Bentuk ................................. Konjungtiva ........................................
Pupil: ( ) Reaksi terhadap cahaya ( ) Isokor ( ) Meiosis ( ) Pin Point ( ) Midriasis
Tanda
radang:...............................................................................................................
Fungsi penglihatan: ( ) Baik ( ) Kabur
Penggunaan alat bantu: ( ) ya ( ) tidak
Apabila ya: ( ) kaca mata ( ) lensa kontak
( ) minus.....ka/ki ( ) plus....ka/ki
Pemeriksaan mata terakhir: .........................................................................................
Riwayat operasi: .........................................................................................................
c. Hidung
Bentuk......................... Warna ............................... Pembengkakan...........Nyeri
tekan........ Pendarahan......... Sinus ...............
Riwayat Alergi......... Cara mengatasi .........................................................................
Penyakit yang pernah terjadi ......................................................................................
Frekuensi.......................................... Cara mengatasi ................................................
d. Mulut dan tenggorokan
Warna bibir ...................... Mukosa.................. Ulkus.........Lesi............ Massa...........
Warna lidah............................Perdarahan gusi .............Karies...................................
Gangg bicara................................................
Pemeriksaan gigi terakhir.............................................................................................
e. Telinga
Bentuk .............................Warna ......................Lesi......... Massa ......... Nyeri..........
Nyeri Tekan...........
Fungsi Pendengaran ......... ....Alat bantu pendengaran ..............................................
Masalah Yang Pernah Terjadi: ...................................................................................
f. Leher
Kekakuan.......... .....................Nyeri/nyeri tekan...................................
Benjolan/ Massa........ ............Keterbatasan gerak........................
Vena jugularis : ..................Tiroid...............Limfe................. Trakea........................
Keluhan: ......................................................................................................................
Upaya untuk mengatasi ...............................................................................................
3. Dada
Bentuk .......................................... Pergerakan
Dada ..........................................................
Nyeri/nyeri tekan......Massa.........Peradangan......Taktil
Fremitus ........................................
Pola Nafas .................................................................
Jantung
Inspeksi................................................................................................................................
Palpasi .................................................................................................................................
Perkusi ................................................................................................................................
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Auskultasi ............................................................................................................................
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Paru:
Inspeksi................................................................................................................................
Palpasi .................................................................................................................................
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Perkusi ................................................................................................................................
Auskultasi ............................................................................................................................
4. Payudara dan ketiak
Benjolan/Massa: .........................Nyeri/nyeri tekan ..............................................
Bengkak ....................... ...Kesimetrisan: ................................................................
5. Abdomen
Inspeksi: .............................................................................................................................
Palpasi: ...............................................................................................................................
Perkusi: ..............................................................................................................................
Auskultasi: ...........................................................................................................................
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6. Genitalia
Inspeksi : ....................................................................................
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Palpasi : ....................................................................................
.......
Perempuan: Siklus Menstruasi ..........................................................................
Kontrasepsi ........................................................................................................
Kehamilan ..........................................................................................................
Keluhan ..............................................................................................................
Pria: Keluhan ......................................................................................................
7. Ekstremitas
Kekuatan otot: .............................................................................................................
Kontraktur ..............Pergerakan .........................Deformitas ..........
Pembengkakan ...........
Edema ............... Nyeri/nyeri tekan ..............Pus/luka ........................................................
8. Kulit dan Kuku
Kulit : Warna .................Jaringan parut: .............
Lesi........... Suhu........... Tekstur .............
Turgor.......................................................
Kuku : Warna .....................................
Bentuk .................................................
Lesi ........................................ Pengisian Kapiler ..................................
Hasil pemeriksaan penunjang
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S. Pengobatan
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T. Perencanaan Pulang
Tujuan Pulang:.......................................................................................................................
Transportasi Pulang:...............................................................................................................
Dukungan Keluarga:...............................................................................................................
Antisipasi bantuan biaya setelah pulang:................................................................................
Antisipasi masalah perawatan diri setalah pulang:..................................................................
Pengobatan:...........................................................................................................................
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Keterangan lain:......................................................................................................................