Prodi S1 Keperawatan

Fakultas Ilmu Kesehatan

Universitas Muhammadiyah Surabaya

FORMAT PENGKAJIAN
KEBUTUHAN DASAR MANUSIA

NamaMahasiswa :Qurrotul Aini

NIM :20171660104
Ruangan :-
Tanggal Pengkajian :24/04/21 Jam 16.30

IDENTITAS

Nama Pasien :An. L

Umur :12 th
No. Register :……………………..
Jenis Kelamin :Perempuan
Suku Bangsa :Jawa
Pekerjaan :Pelajar
Pendidikan :SD
Alamat :Manukan Indah
Tanggal MRS :…………………….
Diagnosa Medis :……………………..

STATUS KESEHATAN

Keluhan utama saat pengkajian :

Keluhan yang dirasakan pasien saat melakukan pengkajian
Riwayat kesehatan :
1. Riwayat Kesehatan/Penyakit sekarang :
Pasien mengatakan An. L mengalami badan panas 2 hari naik turun, mual,
pusing, tidak adanya nafsu makan, An. L terlihat lemas dan mukosa bibir
kering............................................................................................................................
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2. Riwayat Kesehatan/Penyakit dahulu :

Mengatakan An. L mengalami deman ketika ada kegiatan yang cukup
melelahkan dan banyak kegiatan...................................................................................
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3. Riwayat Kesehatan/Penyakit keluarga :
An. L mengatakan anggota keluarga pernah mengalami demam dan tidak .............ada
riwayat penyakit seperti diabetes, hipertensi................................................................
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 Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya

4. Genogram (3 Generasi)

5. POLA FUNGSI KESEHATAN :

1. Pola penatalaksanaan kesehatan / persepsi sehat
Data Subyektif : An. L mengatakan sakitnya karena terllau banyak
bermain dan terlalu lama main air...........................................................................
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Data Obyektif/Pemeriksaan Fisik : An. L tahu jika dirinya sakit demam...............
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2. Pola Nutrisi– Metabolik

Data Subyekatif :An. L mengatakan sebelum sakit dirinya makan 3x sehari,
minum +- 5-6 gelas perhari...........................................................................................
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 Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya

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Data Obyektif/Pemeriksaan Fisik : BB : 38 kg. Porsi makan tidak habis....................
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3. Pola Eliminasi
Eliminasi Alvi
Data Subyektif : An. L mengatakan BAB 1x sehari ....................................................
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Data Obyektif/Pemeriksaan Fisik : An. L BAB 1x sehari............................................
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Eliminasi Uri
Data Subyektif : An. L mengatakan BAK sekitar 4-5x sehari....................................
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Data Obyektif/Pemeriksaan Fisik : An. L Ke kamar mandi untuk BAK.....................
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4. Pola Istirahat dan tidur

Data Subyektif :An. L mengatakan tidak ada gangguan tidur dan tidur 8 jam
sehari.............................................................................................................................
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Data Obyektif/Pemeriksaan Fisik : jam tidur pukul 21.00-05.00.................................
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5. Pola Aktifitas - Latihan

 Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya

Data Subyektif: An. L mengatakan aktivitas seperti biasa makan, minum dan
saat sakit An. L mengatakan sering istirahat di tempat tidur karena merasa
lemas..............................................................................................................................
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Data Obyektif/Pemeriksaan Fisik :An. L makan dengan posisi semi fowler...............
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6. Polakognitif – perseptual – keadekuatan alat sensori
Data Subyektif :An. L mengatakan perkembangan semua indra masih baik...............
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Data Obyektif /Pemeriksaan Fisik : penglihatan dan respon baik...............................
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7. Pola persepsi dan konsepdiri

Pola persepsi
Data Subyektif : An. L mengatakan jika merasa pusing pasien istirahat atau
minum air putih.............................................................................................................
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Data Obyektif Pemeriksaan : Tempat minum Pasien berada di sebelah tempat
tidur ...............................................................................................................................
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Konsep diri
a. Gambaran diri
Data Subyektf : Pasien merasa dirinya baik-baik saja atas apa yang
dimiliknya saat ini.........................................................................................................
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Data Obyektif /Pemeriksaan : Pasien terlihat yakin.....................................................
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b. Harga diri
Data Subyektif : anak L mengatakn tsenang karena merasa dipehatikan oleh
keluarga dan ingin cepat sembuh...................................................................................
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Data Obyektif/Pemeriksaan :An. L terlihat senyum dan yakin untuk sembuh............
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c. Ideal diri
Data Subyektif : An. L memiliki keyakinan untuk sembuh dari demam.....................
Data Obyektif/Pemeriksaan : Pasien terlihat yakin sembuh.........................................
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 Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya

d. Peran diri
Data Subyektif : pasien mengatakan berperan sebagai anak dalam keluarga
dan sebagai pelajar saat di sekolah................................................................................
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Data Obyektif /Pemeriksaan : Pasien anak pertama dalam keluarganya......................
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e. Identitas diri
Data Subyektif :Pasien mengatakan dirinya sebagai pelajar........................................
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Data Obyektif/Pemeriksaan :Pasien seorang pelajar SD..............................................
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8. Pola Reproduksi Seksual
Data Subyektif : AN. L mengatakan berjenis kelamin perempuan ..............................
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Data Obyektif/Pemeriksaan Fisik : tidak ada masalah keperawatan............................
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9. Pola hubungan peran

Persepsi klien tantang pola hubungan

.........................................................................Data Subyektif : An. L mengatakan hubungan pas
saling komunikasi.........................................................................................................
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Data Obyektif/Pemeriksaan : An. L dan ibu terlihat saling meghormati.....................
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Persepsi klien tentang peran dan tanggung jawab

............................................................................Data Subyektif : An. L mengatakan dirinya mem
sebagai pelajar dan mengerjakan tugas jika ada tugas.................................................
Data Obyektif/Pemeriksaan :tampak pasien menunjukkan tugas sekolahnya..............
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10. MekanismeKoping

Kemampuan mengendalian stress

............................................................................Data Subyektif : An. L mengatakan jika bosan, i
kadang handphone........................................................................................................
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 Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya

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Data Obyektif/Pemeriksaan : Tampak ada game di hpnya...........................................
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Sumber pendukung
...........................................................................Data Subyektif :An. L mengatakan jika ada kesu
kepada orang tua...........................................................................................................
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Data Obyektif : Sumber pendukung orang tua.............................................................
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11. Pola tata nilai dan kepercayaan

Data Subyektif : AN.L mengatakan ia beragama islam dan sholat tepat waktu
dan juga tiap sore mengaji di TPA...............................................................................
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PEMERIKSAAN PENUNJANG

1. PemeriksaanLaboratorium (Tanggal:........................)
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2. PemeriksaanRadiologi (Tanggal :.............................)
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3. Pemeriksaan Lain – lain (Tanggal :...................................)

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4. Terapi dan Diet.

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DAFTAR MASALAH KEPERAWATAN

1 Hipertermia………………………………………………………………………
 Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya

2……………………………………………………………………………………
3……………………………………………………………………………………
4……………………………………………………………………………………
5……………………………………………………………………………………
6……………………………………………………………………………………
7……………………………………………………………………………………
Surabaya,
Mahasiswa

(……………………….)
 Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya

ANALISA DATA

NamaPasien : No. Register :

Umur : DiagnosaMedis :

DATA ETIOLOGI PROBLEM

DS : Pasien mengatakan Bakteri berkembang biak Hipertermi
dirinya demam 2 hari yang lalu
DO :
TTV : Memasuki aliran darah
Suhu 38
TD 100/70 mmHG,
RR 18 x/menit Merangsang pelepasan zat
Mukosa bibir kering pirogen oleh leukosit
Bb : 38 kg

Pirogen beredar dalam darah

Gangguan pada termoregulasi

hipertermi
 Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya

DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

NamaPasien : An. L No. Register :

Umur : 12 th DiagnosaMedis :
NO DIAGNOSA KEPERAWATAN TTD
1 Hipertermi
 Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya

RENCANA KEPERAWATAN

NamaPasien : No. Register :

Umur : 12 th DiagnosaMedis : Hipertermi

NO DIAGNOSA TUJUAN KRITERIA HASIL INTERVENSI RASIONAL

KEPERAWATAN
1 Hipertermi Setelah dilakukan 1.Suhu tubuh batas Observasi
keperawatan selama normal 36-37,5 -Monitor suhu tubuh -tanda vital merupakan acuan
1x24 jam suhu tubuh 2.Mukosa bibir lembab -Identifikasi penyebab hipertermi untuk mengetahui keadaan
dalam batas normal 3.Turgor kulit baik -Monitor tanda dan gejala umum pasien
36-37,5 4.Pasien mengetahui hipertermi -pakaian tipis membantu
penyakitnya Terapeutik mempercepat evaporasi
-Ganti pakaian untuk memakai -untuk mengganti energi yang
pakaian yang tipis hilang akibat evaporasi
Edukasi
-Anjurkan makan dan minium
sedikit tapi sering
 Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya

IMPLEMENTASI

NamaPasien :An. L No. Register :

Umur : 12 th DiagnosaMedis :hipertermi

TANGGAL / JAM IMPLEMENTASI TTD

23/4/21 -monitor TTV
Suhu 38
Nadi 96 x/menit
RR 20 x/menit
TD 100/70 mmHG

-Melakukan kompres hangat

-Beri minum sesuai pasien

 Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya

EVALUASI
(CATATAN PERKEMBANGAN PASIEN)

NamaPasien : No. Register :

Umur : DiagnosaMedis :

TGL / CATATAN PERKEMBANGAN EVALUASI

JAM

24/4/21 S : Pasien mengatakan badannya tidak terlalu demam

atau panas
O:
Suhu 37
TD 110/80 mmHG
RR 20 x/menit
A: Hipertermi teratasi
P : Intervensi dihentikan
Prodi S1 Keperawatan
Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Surabaya