PRAKTEK PROFESI NERS P

STIKES WIDYAGAMA HUSADA A

G
E
PENGKAJIAN DASAR KEPERAWATAN 7

Nama Mahasiswa : Tempat Praktik :

NIM : Tgl. Praktik :

A. Identitas Klien
Nama : ........................................... No. RM : ..........................................
Usia : ............. tahun Tgl. Masuk : ..........................................
Jenis kelamin : ........................................... Tgl. Pengkajian : ..........................................
Alamat : ........................................... Sumber informasi : ..........................................
No. telepon : ........................................... Nama klg. dekat yg bisa dihubungi: ................
Status pernikahan : ........................................... ...........................................
Agama : ........................................... Status : ..........................................
Suku : ........................................... Alamat : ..........................................
Pendidikan : ........................................... No. telepon : ..........................................
Pekerjaan : ........................................... Pendidikan : ..........................................
Lama berkerja : ........................................... Pekerjaan : ..........................................

B. Keluhan Utama
1. Saat MRS : ....................................................................................................................
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2. Saat Pengkajian : ....................................................................................................................

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C. Riwayat Kesehatan Saat Ini

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 D. Riwayat Pernikahan P
A
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E
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E. Riwayat Obstetri
1. Riwayat Menstruasi
• Menarche usia :…………….. tahun
• Siklus menstruasi : teratur/tidak,………. hari
• Karakteristik mens : ……………………………………………………………………….
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• G…P…A…
• HMT :…………………………
• HPL :………………………….
2. Riwayat Kehamilan, Persalinan, Nifas Yang Lalu
Penyulit
Anak Nifas
Hamil Tgl Usia Jenis Penolong Kehamilan
Ke Partus Kehamilan Partus & JK BB PB ASI Penyulit
Persalinan
1.

2.

3. Riwayat Hamil Ini

• Taksiran Persalinan : .....................................................................................................
• Keluhan :
a. Trimester I : ...............................................................................................................
b. Trimester II : ...............................................................................................................
c. Trimester III : ...............................................................................................................
• Perawatan antenatal : ...........................................................................................................
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• Gerakan Janin : ....................................................................................................................
• Tanda bahaya dan penyulit kehamilan : ..............................................................................
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• Obat/jamu yang pernah dikonsumsi : ..................................................................................

4. Riwayat Persalinan Sekarang

• Tipe persalinan : .........................................................................................................
• Tanggal dan jam persalinan : ......................................................................................
• BB lahir anak : .............................................................................................................
• Jenis Kelamin : ............................................................................................................
 5. Riwayat Nifas P
A
• Tanggal dan jam : ............................................................................................................ G
E
• Involutio : 7
˗ TFU : .......................................................................................................................
˗ Kontraksi : ...............................................................................................................
• Lochea :
˗ Warna : .....................................................................................................................
˗ Jumlah : ....................................................................................................................
˗ Jenis : .......................................................................................................................
• Laktasi :
˗ Kolostrum : ...............................................................................................................
˗ ASI : .........................................................................................................................
6. Riwayat KB : .........................................................................................................................
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F. Riwayat Kesehatan Terdahulu

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G. Riwayat Keluarga
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H. Riwayat Psikososial Spiritual

1. Komunikasi : ......................................................................................................................................
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2. Keadaan emosional : ( ) Kooperatif ( ) depresi ( ) agresif ( ) hiperaktif ( ) gelisah
3. Hubungan dengan keluarga : ( ) akrab ( ) terganggu ( ) lainnya .........................
4. Hubungan dengan orang lain : ( ) akrab ( ) terganggu ( ) lainnya ........
5. Proses berfikir : ( ) terarah ( ) bingung ( ) ilusi ( ) halusinasi
6. Ibadah / spiritual :...............................................................................................................................
7. Pengambilan keputusan: ( ) sendiri ( ) dibantu orang lain, sebutkan, .......................................

I. Pola Seksualitas
1. Masalah dalam hubungan seksual selama sakit: ( ) tidak ada ( ) ada
 2. Upaya yang dilakukan pasangan: P
A
( ) perhatian ( ) sentuhan ( ) lain-lain, seperti, ..............................................................
G
E
J. Pola Aktifitas-Latihan 7
Rumah Rumah Sakit
• Makan/minum ..................................................... .....................................................
• Mandi ..................................................... .....................................................
• Berpakaian/berdandan ..................................................... .....................................................
• Toileting ..................................................... .....................................................
• Mobilitas di tempat tidur ..................................................... .....................................................
• Berpindah ..................................................... .....................................................
• Berjalan ..................................................... .....................................................
• Naik tangga ..................................................... .....................................................
Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang lain, 4 = tidak mampu

K. Pola Nutrisi
Rumah Rumah Sakit
• Jenis diit/makanan ............................................... ..................................................
• Frekuensi/pola ............................................... ..................................................
• Porsi yg dihabiskan ............................................... ..................................................
• Komposisi menu ............................................... ..................................................
• Pantangan ............................................... ..................................................
• Napsu makan ............................................... ..................................................
• Jenis minuman ............................................... ..................................................
• Frekuensi/pola minum ............................................... ..................................................
• Gelas yg dihabiskan ............................................... ..................................................
• Sukar menelan (padat/cair) ............................................... ..................................................

L. Pola Eliminasi
Rumah Rumah Sakit
• BAB:
- Frekuensi/pola ..................................................... ...................................................
- Konsistensi ..................................................... ...................................................
- Warna & bau ..................................................... ...................................................
- Kesulitan ..................................................... ...................................................
- Upaya mengatasi ..................................................... ...................................................
• BAK:
- Frekuensi/pola ..................................................... ...................................................
- Konsistensi ..................................................... ...................................................
- Warna & bau ..................................................... ...................................................
- Kesulitan ..................................................... ...................................................
- Upaya mengatasi ..................................................... ...................................................
M. Pola Tidur-Istirahat P
Rumah Rumah Sakit A
G
• Tidur siang:Lamanya ............................................... .....................................................
E
- Jam …s/d… .............................................. 7
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- Kenyamanan stlh. tidur .............................................. ...................................................
• Tidur malam: Lamanya ............................................... .....................................................
- Jam …s/d… .............................................. ...................................................
- Kenyamanan stlh. tidur .............................................. ...................................................
- Kebiasaan sblm. tidur .............................................. ...................................................
- Kesulitan .............................................. ...................................................
- Upaya mengatasi .............................................. ...................................................

N. Pola Kebersihan Diri

Rumah Rumah Sakit
• Mandi:Frekuensi .................................................. ..................................................
- Penggunaan sabun ................................................. .................................................
• Keramas: Frekuensi .................................................. ..................................................
- Penggunaan shampoo ................................................. .................................................
• Gosok gigi: Frekuensi .................................................. ..................................................
- Penggunaan odol ................................................. .................................................
• Ganti baju:Frekuensi .................................................. ..................................................
• Upaya yg dilakukan .................................................. ..................................................

O. Pola Kebiasaan Yang Mempengaruhi Kesehatan

• Merokok : .........................................................................................................................................
• Minuman keras : ................................................................................................................................
• Ketergantungan obat : ......................................................................................................................
P. Pemeriksaan Fisik
1. Keadaan Umum: ...................................................................................................................................
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• Kesadaran: .......................................................................................................................................
• Tanda-tanda vital: - Tekanan darah :……… mmHg - Suhu :………oC
- Nadi :……... x/meni - RR :……… x/menit
• Tinggi badan: .................................... cm Berat Badan: .........................kg
2. Kepala & Leher
a. Kepala:
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b. Mata:
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c. Hidung:
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d. Mulut & tenggorokan:
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e. Telinga:
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f. Leher:
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3. Thorak & Dada:

• Jantung
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• Paru
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 4. Payudara & Ketiak P
A
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E
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5. Abdomen
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6. Genetalia & Anus
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7. Ekstermitas
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8. Sistem Integumen
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Q. Hasil Pemeriksaan Penunjang

R. Terapi
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