PENGKAJIAN KEPERAWATAN DASAR PROFESI

Nama Mahasiswa : Tri Widya Romadaningsih

NIM :
Kelompok : F1
Tanggal Praktik/Minggu ke :
Tempat Praktik :

Tanggal/ jam pengkajian :

Tanggal/ jam MRS :

Identitas Pasien
Nama : Ny. SH
Umur : 57 th 5 bln
Jenis Kelamin : Perempuan
Alamat :
Pendidikan Terakhir : SMP
Suku :
Agama :
Status Perkawinan :
Pekerjaan :
No. Rekam Medik :
Diagnosis : Malaise+Dispepsia+Hiperglikemia
Keadaan Umum : Terdapat luka kemerahan pada tumit dan sacrum sepanjang 1 cm dan
kedalaman 0,3 cm
Keluhan Utama : Klien mengalami penurunan kesadaran GCS 333

1. Pola Persepsi Kesehatan dan Penanganan Kesehatan

Alasan masuk rumah sakit :

Pasien datang dalam keadaan tidak dapat bergerak

a) Riwayat penyakit sekarang :
Pasien sudah dirawat keluarga selama 1 bulan karena post stroke namun kondisi px
melemah sejak 2 hari yang lalu
b) Riwayat penyakit dahulu :
DM dan hipertensi
c) Riwayat penyakit keluarga :
DM
Riwayat medik dan sosial
 Kecelakaan : ............................................
 Dirawat : ..................................................
..................................................................
 Operasi : ...................................................
 Alergi : .....................................................
 Penyakit : .................................................
..................................................................
 Lain-lain : ................................................
...................................................................
Diagnosis Keperawatan :
Riwayat pengobatan
 Sebelumnya : .........................................
.................................................................
................................................................
 Saat ini : .................................................
.................................................................
.................................................................
 Persepsi klien tentang kesehatan :
.................................................................
.................................................................

2. Pola Nutrisi – Metabolik

Intake nutrisi sebelum sakit Intake nutrisi saat sakit
 Makanan  Makanan

 Minuman  Minuman

 Nafsu makan  Nafsu makan

 Muntah  Muntah

 Keluhan/ masalah yang memengaruhi  Keluhan/ masalah yang memengaruhi

asupan nutrisi : asupan nutrisi

 Keadaan kulit, rambut dan kuku

............................................................................................................................................
............................................................................................................................................
.........................................................................................................................................
BB : .......... kg TB : .......... cm Suhu : ..........°C
 Kelembaban kulit : ..........................................................................................................
 Warna kulit : ...................................................................................................................
Turgor : ...........................................................................................................................
 Kondisi kulit : .................................................................................................................
 Kuku : .............................................................................................................................
 Rambut dan kepala : .......................................................................................................
 Kelenjar tiroid : ..............................................................................................................
 JVP : ...............................................................................................................................
 Kaku kuduk. : .................................................................................................................
 Mukosa bibir : ................................................................................................................
 Kebersihan mulut : .........................................................................................................
 Peradangan tonsil : .........................................................................................................
 Gigi : ...............................................................................................................................
 Penggunaan NGT : .........................................................................................................
 Terapi intravena / parenteral : ........................................................................................
 Lain-lain ........................................................................................................................
........................................................................................................................................
Diagnosis Keperawatan :

3. Pola Eliminasi
 Tanggal defekasi terakhir : ................................................................................................
 Frekuensi defekasi : ...........................................................................................................
Konsistensi : ......................................................................................................................
Warna : ..............................................................................................................................
 Masalah defekasi : .............................................................................................................
 Penggunaan alat bantu (laksatif/ pispot) : .........................................................................
 Bising usus : ......................................................................................................................
 Struktur abdomen :
 I : ..................................................................................................................................
 A : ................................................................................................................................
 P : .................................................................................................................................
 P : .................................................................................................................................
 Distensi : ............................................................................................................................
 Nyeri tekan : ......................................................................................................................
 Lain-lain : ..........................................................................................................................
............................................................................................................................................
 Frekuensi berkemih : .........................................................................................................
Jumlah : .............................................................................................................................
Warna : ..............................................................................................................................
 Penggunaan alat bantu berkemih : ....................................................................................
 Keluhan /masalah berkemih : ............................................................................................
 Sakit pinggang : .................................................................................................................
 Palpasi ginjal : ...................................................................................................................
 Perkusi ginjal : ...................................................................................................................
 Kondisi blast : ....................................................................................................................
 Lain-lain ……………………………………………………………………………….....
............................................................................................................................................
Diagnosis Keperawatan :

4. Pola Aktivitas - Latihan

Kemampuan perawatan diri:
SMRS MRS
Aktivitas
0 4 0 1 2 3 1 2 3 4
Mandi
Berpakaian/ berdandan
Eliminasi/ toileting
Mobilitas di tempat
tidur
Berpindah
Berjalan
Naik tangga
Berbelanja
Memasak
Pemeliharaan rumah
Skor:
0 = mandiri
1 = alat bantu 3 = dibantu orang lain & alat
2 = dibantu orang lain 4 = tergantung/ tidak mampu
Kebersihan diri:
Di rumah
 Mandi : ..........  /hr
 Gosok gigi : ..........  /hr
 Keramas : ..........  /mgg
 Potong kuku : ..........  /mgg
Di rumah sakit
 Mandi : ..........  /hr
 Gosok gigi : ..........  /hr
 Keramas : ..........  /mgg
 Potong kuku : ..........  /mgg
Pernapasan
 Frekuensi napas : ............... x/ menit
Kedalaman : ......................................................................................................................
Irama : ...............................................................................................................................
 Bunyi napas : ....................................................................................................................
 Riwayat merokok : ............................................................................................................
 Riwayat asma/ bronchitis/ emfisema : ..............................................................................
 Riwayat penyakit paru dalam keluarga : ..........................................................................
 Batuk : ..............................................................................................................................
 Penggunaan otot bantu napas : .........................................................................................
 Suara napas tambahan : .....................................................................................................
 Adanya sputum : ...............................................................................................................
 Lain-lain : Pemeriksaan dada (Pernafasan)
 I : .................................................................................................................................
 P : ................................................................................................................................
 P : ................................................................................................................................
 A : ...............................................................................................................................
Sirkulasi
 Frekuensi nadi : ............... x/ menit
Irama : ...............................................................................................................................
TD : .................... mmHg
 Pemeriksaan dada (Jantung)
 I : .................................................................................................................................
 P : ................................................................................................................................
 P : ................................................................................................................................
 A : ...............................................................................................................................
 Nyeri dada : ......................................................................................................................
 Capillary refill : ................................................................................................................
 Edema : ............................................................................................................................
 Palpitasi : ..........................................................................................................................
 Suhu ekstrimitas : .............................................................................................................
 Riwayat penyakit jantung dalam keluarga : .....................................................................
Mobilitas
 Pola latihan yang biasa dilakukan : ...................................................................................
 Aktivitas di waktu luang : .................................................................................................
...........................................................................................................................................
Sejak sakit : .......................................................................................................................
...........................................................................................................................................
 Rentang gerak : .................................................................................................................
...........................................................................................................................................
Skala kekuatan otot :

 Keseimbangan dan cara jalan : ..........................................................................................

Bentuk tulang belakang : ..................................................................................................
 Genggaman tangan/ refleks : ............................................................................................
 Penggunaan tongkat/ walker/ prostese : ...........................................................................
 Persendian:
Nyeri : ...............................................................................................................................
Edema : .............................................................................................................................
Kekakuan : ........................................................................................................................
 Deformitas : ......................................................................................................................
 Lain-lain : .........................................................................................................................
...........................................................................................................................................
Diagnosis Keperawatan :

5. Pola Istirahat dan Tidur

 Waktu tidur
Sebelum sakit : ..................................................................................................................
Saat sakit : .........................................................................................................................
 Keluhan yang mempengaruhi tidur : .................................................................................
............................................................................................................................................
............................................................................................................................................
 Keluhan letih : ...................................................................................................................
 Lingkaran gelap di mata : ..................................................................................................
 Penggunaan hipnotik/ sedasi : ...........................................................................................
 Lain-lain ............................................................................................................................
...........................................................................................................................................
Diagnosis Keperawatan :

6. Pola Kognitif – Persepsi

 Fungsi penglihatan : ..........................................................................................................
 Posisi bola mata : ..............................................................................................................
 Gerakan mata : ..................................................................................................................
 Konjungtiva : ....................................................................................................................
 Kornea : ............................................................................................................................
 Sklera : ..............................................................................................................................
 Pupil : ...............................................................................................................................
 Pemakaian alat bantu penglihatan : ..................................................................................
 Fungsi pendengaran : ........................................................................................................
 Struktur luar telinga : ........................................................................................................
 Cairan dari telinga : ..........................................................................................................
 Perasaan penuh dalam telinga : ........................................................................................
 Tinnitus : ..........................................................................................................................
 Penggunaan alat bantu dengar : ........................................................................................
 Fungsi penciuman : ..........................................................................................................
 Kondisi hidung : ..............................................................................................................
 Cairan dari hidung : ..........................................................................................................
 Keluhan nyeri : ................................................................................................................
 Vertigo : ...................................................Pusing : ..........................................................
 Tingkat kesadaran : ........................................................ GCS : E ........ V ........ M ........
 Kemampuan mengambil keputusan : ...............................................................................
 Lain-lain ………………………………………………………………………………...
 Pengkajian nyeri :
P : ......................................................................................................................................
Q : .....................................................................................................................................
R : .....................................................................................................................................
S : ......................................................................................................................................
T : ......................................................................................................................................
Diagnosis Keperawatan :

7. Pola Persepsi Diri – Konsep Diri

 Persepsi klien tentang penyakitnya : .................................................................................
............................................................................................................................................
 Harapan setelah dirawat : ..................................................................................................
............................................................................................................................................
 Persepsi klien tentang diri : ...............................................................................................
...........................................................................................................................................
 Ekspresi afek/emosi : ........................................................................................................
 Isyarat non verbal perubahan harga diri : .........................................................................
...........................................................................................................................................
 Lain-lain ………………………………………………………………………………
…………………………………………………………………………………………
Diagnosis Keperawatan :

8. Pola Seksualitas – Reproduksi

 Dampak sakit terhadap seksualitas : ..................................................................................
............................................................................................................................................
 Riwayat haid : ....................................................................................................................
............................................................................................................................................
 Pemeriksaan payudara sendiri : .........................................................................................
............................................................................................................................................
 Keluhan mengenai keturunan : ..........................................................................................
............................................................................................................................................
 Tindakan pengendalian kelahiran : ...................................................................................
...........................................................................................................................................
 Riwayat penyakit hubungan seksual : ..............................................................................
...........................................................................................................................................
 Keluhan gatal-gatal : ........................................................................................................
...........................................................................................................................................
 Lain-lain ………………………………………………………………………………
…………………………………………………………………………………………
Diagnosis Keperawatan :
9. Pola Koping – Toleransi Stres
 Cara pengambilan keputusan klien : .................................................................................
...........................................................................................................................................
 Stresor dalam 1 tahun terakhir : .......................................................................................
 Koping yang biasa digunakan : ........................................................................................
..........................................................................................................................................
 Pengobatan untuk mengatasi stress : ...............................................................................
..........................................................................................................................................
 Kecemasan : .....................................................................................................................
..........................................................................................................................................
 Sistem pendukung : ..........................................................................................................
..........................................................................................................................................
 Perilaku yang ditunjukkan klien : ....................................................................................
 Lain-lain ………………………………………………………………………………
…………………………………………………………………………………………
Diagnosis Keperawatan :

10. Pola Peran – Hubungan

 Peran dalam keluarga : .....................................................................................................
...........................................................................................................................................
 Hubungan dengan orang terdekat : ...................................................................................
...........................................................................................................................................
 Interaksi dengan pasien lain : ...........................................................................................
...........................................................................................................................................
 Cara berkomunikasi : .........................................................................................................
 Efek perubahan peran : ......................................................................................................
............................................................................................................................................
 Perilaku selama dirawat : ..................................................................................................
............................................................................................................................................
 Bahasa yang digunakan sehari-hari : .................................................................................
 Lain-lain ………………………………………………………………………………
…………………………………………………………………………………………
Diagnosis Keperawatan :

11. Pola Nilai – Kepercayaan

 Persepsi klien tentang agama : ...........................................................................................
............................................................................................................................................
 Kegiatan keagamaan : .......................................................................................................
...........................................................................................................................................
 Sikap terhadap nilai : ........................................................................................................
...........................................................................................................................................
 Bantuan spiritual : .............................................................................................................
...........................................................................................................................................
 Lain-lain ............................................................................................................................
...........................................................................................................................................
Diagnosis Keperawatan :
 PEMERIKSAAN PENUNJANG
1. Laboratorium
NILAI
PEMERIKSAAN HASIL SATUAN METODA
RUJUKAN
HEMATOLOGI
Hemoglobin 12.50 – 16.70 g/dl Colorimetric
Leukosit 4.65 - 10.3 ribu/ul Impedance
Eritrosit 4.10 – 6.00 juta/ul Impedance
Hematokrit 42.00 - 52.00 vol% Analyze Calculates
Trombosit 150 – 356 ribu/ul Impedance
RDW-CV 12.1 - 14.0 % Analyze Calculates
MCV, MCH, MCHC
MCV 75.0 - 96.0 fl Analyze Calculates
MCH 28.0 - 32.0 pg Analyze Calculates
MCHC 33.0 – 37.0 % Analyze Calculates
HITUNG JENIS
Gran% 50.0 – 70.0 % Impedance
Limfosit% 25.0 – 40.0 % Impedance
MID% 4.0 – 11.0 % Impedance
Gran# 2.50 – 7.00 ribu/ul Impedance
Limfosit# 1.25 – 4.0 ribu/ul Impedance
MID# ribu/ul Impedance
PROTHROMBIN TIME
Hasil PT 9.9 – 13.5 Detik Nephelometri
INR - Nephelometri
Control Normal
- - Nephelometri
PT
Hasil APTT 22.2 – 37.0 Detik Nephelometri
Control Normal
- Nephelometri
APTT
KIMIA
GULA DARAH
Gula darah
<200 mg/dl GOD-PAP
sewaktu
URINALISA
Warna Kekeruhan Kuning-jernih Urinalysis Strips
BJ 1.005 – 1.030 Urinalysis Strips
pH 5.0 – 6.5 Urinalysis Strips
Keton Negative Urinalysis Strips
Protein-Albumin Negative Urinalysis Strips
Glukosa Negative Urinalysis Strips
Bilirubin Negative Urinalysis Strips
Darah Samar Negative Urinalysis Strips
Nitrit Negatif Urinalysis Strips
Urobilinogen 0.1 – 1.0 Urinalysis Strips
Leukosit Negative Urinalysis Strips
URINALISA (SEDIMEN)
Leukosit 0–3 Manual Mikroskop
Eritrosit 0–2 Manual Mikroskop
Selinder Negative Manual Mikroskop
Epithel 1+ Manual Mikroskop
Bakteri Negative Manual Mikroskop
Kristal Negative Manual Mikroskop
Lain-lain Negative Manual Mikroskop
FAAL LEMAK DAN JANTUNG
CKMB 0 - 24 U/L Optimised (C)
HATI
SGOT 0 - 46 U/I IFCC
SGPT 0 - 45 U/I IFCC
Albumin 3.5 – 5.5
GINJAL
Ureum 10 – 50 mg/dl Moodif-Berhelot
Creatinin 0.7 – 1.4 mg/dl Jaffe
ELEKTROLIT
Natrium 135 – 146 mmol/I ISE
Kalium 3.4 – 5.4 mmol/I ISE
Chlorida 95 – 100 mmol/I ISE
2. Rontgen
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3. CT-Scan
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4. EKG
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 TERAPI MEDIS
Rute
Tanggal Nama Obat Dosis Indikasi
Pemberian
 ANALISA DATA

Nama Klien : Ny. SH

Umur : 57 th
Ruangan/ Kamar : ..............................................................................................
No. RM : ..............................................................................................

No. Data Etiologi Masalah

DO : Gangguan Risiko Infeksi

Integritas kulit (00004)
1 - Terdapat luka kemerahan pada tumit
dan sacrum sepanjang 1 cm dan
kedalaman 0,3 cm

- Klien hanya berbaring dan tidak

dimiringkan

DO : Gangguan Risiko Jatuh

mobilitas
2 - pasien tidak dapat bergerak

- Pasien tidak dapat bergerak dan

mengalami penurunan kesadaran
dengan GCS 333

DS :

- keluarga pasien mengatakan semenjak

2 hari mengalami penurunan
kesadaran karena tidak mau makan
 PRIORITAS MASALAH

Nama Klien : ..............................................................................................

Umur : .............................................................................................
Ruangan/ Kamar : .............................................................................................
No. RM : .............................................................................................

Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama Perawat)
 RENCANA KEPERAWATAN

No Diagnosa Tujuan dan Kriteria

Intervensi Rasional
. Keperawatan Hasil
1. Risiko Infeksi Kontrol risiko Pengecekan kulit Setelah dilakukan tindakan
b/d Gangguan - Mengidentifikasi keperawatan selama 3x24 jam,
Integritas kulit faktor risiko - Amati warna, kehangatan, bengkak, diharapkan Risiko infeksi dapat diatasi
(00004) - Menjalankan pulsasi, tekstur
strategi kontrol - Monitor sumber tekanan dan
risiko yang sudah gesekan
ditetapkan
- Ajarkan anggota keluarga asuhan
Deteksi risiko (1908) mengenai tanda-tanda kerusakan
- Mengenali tanda kulit
dan gejala yang
mengendalikan
risiko
- Melakukan skrining
sesuai waktu yang
dianjurkan

2. Risiko Jatuh Kejadian Jatuh Pencegahan jatuh (6490) Setelah dilakukan tindakan
(00155) Kejadian Jatuh - Identifikasi perilaku dan faktor keperawatan selama 2x24 jam,
yang mempengaruhi risiko jatuh diharapkan Risiko jatuh dapat diatasi
- Jatuh dari tempat - Identifikasi karakteristik dari
 tidur lingkungan yang mungkin
- Jatuh saat duduk meningkatkan potensi jatuh

- Jatuh saat
Manajemen Lingkungan Keselamatan
dipindahkan (6486)
- Identifikasi kebutuhan keamanan
pasien berdasarkan fungsi fisik dan
kognitif
- Gunakan alat perlindungan
- Bantu pasien saat melakukan
perpindahan ke tempat yang aman
 TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

No. Dx Waktu Tgl/ Waktu Tgl/

Tindakan TT Catatan Perkembangan (SOAP) TT
Kep jam jam