U N I V E R S I T A S B O N D O W O S O

PROGRAM STUDI DIII KEPERAWATAN

Jalan Chairil Anwar No.3B Tlp/Fax. (0332) 433015 Bondowoso

FORMAT PENGKAJIAN
KEBUTUHAN ELIMINASI

Rumah sakit :………………………………………………………………………………..

Ruangan :………………………………………………………………………………..
Tgl/Jam MRS :………………………………………………………………………………..
Dx. Medis :………………………………………………………………………………..
No. Register :………………………………………………………………………………..

Pengkajian Oleh :..............................................................................................................

Tgl/Jam pengkajian :..............................................................................................................

I. BIODATA PENANGGUNG JAWAB

Nama Klien Nama :……………………........
:..............................................................................................................
Umur Umur :………………………….
:..............................................................................................................
Jenis Kelamin Pendidikan :………………………….
:..............................................................................................................
Pendidikan Pekerjaan :………………………….
:..............................................................................................................
Pekerjaan Alamat :………………………….
:..............................................................................................................
Agama Hubungan dengan klien
:..............................................................................................................
Gol. Darah Suami/ Istri/Orangtua/…………………..
:..............................................................................................................
Alamat :..............................................................................................................

II. RIWAYAT KESEHATAN

1. Keluhan Utama :
a. Saat MRS
.........................................................................................................................................
.........................................................................................................................................
b. Saat Pengkajian
.........................................................................................................................................
.........................................................................................................................................
2. Riwayat Penyakit Sekarang :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
3. Riwayat Penyakit Dahulu :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
 4. Riwayat Penyakit Keluarga :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
5. Genogram :
Ket :.........................................

III. POLA FUNGSI KESEHATAN

a. Pola Persepsi dan Tata Laksana Kesehatan
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
b. Pola Nutrisi
Macam Sebelum Sakit Saat sakit
Makan
 Frekuensi ............................... ................................
 Jenis ............................... ................................
 Porsi ............................... ................................

 Keluhan ............................... ................................

Minum
 Frekuensi ............................... ................................
 Jenis ............................... ................................
 Jumlah ............................... ................................

 Keluhan ............................... .................................

c. Pola Eliminasi
Kebiasaan BAB
Karakteristik BAB Sebelum sakit Saat sakit

 Frekuensi ....................................... .......................................

 Jumlah ....................................... .......................................
 Bau ....................................... .......................................

 Warna ....................................... .......................................

 Konsistensi ....................................... .......................................

 Bentuk ....................................... .......................................

 Keluhan ....................................... ......................................

 Deskripsi lengkap tentang gangguan eliminasi BAB yang sedang dialami :
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
Kebiasaan BAK
Karakteristik BAB Sebelum sakit Saat sakit

 Frekuensi ....................................... .......................................

 Pancaran ....................................... .......................................
 Jumlah ....................................... .......................................

 Bau ....................................... .......................................

 Warna ....................................... .......................................

 Perasaan setelah BAK ....................................... .......................................

 Total Produksi Urine ....................................... .......................................

 Keluhan ....................................... .......................................

Deskripsi lengkap tentang gangguan eliminasi BAK yang sedang dialami :

........................................................................................................................................
........................................................................................................................................
........................................................................................................................................

d. Pola Aktivitas dan kebersihan diri

Keterangan Sebelum Sakit Saat Sakit
Mobilitas Rutin
Waktu Senggang
Mandi
Berpakaian
Berhias
Toileting
Makan-minum
Keterangan :
0 : mandiri
1 : dengan alat bantu
2 : dibantu oleh orang lain
3 : dibantu oleh orang lain dan alat
4 : tergantung secara total
 e. Pola Istirahat-Tidur
Keterangan Sebelum Sakit Saat Sakit
Lama tidur siang
Lama tidur malam
Pengantar tidur
Gangguan tidur

f. Pola Kognitif dan Persepsi Sensori

........................................................................................................................................
........................................................................................................................................
........................................................................................................................................

IV. PEMERIKSAAN FISIK

1. Keadaan Umum :..................................................................................................................
Kesadaran :.....................................................................................................................
Suhu :...............................oC TB :................................cm
RR :...............................x/mnt BB saat ini :..........................Kg
TD :...............................mmHg BB Ideal :...........................Kg
Nadi :...............................x/mnt

2. Kepala dan Leher

 Rambut : ……………………………………………………………………………….....
 Wajah : ……………………………………………………………………………….....
 Mata : ……………………………………………………………………………….....
 Hidung : ……………………………………………………………………………….....
 Mulut : ……………………………………………………………………………….....
 Gigi : ……………………………………………………………………………….....
 Telinga : ……………………………………………………………………………….....

3. Leher
I.............................................................................................................................................
P...........................................................................................................................................

4. Payudara dan Ketiak

I.............................................................................................................................................
P...........................................................................................................................................

5. Dada
Paru-Paru
I……………………………………………………………………………………………………
P...........................................................................................................................................
P...........................................................................................................................................
A………………………………………………………………………………………………….
 Jantung
I……………………………………………………………………………………………………..
P..............................................................................................................................................
P..............................................................................................................................................
A…………………………………………………………………………………………………....

6. Abdomen
I………………………………………………………………………………………………………
A…………………………………………………………………………………………………….
P…………………………………………………………………………………………………….
P…………………………………………………………………………………………………….

7. Ekstremitas
Atas
I…………………………………………………………………………………………………….
P……………………………………………………………………………………………………
Gerakan Sendi……………………………………………………………………………………
……………………………………………………………………………………………………..
Kekuatan Otot…………………………………………………………………………………….
Bawah
I………………………………………………………………………………………………………
P……………………………………………………………………………………………………..
Gerakan Sendi…………………………………………………………………………………….
……………………………………………………………………………………………………....
Kekuatan Otot…………………………………………………………………………………….

8. Tulang Belakang/ Punggung-pinggang

I ……………………………………………………………………………………………………..
P……………………………………………………………………………………………………..

9. Anus – Genetalia
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..

10. Pemeriksaan Neurologis

Kesadaran…………………………………………………………………………………………
Meningeal Sign……………………………………………………………………………………
Refleks
 Fisiologis…………………………………………………………………………………....
 Patologis…………………………………………………………………………………....
 Pemeriksaan Saraf Kranial (I-XII)
……………………………………………………………………………………………………....
……………………………………………………………………………………………………....
……………………………………………………………………………………………………....
……………………………………………………………………………………………………....
……………………………………………………………………………………………………....

IV. Pemeriksaan diagnostik (cantumkan tanggal pemeriksaan)

.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

V. Pemeriksaan Laboratorium (cantumkan tanggal dan nilai normal)

.....................................................................................................................................................
....................................................................................................................................................
.....................................................................................................................................................

VI. Terapi (disertai dosis tiap pemberian)

Oral
.....................................................................................................................................................
.....................................................................................................................................................
Parenteral
.....................................................................................................................................................
.....................................................................................................................................................

………………,…………………..20…..
Mahasiswa

( )
NIM…………………………