1. Identitas Klien
Inisial : No RM :
Usia : Tgl Masuk :
Jenis : Tgl Pengkajian :
Kelamin : Sumber Informasi :
Alamat : Keluarga Terdekat :
No Telepon : status :
Status : Alamat :
Agama : No Telepon :
Suku : Pendidikan :
Pekerjaan : Pekerjaan :
Lama : Bekerja :
2. Riwayat Kesehatan
a. Keluhan Utama (saat masuk RS)
......................................................................................................................
......................................................................................................................
..................................
b. Keluhan utama (saat pengkajian)
......................................................................................................................
......................................................................................................................
..................................
c. Riwayat Kesehatan Saat Ini
......................................................................................................................
......................................................................................................................
..................................
d. Riwayat Kesehatan Terdahulu
1. Penyakit yang pernah dialami:
a. Kecelakaan :
…………………………………………
b. Operasi (jenis dan waktu) :
…………………………………………
c. Penyakit (kronis dan akut) :
…………………………………………
d. Terakhir masuk RS :
…………………………………………
2. Alergi (obat, makanan, plester, dsb)
.................................................................................................................
.................................................................................................................
..................................
3. Imunisasi (tambahan; flu, pneumonia, tetanus, dll)
.................................................................................................................
.................................................................................................................
..................................
4. Kebisasaan
Jenis Frekuensi Jumlah Lamanya
a. Merokok ………………… …………………… ……………....……
b. Kopi ………………… …………………… ……………....……
c. Alkohol ………………… …………………… ……………....……
3. Riwayat Keluarga
..........................................................................................................................
..........................................................................................................................
..................................
4. Catatan Penanganan Kasus (Dimulai saat pasien di rawat di
ruang rawat sampai pengambilan kasus kelolaan)
..........................................................................................................................
..........................................................................................................................
..................................
5. Pengkajian Keperawatan (12 Domain NANDA)
Intruksi: Beri tanda cek () pada istilah yang tepat/ sesuai dengan data-data
di bawah ini. Gambarkan semua temuan abnormal secara objektif, gunakan
kolom data tambahan bila perlu.
1. Peningkatan Kesehatan
Pengetahuan tentang penyakit/perawatan:
......................................................................................................................
......................................................................................................................
..................................
Masalah keperawatan:
......................................................................................................................
......................................................................................................................
..................................
2. Nutrisi
a. Mulut
Trismus ( ), Halitosis ( )
Bibir: lembab( ), pucat( ),sianosis( ),labio/palatoskizis( ),
stomatitis( )
Gusi: ( ), plak putih( ), lesi( )
Gigi: Normal( ), Ompong( ), Caries( ), Jumlah
gigi:...................
Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
b. Leher
Kaku Kuduk ( ) Simetris( ), Benjolan ( ) Tonsil ( )
Kelenjar Tiroid : normal ( ), pembesaran ( )
Tenggorok : kesulitan menelan ( ),
dll..........................................................................................................
..............................................................................................................
..............................................................................................................
...
4. Aktivitas/Istirahat
Kebiasaan sebelum tidur (perlu mainan, dibacakan cerita, benda yang
dibawa saat tidur,dll):
Kebiasaan Tidur siang:......................................jam/hari
Skala Aktivitas:
Kemampuan perawatan diri 0 1 2 3 4
Makan/minum
Mandi
Toileting
Berpakaian
Mobilitas di tempat tidur
Berpindah
Ambulasi/ROM
0: mandiri, 1: alat Bantu, 2: dibantu orang lain, 3: dibantu orang lain dan alat, 4:
tergantung total
Persendian:
Nyeri Sendi ( ), pergerakan
sendi:.....................................................................................
ROM ( Range Of Motion):
................................................................................................................................
................................................................................................................................
..................................
Kekuatan Otot :
................................................................................................................................
................................................................................................................................
..................................
Kelainan Otot:
................................................................................................................................
................................................................................................................................
..................................
Tonus/aktifitas
Aktif ( ) Tenang ( ) Letargi ( ) Kejang ( )
Menagis keras ( ) lemah ( ) melengking ( ), Sulit menangis (
)
Ekstremitas
Amelia ( ), Sindaktili ( ), Polidaktili( )
Reflek Pat0logis :
Babinsky : + ( ), - ( )
Kernig : + ( ), - ( )
Brudzinsky : + ( ), - ( )
Reflek Fisiologis
Biceps : + ( ), - ( )
Triceps : + ( ), - ( )
Patella : + ( ), - ( )
Jantung
Inspeksi: ictus cordis/denyut apeks( ), normal( ) melebar( )
Palpasi: kardiomegali( )
Perkusi: redup( ), pekak( )
Auskultasi: HR............x/mnt. Aritmia( ),Disritmia( ) , Murmur ( )
Mandi :...................x/mnt
Sikat gigi :........................................x/mnt
Ganti Pakaian :..................................x/mnt
Memotong kuku :...............................x/mnt
DATA TAMBAHAN :
......................................................................................................................
......................................................................................................................
..................................
Masalah keperawatan:
......................................................................................................................
......................................................................................................................
..................................
5. Persepsi/Kognitif
Kesan Umum
Tampak Sakit: ringan ( ),sedang( ),berat ( ), pucat ( ), sesak ( ),
kejang( )
1. Kepala
a. Rambut: warna...........mudah dicabut ( ), ketombe( ),
kutu( )
b. Kelainan bentuk
kepala......................................................................
2. Mata
Mata: jernih( ), mengalir, kemerahan( ), sekret( )
Visus: 6/6( ), 6/300( ), 6/ tak terhingga( ),
Pupil: Isokor( ), anisokor( ), miosis( ), midriasis( ),
reaksi terhadap cahaya: kanan Positif( ), negatif( ),kiri negatif( )
positif( ),
alat bantu: kacamata( ), Softlens( )
Conjungtiva: merah jambu( ), anemis( )
Sklera: Putih( ), Ikterik( )
3. Bibir, Lidah
a. Bibir : normal ( ) sumbing ( )
b. Sumbing langit-langit/palatum ( )
c. Lidah: bersih ( ), kotor/ putih ( ), jamur ( )
4. Telinga, Hidung, Tenggorok
a. Telinga: Normal ( )Abnormal ( ) Sekret( )
b. Hidung: Simetris ( )Asimetris ( ) Sekret ( )
Nafas cuping hidung ( )
c. Tenggorok: Tonsil( ), radang( )
Data Tambahan
......................................................................................................................
......................................................................................................................
..................................
Masalah keperawatan:
......................................................................................................................
......................................................................................................................
..................................
6. Persepsi Diri
Perasaaan klien terhadap penyakit yang dideritanya
..................................................
Persepsi klien terhadap
dirinya....................................................................................
Konsep
diri................................................................................................................
..
Tingkat
kecemasan....................................................................................................
...
Citra Diri/Bodi
image:.................................................................................................
Data tambahan
......................................................................................................................
......................................................................................................................
..................................
Masalah keperawatan:
......................................................................................................................
......................................................................................................................
..................................
7. Peran Hubungan
Budaya:
Suku:
Agama yang di anut:
Bahasa yang digunakan :
Masalah sosial yang penting:
Hubungan dengan orang tua:
Hubungan dengan saudara kandung:
Hubungan dengan lingkungan sekitar
Data Tambahan
......................................................................................................................
......................................................................................................................
..................................
Masalah keperawatan:
......................................................................................................................
......................................................................................................................
..................................
9. Toleransi/Koping Stress
GCS :.......
E :........................................................................................
V : .......................................................................................
M :.......................................................................................
Data Tambahan:
......................................................................................................................
......................................................................................................................
..................................
Masalah keperawatan:
.....................................................................................................................
.....................................................................................................................
..................................
10. Prinsip Hidup
Budaya :
Spritual / Religius :
Harapan :
Psikososial :
a. Persepsi klien terhadap penyakitnya
b. Reaksi saat interaksi
Kooperatif………… Tidak kooperatif………….
c. Status emosional
Tenang…….. Cemas……. Marah…….. Menarik
Diri………………..…
Tidak sabar…… lainnya:
………………………………………………..…..
Data Tambahan
......................................................................................................................
......................................................................................................................
..................................Masalah keperawatan:
.....................................................................................................................
.....................................................................................................................
..................................
11. Keselamatan/Perlindungan
Tingkat Kesadaran : Composmentis ( ), Apatis ( ), Somnolen ( ), Sopor
( ),Soporocoma ( ) Coma ( )
TTV : Suhu.............O C, Nadi........x/min, TD...............mmHg,
RR..........x/min
Warna kulit :
Sianosis ( ), I kterus ( ), eritematosus rash ( ), discoid lupus ( ), oedema( ),
Bula ( ), Ganggren ( ), nekrotik jaringan ( ), Hiperpigmentasi ( )
Echimosis ( ), Petekie ( )
Turgor Kulit: elastis ( ), tidak elastis ( )
Data Tambahan
......................................................................................................................
......................................................................................................................
..................................
Masalah keperawatan:
......................................................................................................................
......................................................................................................................
..................................
12. Kenyamanan
Provaiking :
Quality :
Regio :
Scala :
Time :
Data Tambahan:
......................................................................................................................
......................................................................................................................
..................................
Masalah keperawatan:
......................................................................................................................
......................................................................................................................
..................................
Terapi
Tanggal Terapi :
Nama Cara Golongan Kontra
No Dosis Indikasi
Terapi Pemberian Obat Indikasi
Pemeriksaan Penunjang :
Laboratorium ( Tanggal Pemeriksaan )
USG ( Tanggal Pemeriksaan )
EKG ( Tanggal Pemeriksaan )
Rontsen ( Tanggal Pemeriksaan )
EEG ( Tanggal Pemeriksaan )
Dll.................................................................................................................
......................................................................................................................
...............................................................................................................