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 CAIRAN DAN ELEKTROLIT

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
.......................................................................................................................................
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2. Riwayat Penyakit Sekarang :
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3. Riwayat Penyakit Dahulu :
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4. Riwayat Penyakit Keluarga :
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5. Genogram :
Ket :.......................................

III. POLA FUNGSI KESEHATAN

1. Pola Persepsi dan Tata Laksana Kesehatan
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
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2. Pola Nutrisi
Keterangan Sebelum sakit Saat sakit
Frekuensi
Jenis
Cara Makan
Porsi/Jumlah (cc/hari)
Keluhan:
- Mual
- Muntah(..x/hari,...cc/hari)
 - Sariawan
- Masalah mengunyah
- Kesulitan menelan
- ................................

Deskripsikan singkat mengenai keluhan yang

dirasakan : ...............................................................................................................................
.................. ..............................................................................................................................
...................
Pola Minum
Keterangan Sebelum Sakit Saat Sakit
Jenis
Jumlah (….cc/ hari)
Keluhan

Deskripsikan singkat mengenai keluhan yang

dirasakan : ...............................................................................................................................
.................. ..............................................................................................................................
...................
3. Pola Eliminasi
a. Eliminasi Urine
Keterangan Sebelum Sakit Saat Sakit
Frekuensi
Jumlah
Warna
Bau.
Keluhan:

Deskripsikan singkat mengenai keluhan yang

dirasakan :..............................................................................................................................
...............................................................................................................................................
............................
...............................................................................................................................................
......
b. Eliminasi Alvi
Keterangan Sebelum Sakit Saat Sakit
 Frekuensi
Konsistensi
Jumlah
Warna
Bau.
Keluhan:
- Feses campur darah
- Melena
- Konstipasi
- Diare
- Colostomy
- Penggunaan obat
pencahar
- ………………………

Deskripsikan singkat mengenai keluhan yang dirasakan :

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

4. Pola Aktifitas 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

5. Pola Istirahat – Tidur

 Keterangan Sebelum Sakit Saat Sakit
Lama tidur siang
Lama tidur malam
Pengantar tidur
Gangguan tidur

6. Pola Kognitif dan Persepsi Sensori

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IV. PEMERIKSAAN FISIK

1. Status Kesehatan Umum
Keadaan Umum
:..................................................................................................................
Kesadaran : ............................................................................................................
.....
Tensi : .................................... mmHg
Nadi : .................................... x/ menit
Suhu : .................................... oC
RR : .................................... x/menit
Berat Badan
BB Sebelum sakit : ....................................kg
BB saat ini : ....................................kg
BB Ideal : ....................................kg
TB :.....................................cm
Status Hidrasi : ....................................
Analisis keseimbangan cairan
 Intake :
Makan : .................................... cc
Minum : .................................... cc
Air Metabolisme : .................................... cc
Infus : .................................... cc
Injeksi : .................................... cc
Tranfusi :......................................cc
Total Intake : .................................... cc
  Out put
Urine :.................................... cc
Feses : .................................... cc
Muntah :.................................... cc
Drainage :..................................... cc
Perdarahan :..................................... cc
Diare :..................................... cc
IWL : .................................... cc
Total out put : .................................... cc
- Balance cairan :
Intake : .................................... cc
Output : .................................... cc
.................................... cc
2. Kepala
 Rambut :
……………………………………………………………………………….................
 Wajah :
………………………………………………………………………………................
 Mata :
……………………………………………………………………………….................
 Hidung :
………………………………………………………………………………................
 Mulut :
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 Gigi :
……………………………………………………………………………….................
 Telinga : ……………………………………………………………………………….....
.........

3. Leher
I................................................................................................................................................
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P...............................................................................................................................................
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4. Payudara dan ketiak

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

Jantung
I……………………………………………………………………………………………………........
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P...............................................................................................................................................
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P...............................................................................................................................................
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A…………………………………………………………………………………………………..........
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6. Abdomen
I………………………………………………………………………………………………………....
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A……………………………………………………………………………………………………......
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P……………………………………………………………………………………………………......
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P……………………………………………………………………………………………………......
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7. Ekstremitas
Atas
 I………………………………………………………………………………………………………....
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P……………………………………………………………………………………………………......
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Gerakan
Sendi……………………………………………………………………………………........
…………………………………………………………………………………………………….........
....
Kekuatan
Otot……………………………………………………………………………………........

Bawah
I………………………………………………………………………………………………………....
.....
P……………………………………………………………………………………………………......
....
Gerakan
Sendi……………………………………………………………………………………........
…………………………………………………………………………………………………….........
....
Kekuatan
Otot……………………………………………………………………………………..........

8. Tulang Belakang/ Punggung-pinggang

I
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..
P……………………………………………………………………………………………………......
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9. Anus – Genetalia
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..
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10.Pemeriksaan Neurologis
 Kesadaran………………………………………………………………………………………….....
...
Meningeal
Sign……………………………………………………………………………………..........
Refleks
 Fisiologis…………………………………………………………………………………......
......
 Patologis…………………………………………………………………………………......
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Pemeriksaan Saraf Kranial (I-XII)

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...

V. Pemeriksaan diagnostik (cantumkan tanggal pemeriksaan)

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VI. Pemeriksaan Laboratorium (cantumkan tanggal dan nilai normal)

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VII. Terapi (disertai dosis tiap pemberian)
Oral
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Parenteral
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………………,…………….…20…
Mahasiswa

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NIM…………………………