FORMAT PENGKAJIAN

KEPERAWATAN DASAR PROFESI

STIKes IMC BINTARO

Nama Mahasiswa : ............................

NPM : ............................

INFORMASI UMUM

Nama .............................................................................................Usia ....................

Tanggal Lahir .............................................................Jenis Kelamin........................
Suku Bangsa ............................................. Tanggal Masuk ......................................
Waktu ......................................................Dari ..........................................................
Sumber Informasi ......................................................................................................

AKTIVITAS / ISTIRAHAT

Gejala (Subjektif)
Pekerjaan ......................................Aktivitas / hobi ...................................................
AktivitasWaktu luang : .............................................................................................
Perasaan bosan / tidak puas : ....................................................................................
Keterbatasan karena kondisi : ..................................................................................
Tidur Jam : ...........Tidur Siang .............................. Kebiasaan tidur.........................
Insomnia ...............Yang berhubungan dengan ...............................................
Rasa segar saat bangun ....................................................................................
Lain-lain ...........................................................................................................
Tanda (Objektif)
Respons terhadap aktivitas yang teramati : Kardiovaskular : ...................................
Pernapasaan : ..................................
Status mental (mis , menarik diri / letargi) : .............................................................
Pengkajian neuromuskular : ......................................................................................
Massa / tonus otot : ..........................................................................................
Postur ............................................. Tremor : .................. ..............................
Rentang gerak .....................................Kekuatan .............................................
Deformitas : .....................................................................................................

SIRKULASI

Gejala (Subjektif)
Riwayat tentang : Hipertensi : .....................Masalah jantung : ...............................
Demam rematik : .................Ederma mata kaki / kaki : ..................................
Flebitis : .........................Penyembuhan lambat ...............................................
Klaudikasi : ......................................................................................................
Ekstremitas : Kesemutan : ...................... Kebas : ...........................................
Batuk / hemoptisis : .........................................................................................
Perubahan frekuensi / jumlah urine : ...............................................................
Tanda ( Objektif)
TD : ka. Dan. Ki : barang / duduk / berdiri : .............................................................
Tekanan nadi : ......................... Gap auskultatori : ..........................................
Nadi (palpasi) : Karotis : ............................... Temporalm : .....................................
Jugularis : ......................................... Radialis : ...............................................
Femoralis : ...................................... Popliteal : ...............................................

Postibial : .......................................Dorsalis pedis : .......... ...............................

Jantung (palpasi) :
Getaran ...................................... Dorongan : ...................................................
Bunyi jantung : Frekwensi : .................... Irama : .................Kualitas .....................
Friksi gesek : .............................. Murmur : ........................ ...........................
Bunyi napas : Desiran vaskular : .................... Distensi vena jugularis ....................
Ekstremitas : suhu : ...................................... Warna : ..............................................
Pengisian kapiler : ............................................................................................
Tanda Homan’s : .............................. Varieses ...............................................
Abnormalitas kuku : ........................................................................................
Penyebaran / kualitas rambut : .........................................................................
Warna : .........................Membran mukosa ....................... Bibir :.............................
Pungggung kuku : ........Konjungvia : .................... Sklera : ............................
Diaforesis : .......................................................................................................

INTEGRITAS EGO

Gejala (Subjektif)
Faktor stres : .............................................................................. ...............................
Cara menganangani stres : ........................................................................................
Masalah-masalah finansial : ......................................................................................
Status hubungan : ......................................................................................................
Faktor-faktor budaya : ...............................................................................................
Agama : .................................. Kegiatan keagamaan : .............................................
Gaya hidup : ................................ Perubahan terakhir : ............................................
Perasaan-perasaan : Ketik berdayaan : ......................................................................
Keputusassaan : ............Ketidak berdayaan : .................................................
Tanda (Obyektif)
Status emosional (beri tanda cek untuk yang sesuai ) :
Tenang : .................. Cemas ................. Marah ...............................................
Menarik diri : ........................................Takut .................................................
Mudah tersinggung : .................. Tidak sabar : ...............................................
Euforik : ...........................................................................................................
Respons-respons fisiologis yang terobservasi : .........................................................

ELIMINASI

Gejala (Subjektif)
Pola BAB : ……………….. Penggunaan laksatif ………………............................
Karakter fases : ……………………..BAB terakhir …………….............................
Riwayat perdarahan : …………………… Hemoroid : …………………................
Konstipasi : ……………………………Diare : ………………................................
Pola BAK : ………………........Inkontimensia / kapan : ……….............................
Dorongan : …………….Frekwensi : ………..Retensi : .................................
Karakter urine : .........................................................................................................
Nyeri / rasa terbakar / kesulitan BAK : ..................................... ...............................
Riwayat penyakit ginjal / kandung kemih : ...............................................................
Penggunaan diuretik : ................................................................................................
Tanda (Objektif)
Abdomen : Nyeri tekan ...................................... Lunak / keras : .............................
Massa : ................................ Ukuran / lingkaran Abdomen :..........................
Bising usus : .....................................................................................................
Hemoroid : ................................................................................................................
Perubahaan kandungan kemih : BAK terlalu sering .................................................
MAKANAN / CAIRAN

Gejala (Subjtektif)
Diit biasa (tipe) : ................................ Jumlah makanan pr hari :.............................
Makan terakhir / masukan : ..................................Pola diit : ....................................
Kehilangan selera makan : .................................Mual / muntah : .............................
Nyeri ulu hati / salah cerna : Yang berhubungan dengan .........................................
Disembuhkan oleh : ...................................................................................................
Alergi / intoleransi makanan : ...................................................................................
Masalah-masalah mengunyah / menelan : ................................................................
Gigi : ................................................................................................................
Berat badan biasa : ...................................Perubahan berat badan ............................
Penggunaan diuretik : ................................................................................................

Tanda (Objektik)
Berat badan sekarang ................Tinggi badan : ..................Bentuk tubuh : .............
Turgor kulit : ..............Kelembaban / kering membran mukosa : .............................
Edema : Umum :................................. Dependen : ................... ...............................
Periorbital : .........................................Asites : ................................................
Distensi vena jugularis : ............................................................................................
Pembesaran teroit : ......................herna / massa : ..........Halitosis.............................
Kondisi gigi / gusi : ................................................................... ...............................
Penampilan lidah : ...................................................................................................
Membran mukosa : ..........................................................................................
Bising usus : ..............................................................................................................
Bunyi napas : .............................................................................................................
Urin S/ A atau Kemstiks : ………………………………………….........................

HIGIENE

Gejala (Subjektif)
Aktivitas Sehari-hari : Tergantung / Mandiri : .........................................................
Mobilitas : ......................Makan .....................................................................
Higiene : ....................Berpakaian : .................................. ..............................
Toileting : .........................................................................................................
Waktu mandi yang diinginkan : ......................................................................
Pemakaian alat bantu / prostetik : ....................................................................
Bantu diberikan oleh : ......................................................................................
Tanda (Objektif)
Penampilan umum : ...................................................................................................
Cara berpakaian : .............................. Kebiasaan pribadi : .......................................
Bau badan : ................................Kondisi kulit kepala : ............................................
Adanya kutu : ............................................................................................................

NEUROSENSORI

Gejala (Subjektif)
Rasa ingin pingsan / pusing : ....................................................................................
Sakit kepala : Lokasi nyeri : .................................Frekwensi .... ..............................
Kesemutan / kebas / kelemahan (lokasi ): ................................................................
Stroke (gejala sisa) : .................................................................. ...............................
Kejang : ...............Tipe : ................Aura : ......................Frekuensi : ........................
Status postikal : ..........................Cara Mengontrol : .......................................
Mata : kehilangan pengelihatan : .......... Pemeriksaan terakhir : .............................
Glaukoma : ......................Katarak : ................................................................
Telinga : Kehilangan pendengaran : .........Pemeriksaan terakhir : ...........................
Epistaksis : ................................................................................................................
Tanda (Objektif)
Status mental : ...........................................................................................................
Teorientasi / disorientasi : Waktu : ..................................................................
Tempat : .................................................................
Orang : ..................................................................
Kesadaran : ................Mengantuk : ....................Letargi : ..............................
Stupor : .......................................Koma : ........................................................
Kooperatif : ................. Menyerang : .....................Delusi :.............................
Halusinasi : ............................Afek (gambarkan) : ..........................................
Memori : Saat ini : ............................. Yang lalu : ....................................................
Kaca mata : ............. Kontak lensa : ............. Alat bantu dengar : ...........................
Ukuran / reaksi pupil : Ka / Ki : ................................................................................
Facial drop : ......................................Menelan ..........................................................
Genggaman tanggal / lepas : Ka/Ki : ................................Postur .............................
Refleks tendom dalam : .................. Paralisis ...........................................................

NYERI / KETIDAKNYAMANAN

Gejala (Subjektif)
Lokasi ........ intensitas (1-10 dimana 10 sangat nyeri ) .............. Frekwensi ............
Kualitas : ....................Durasi : ................... Penjalaran : .........................................
Faktor-faktor pencetus : ............................................................................................
Cara menghilangkan, faktor-faktor yang berhubungan : ..........................................

Tanda (Objektif)
Mengkerut muka : .............................. Menjaga area yang sakit : ............................
Respon emosional : ......................... Penyempitan fokus : ......................................

PERNAFASAN
Gejala (Subjektif)
Dispnea yang berhubungan dengan batuk / sputum : ................................................
Riwayat bronkitis : ........................... Asma ..............................................................
Tuberkulosis : ..................... Emifisema : .......................................................
Pneumonia kambuhan : ...................................................................................
Pemanjanan terhadap udara berbahaya : .........................................................
Perokok : ................ Pak / hari : ........... Lama dalam tahun : ...................................
Penggunaan alat bantu pernafasan : ........................... Oksigen : ..............................
Tanda (Objektif)
Pernafasan : Frekwensi : ........... Kedalaman : ..............Simetris : ............................
Penggunaan otot-otot asesori : ........... Napas cuping hidung : ...............................
Fremitus : ..................................................................................................................
Bunyi nafas : .............................................................................................................
Egofoni : ....................................................................................................................
Sianosis : ................................. Jari tubuh : ..............................................................
Karakteristik sputum : ...............................................................................................
Fungsi mental / gelisah : ...........................................................................................

KEAMANAN
Gejala (Subjektif)
Alergi/sensitivitas : ........................................ Reaksi : .............................................
Perubahan sistem imun sebelumnya : .......................... Penyebab : ..........................
Riwayat penyakit hubungan seksual (tanggal/tipe ) : ................................................
Perilaku resiko tinggi : .................... Pemeriksaan : ..................................................
Tranfusi darah / jumlah : ........................... Kapan : ................................................
Gambaran reaksi : ............................................................................................
Riwayat cedera kecelakaan : .....................................................................................
Fraktur / dislokasi : ....................................................................................................
Masalah punggung : ..................................................................................................
Perubahan pada tahi lalat : ............................ .Pembesaran nodus : .........................
Kerusakan penglihatan, pendengaran : ......................................................................
Protese : ............................ Alat ambulatori : ............................................................

Tanda (Objektif)
Suhu tubuh : ...................................... Diaforesis : ....................................................
Integeritas kulit : .......................................................................................................
Jaringan parut : ................................... Kemerahan : .......... ............................
Laserasi : ......................................... Ulserasi : ................................................
Ekimosis : ............................................ Lepuh : ..............................................
Luka bakar : (derajat / persen) : .......................................Drainase : ...............
Tandai lokasi pada diaram dibawah ini :

Kekuatan Umum : ......................................... Tonus otot : .......................................

Cara berjalan : .......................................... ROM : ...........................................
Parestesia / paralisis : .......................................................................................
Hasil kultur, Pemeriksaan sistem imun : .........................................................

SEKSUALITAS (Komponen dari Interaksi sosial)

Aktif melakukan hubungan seksual : ........................................................................

Penggunaan Kondom : ..............................................................................................
Masalah-masalah / kesulitan seksual : ......................................................................
Perubahan terakhir dalam frekuensi / minat : ...........................................................

Wanita
Gejala (Subjektif)
Usia menarke : ................. Lamanya siklus : .................... Durasi : .........................
Periode mentruasi terakhir : ..................... Menopouse : ..........................................
Rabas vaginal : ..................... Berdarah antara periose : ...........................................
Melakukan pemeriksaan payudara sendiri / mammogram : ......................................
PAP smer terakhir : ...................................................................................................

Pria
Gejala (Subjektif)
Rabas penis : ....................................... Gangguan Prostat : ......................................
Sukumsisi : ..................................... Vasektomi : ......................................................
Melakukan pemeriksaan sendiri : .................. Payudara / testis : .............................
Prostoskop / pemeriksaan prostat terakhir : ...................................................................

Tanda (Objektif)
Pemeriksaan : ..................... Payudara / penis / testis : .............................................
Kutil genital / lest : ....................................................................................................

INTERAKSI SOSIAL

Gejala (Subjektif)
Status perkawinan : ............................... Lama : .............................. ........................
Hidup dengan : .................................................................................................
Masalah-masalah / stres : .................................................................................
Keluarga besar : .........................................................................................................
Orang pendukung lain : .............................................................................................
Peran dalam struktur keluarga : .................................................................................
Masalah-masalah yang berhubungan dengan penyakit / kondisi : ............................
Perubahan bicara : penggunaan alat bantu komunikasi :
Adanya laringektomi : ...............................................................................................

Tanda (Objektif)
Bicara : ......................................... jelas : Tak Jelas : ................................................
Tidak dapat dimengerti : .................................... Afasia : ...............................
Pola bicara tak biasa / kerusakan : ...................................................................
Penggunaan alat bantu bicara : ........................................................................
Komunikasi vebal / nonverbal dengan keluarga / orang terdekat lain: .....................
..........................................................................................................................
Pola interaksi keluarga (perilaku) : ...........................................................................

PENYULUHAN / PEMBELAJARAN

Gejala (Subjektif)
Bahasa domain (khusus) : ............................. Melek huruf : ...............................
Tingkat pendidikan : .................................................................................................
Ketidakmampuan belajar (khusu) : ...........................................................................
Keterbatasan konnitif : ..............................................................................................
Keyakinan kesehatan / yang dilakukan : ...................................................................

Orientasi spesifik terhadap perawatan kesehatn (spt, dampak dari agama / kultural yang di
anut ) : .......................................................................................................................
Faktor resiko keluarga (ditandai hubungan) : ...........................................................
Diabetes : .................................... Tuberkulosis : ............................................
Penyakit jantung : ............................. Stroke : ................................................
TD tinggi : ................................. Epilepsi : .....................................................
Penyakit ginjal : ............................... Kanker : ................................................
Penyakit jiwa : .................................... Lain-lain : ...........................................
Obat yang diresepkan (lingkari dosis terakhir) :
Obat Dosis Waktu Diminum secara teratur Tujuan
................... .................. .................. ...................................... ........................
................... .................. ................. ..................................... ........................
................... ................... ................. ..................................... .......................
Obat tanda resep : Obat-obat bebas : ........................................................................
Obat-obat jalanan : .......Tembakau : .......... Perokok tembakau : .............................
Penggunaan alkohol (jumalh / rekuensi) : .................................................................
Diagnosa saat masuk perdokter : ...............................................................................
Alasan di rawat per pasien : ......................................................................................
Riwayat keluhan terakhir : ........................................................................................
Harapan pasien terhadap perawatan / pembedahan sebelumnya : ............................
................................................................................................... ...............................
Bukti kegagaln untuk perbaikan : .............................................................................
Pemeriksaan fisik lengkap terakhir : .........................................................................

Pertimbangan Rencana Pulang

DRG yang menunjukkan lama dirawat rata-rata : ....................................................
Tanggal Informasi didapatkan : ................................................................................
1. Tanggal pulang yang diantisipasi : ..................................................................
2. Sumber-sumber yang tersedia : orang : ...........................................................
Keuangan : ……………………………………………………......................
3. Perubahan-perubahan yang diantispasi dalam situasi kehidupan setelah
pulang ..............................................................................................................
4. Area yang mungkin membutuhkan perubahan / bantuan : ..............................
Penyiapan makanan : ............................... Berbelanja : ............................................
Transportasi : ....................................... Ambulans: ..................................................
Obat / trapi IV : .................................... Pengobatan : ..............................................
Perawatan luka : ...................................... Peralatan : ...............................................
Bantuan perawatan diri (khusus) : .............................................................................
Gambaran fisik rumah (khusus) : ..............................................................................
Bantuan merapihkan / pemeliharaan rumah : ............................................................
fasilitas kehidupan selain rumah (khusus) : .....................................................

TEST DIAGNOSTIK
- Laboratorium (tulis nilai normalnya) : …………………………….
- Ro foto : …………………………….
- CT Scan : …………………………….
- MRI, USG, EEG, ECG, dll. : …………………………….

Therapy saat ini (tulis dengan rinci) :

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 DATA FOKUS
( CP.1 A )

NAMA PASIEN : ………………. NAMA MAHASISWA : …………

NO.REKAM MEDIK : ………………. NIM :………….
RUANG RAWAT : ………………………….

DATA SUBJEKTIF DATA OBJEKTIF

 ANALISA DATA
( CP.1 B )

NAMA PASIEN : ………………… NAMA MAHASISWA :………….

NO.REKAM MEDIK : NIM : ………..
RUANG RAWAT : ………………………….

NO DATA MASALAH ETIOLOGI

 DIAGNOSA KEPERAWATAN
( CP.2 )
NO.REKAM MEDIK : NAMA MAHASISWA :
RUANG RAWAT : NIM :

NO MASALAH/DIAGNOSA TGL.DITEMUKAN TGL.TERATASI

 RENCANA KEPERAWATAN
( CP.3 )

NAMA PASIEN : NAMA MAHASISWA :

NO.REKAM MEDIK : NIM :
DIAGNOSA MEDIK :

NDX. DAN
TGL TUJUAN RENCANA TINDAKAN
DATA PENUNJANG
 CATATAN TINDAKAN
( CP.4 )

NAMA PASIEN : NAMA MAHASISWA :

NO.REKAM MEDIK : NIM :
RUANG RAWAT :

TINDAKAN
KODE NDx JAM KEPERAWATAN
TGL
DAN HASIL
 CATATAN PERKEMBANGAN
( CP.5 )

NAMA PASIEN : NAMA MAHASISWA : ……

NO.REKAM MEDIK : NIM : ………
RUANG RAWAT : ………………………….

KODE
TGL JAM EVALUASI / SOAP
NDx
 RESUME KEPERAWATAN
( CP.6 )

NAMA : NO. REKAM MEDIK :

UMUR : RUANG RAWAT :
J.KELAMIN : TGL. MASUK RS :
AGAMA : TGL. KELUAR RS :

1. Masalah Keperawatan pada pasien dirawat

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2. Tindakan Keperawatan selama dirawat

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3. Evaluasi
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4. Nasihat Pada Pasien Pulang

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Nama Mahasiswa :
NIM :