FORMAT PENGKAJIAN ASUHAN KEPERAWATAN

KEPERAWATAN DASAR PROFESI

IKesT MUHAMMADIYAH PALEMBANG

Nama Mahasiswa : Lisa fitriani

Tempat Praktek : Zaal anak
Tanggal Praktek : 18 – 23 oktober 2022
Pengkajian Dilakukan Tanggal 18 0ktober jam 18:30 WIB

1. Identitas Klien
Inisial : An. F No RM :
Usia : 15 tahun Tgl Masuk :17-10-2022
Jenis : Tgl Pengkajian :18-10-2022
Kelamin : Laki-laki Sumber Informasi :keluarga
Alamat : Keluarga Terdekat :orang tua
No Telepon : status :
Status : Alamat :
Agama : islam No Telepon :
Suku : Palembang Pendidikan :
Pekerjaan : pelajar Pekerjaan :
Lama : Bekerja :
2. Riwayat Kesehatan
a. Keluhan Utama (saat masuk RS)
Keluarga klien mengatakan ada bengkak pada bagian kaki mata dan perut
b. Keluhan utama (saat pengkajian)
Keluarga klien mengatakan adanya bengkak pada bagian mata kaki dan
perut
Klien tampak lesu
Klien tampak pucat
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)
Keluarga klien mengatakan klien tidak memiliki alergi
3. Imunisasi (tambahan; flu, pneumonia, tetanus, dll)
.................................................................................................................
.................................................................................................................
..................................
4. Kebisasaan
Jenis Frekuensi Jumlah Lamanya
a. Merokok - - -
b. Kopi - - -
c. Alkohol - - -

5. Obat-obatan yang digunakan

Jenis Lamanya Dosis
…………………….. ………………...……… ………………….……
…………………….. ………………...……… ………………….……

3. Riwayat Keluarga
Tidak ada riwayat dari 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:
Keluarga klien mengatakan bahwa tidak tahu tentang penyakit yang
dialami oleh klien jika tidak di bawa ke rumah sakit
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..........................................................................................................
..............................................................................................................
..............................................................................................................
...

Kebutuhan Nutrisi dan Cairan

BB sebelum sakit: kg BB sakit:
kg
Program Diit RS :
Makanan yang disukai
:........................................................................
Selera makan
:........................................................................
 Alat makan yang digunakan
:........................................................................
Pola makan( x/ hari)
:........................................................................
Porsi makan yang dihabiskan
:........................................................................
Pola Minum .............................gelas/hari) jenis air
minum :................................
Intake Makanan
:........................................................................
..............................................................................................................
..............................................................................................................
..................................
Intake Cairan
:........................................................................
..............................................................................................................
..............................................................................................................
..................................
c. Abdomen
Inspeksi : Bentuk: simetris( ), tidak simetris( ), kembung( ),
asites( ),
Palpasi : massa ( ), nyeri ( )
Kuadran I :
Kuadran II :
Kuadran III :
Kuadran IV :
Auskultasi : bising usus........................x/mnt
Perkusi : Timpani ( ), redup ( )
BAB : warna........................................Frekuensi................................x/hari
Konsisitensi:.................................. lendir ( ), darah ( ), ampas ( )
Konstipasi ( )
Data Tambahan :
......................................................................................................................
......................................................................................................................
..........................................................................................................
Masalah keperawatan:
 ......................................................................................................................
......................................................................................................................
..................................
3. Eliminasi dan Pertukaran
a. BAK :
b. Warna :
c. Konsistensi:
d. Frekuensi : x/ hari
e. Urine Output : cc
f. Penggunaan Kateter :................................................................
g. Vesika Urinaria: Membesar .....................Nyeri
tekan............................
h. Gangguan; Anuaria ( ), Oliguria ( ), Retensi Uria ( ), nokturia ( ),
Inkontinensia Urin ( ), Poliuria ( ), Dysuria ( )lan nafas: Sputum
( ), warna sputum ( ) konsisitensi:........................................
Batuk ( ) frekuensi:..............................
Dada
Bentuk: Simetris ( ), Barrel chest/dada tong( ), pigeon chest/dada
burung ( ) benjolan ( ), dll………………..
Paru-paru:
Inspeksi: RR………x/ min,
Palpasi: Normal ( ), ekspansi pernafasan( ), taktil fremitus( )
Perkusi: Normal/ Sonor( ), redup/pekak( ), hiper sonor( )
Auskultasi: irama( ), teratur( ),
Suara nafas: vesicular( ), bronkial( ), Amforik ( ), Cog Wheel
Breath Sound
( ) metamorphosing breath sound ( )
Suara Tambahan: Ronki ( ), pleural friction( )
Data Tambahan:
......................................................................................................................
......................................................................................................................
..................................

Masalah keperawatan:
......................................................................................................................
......................................................................................................................
..................................
 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: islam
Bahasa yang digunakan : palembang
Masalah sosial yang penting:
Hubungan dengan orang tua:dekat
Hubungan dengan saudara kandung:
Hubungan dengan lingkungan sekitar:
Data Tambahan
......................................................................................................................
......................................................................................................................
..................................
Masalah keperawatan:
......................................................................................................................
......................................................................................................................
..................................

8. Seksualitas Dan Reproduksi

Genitalia dan Anus
 Laki-laki
Penis: normal/ada ( ), Abnormal…………………,
Scrotum dan testis: normal( ), hernia( ), hidrokel( )
Anus ; normal/ada ( ), atresia ani( )
Perempuan
Vagina: sekret( ), warna( )
Anus: normal/ada ( ), atresia ani( )
Riwayat kehamilan dan kelahiran :
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.................................................................................................................
......................................................................................................................
...............................................................................................................