INSTITUT TEKNOLOGI SAINS DAN KESEHATAN RS dr.

SOEPRAOEN
PROGRAM STUDI KEPERAWATAN

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Sylvi AP TempatPraktik: rumah
NIM : 201183 TglPraktik : 10-03-2021

A. IdentitasKlien
Nama : Tn. M. No. RM :-
Usia : 19 thn TanggalMasuk : 10-03-2021
Jeniskelamin :L TanggalPengkajian : 10-03-2021
Alamat : Dwiga Regency SumberInformasi : Klien
No. Telepon : 0857-0763-5716 Nama klg. dekat yang bisadihubungi: ayahnya
Status pernikahan : Pelajar Tn. Sumariono
Agama : Islam Status : Menikah
Suku : WNI Alamat : Dwiga Regency
Pendidikan : SMA No. telepon : 0851-9778-3915
Pekerjaan : Pelajar Pendidikan : S1
Lama bekerja :- Pekerjaan : Swasta

B. Status Kesehatan SaatIni

1. Keluhanutama :
DS : sesak mulai hari ini+ , batuk+ , pilek mulai kemarin+ , grok-grok mulai kemarin+ , dahak+
2. Lama keluhan : 3 hari
3. Kualitaskeluhan: 4/10
4. Faktorpencetus : cuaca
5. Faktorpemberat: pola hidup
6. Upaya yang telahdilakukan: minum obat bebas, periksa ke puskesmas
7. Keluhan saat pengkajian:
DO : Nadi kuat, T. 120/80 mmHg , N + 97x/m S : 36 RR : 26x/m

Diagnosa Medis:

1. Asma

2. Sinusitis

C. Riwayat Kesehatan SaatIni

D. Riwayat Kesehatan Dahulu
1. Penyakit Yang PernahDialami : Asma dan Sinusitis
a. Kecelakaan (Jenis&waktu) : tdk pernah
b. Operasi (Jenis&waktu) : tdk pernah
c. Penyakit :
 Kronis : -
 Akut : Asma dan Sinusitis
d. Terakhirmasuk RS : 2 tahun lalu
2. Alergi (obat, makanan, plester, dll) : alergiu denu dan dingin sejak kecil
3. Imunisasi
( )BCG ( )Hepatitis
( )Polio ( )Campak
( )DPT ( )……………
4. Kebiasaan Merokok
Jenis Frekuensi Jumlah Lamanya
tdk tdk pernah tdk pernah tdk pernah
pernah

5. Obat-obatan yang digunakan : ipratropium, teofilin, kartikosteroid.

E. Riwayat Kesehatan Keluarga

Dalam keluarga, ayah pasien riwayat hipertensi dan asma. Ibu pasien riwayat hipertensi

F. Genogram
G. Riwayat Lingkungan
Jenis Rumah Pekerjaan
 Kebersihan
 BahayaKecelakaan
 Polusi
 Ventilasi
 Pencahayaan

H. Pola Aktivitas – Latihan

Jenis Rumah Rumahsakit
Sebelumsakit Sesudahsakit
 Makanminum
 Mandi
 Berpakaian/berdandan
 Toileting
 Mobilitas di tempattidur
 Berpindah
 Berjalan
 Naik tangga
Pemberianskor : 0 = mandiri, 1 = alat bantu, 2 = dibantu 1 orang, 3 = dibantu>1 orang, 4 =
tidakmampu
I. Pola NutrisiMetabolik
Jenis Rumah Rumahsakit
 Jenis diet
 Frekuensi/pola
 Porsiyngdihabiskan
 Komposisi menu
 Pantangan
 Nafsumakan
 Fluktuasi BB 6 bulanterakhir
 Jenisminuman
 Frekuensi/pola
J. Pola Eliminasi
Rumah Rumahsakit
BAB
 Frekuensi/pola
 Konsistensi
 Warna&bau
 Kesulitan
 Upayamengatasi
BAK
 Frekuensi/pola
 Konsistensi
 Warna&bau
 Kesulitan
 Upayamengatasi
K. Pola Tidur – Istirahat
Rumah Rumahsakit
Tidursiang : lamanya
 Jam….s/d…..
 Kenyamananstlhtidur
Tidurmalam : lamanya
 Jam….s/d…..
 Kenyamananstlhtidur
 Kebiasaansblmtidur
 Kesulitan
 Upayamengatasi

L. Pola KebersihanDiri
Rumah Rumahsakit
 Mandi : frekuensi
Penggunaansabun
 Keramas : frekuensi
Penggunaansampo
 Gosokgigi : frekuensi
Penggunaanodol
 Ganti baju : frekuensi
 Potong kuku : frekuensi
 Kesulitan
 Upayaygdilakukan

M. Pola Toleransi Koping-Stress

1. Pengambilankeputusan: ( ) sendiri ( ) dibantu orang lain, sebutkan
2. Masalahutamaterkaitdenganperawatan di RS ataupenyakit (biaya, perawatandiri, dll)
3. Yang biasadilakukanapabila stress/mengalamimasalah
4. Harapan setelahmenjalaniperawatan:
5. Perubahan yang dirasasetelahsakit:
N. KonsepDiri
1. Gambaran
2. Ideal diri
3. Harga diri
4. Peran
5. Identitasdiri
O. Pola Peran dan Hubungan
1. Peran dalamkeluarga: kepala keluarga
2. Sistempendukung: suami/istri/anak/tetangga/teman/saudara/tidakada/lain-lain, sebutkan:
3. Kesulitandalamkeluarga: -
( ) hubungandengan orang tua ( ) hubungandenganpasangan
( ) hubungandengansanaksaudara ( ) hubungandengananak
( ) lain-lain sebutkan,
4. Masalahtentangperan/hubungandengankeluargaselamaperawatan di RS:
5. Upaya yang dilakukanuntukmengatasi
P. Pola Komunikasi
1. Bicara ( ) Normal ( ) bahasautama
( ) Tidak jelas ( ) bahasadaerah
( ) bicaraberputarputar ( ) rentangperhatian
( ) Mampu mengertipembicaraan orang lain ( ) afek
Q. Pola Seksualitas
1. Masalahdalamhubunganseksualselamasakit: ( ) tidakada ( ) ada
2. Upaya yang dilakukanpasangan:
( ) perhatian ( ) sentuhan ( ) lain-lain, seperti
R. Pola Nilai dan Kepercayaan
1. ApakahTuhan, agama, dan kepercayaanpentinguntuk Anda, Ya/Tidak
2. Kegiatan agama/kepercayaan yang dilakukan di rumah (jenis dan frekuensi)
3. Kegiatan agama/kepercayaantidakdapatdilakukan di RS
4. Harapan klienterhadapperawatuntukmelakukanibadahnya
S. PemeriksaanFisik
1. Keadaanumum :
 Kesadaran :
 Tanda tanda vital :
TekananDarah :Suhu :
Nadi : RR :
 Tinggi Badan: cm Berat Badan : kg

2. Kepala&Leher
a. Kepala
 Bentuk:
 Massa:
 Distribusi rambut:
 Warna kulit kepala:
 Keluhan: pusing/sakit kepala/migraine, lainnya:
b. Mata
 Bentuk:
 Konjungtiva:
 Pupil: ( ) reaksi terhadap cahaya ( ) isokor ( ) miosis ( ) pin point ( ) midriasis
  Tanda radang:
 Fungsi penglihatan:
 Penggunaan alat bantu:
c. Hidung
 Bentuk :
 Warna :
 Pembengkakan :
 Nyeri tekan :
 Perdarahan :
 Sinus :
d. Mulut&Tenggorokan
 Warnabibir :
 Mukosa :
 Ulkus :
 Lesi :
 Massa :
 Warnalidah :
 Perdarahangusi :
 Karies :
 Gangguanbicara :
e. Telinga
 Bentuk :
 Warna :
 Lesi :
 Massa :
 Nyeri :
 Nyeri tekan :
f. Leher
 Kekakuan :
 Benjolan/massa :
 Vena jugularis :
 Nyeri :
 Nyeri tekan :
 Keterbatasangerak :
 Keluhan lain :
3. Thorak& Dada
 Jantung
- Inspeksi :

- Palpasi :..................................................................................................................................
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- Perkusi :...................................................................................................................................
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- Auskultasi : .............................................................................................................................
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 Paru
- Inspeksi ..................................................................................................................................
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- Palpasi : ..................................................................................................................................
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- Perkusi : ..................................................................................................................................
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- Auskultasi : .............................................................................................................................
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4. Payudara&Ketiak
 Benjolan/massa : ..........................................................................................................................
 Bengkak : ......................................................................................................................................
 Nyeri : ...........................................................................................................................................
 Nyeri tekan : ................................................................................................................................
 Kesimetrisan : ...............................................................................................................................
5. Punggung&TulangBelakang
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6. Abdomen
 Inspeksi ............................................................................................................................................
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 Palpasi...............................................................................................................................................
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 Perkusi..............................................................................................................................................
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 Auskultasi..........................................................................................................................................
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7. Genitalia & Anus

 Inspeksi : ..........................................................................................................................................
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 Palpasi...............................................................................................................................................
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8. Ekstremitas (kekuatanotot, kontraktur, deformitas, edema, luka, nyeri/nyeritekan, pergerakan)
 Atas : ................................................................................................................................................
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 Bawah ..............................................................................................................................................
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9. SistemNeurologi 9SSP : I-XII, reflek, motorik, sensorik)
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10. Kulit& Kuku
 Kulit : (warna, lesi, turgor, jaringanparut, suhu, tekstur, diaphoresis)
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 Kuku : (warna, lesi, bentuk, CRT)
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T. Hasil PemeriksaanPenunjang (Laboratorium, USG, Rontgen, MRI)
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U. Terapi (Medis, RehabMedik, Nutrisi)
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V. PersepsiKlienTerhadapPenyakitnya
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W. Kesimpulan
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X. PerencanaanPulang
 TujuanPulang.......................................................................................................................................
 Transportasipulang..............................................................................................................................
 Dukungankeluarga...............................................................................................................................
 Antisipasibantuanbiayasetelahpulang.................................................................................................
 Antisipasimasalahperawatandirisetelahpulang...................................................................................
 Pengobatan..........................................................................................................................................
 Rawat jalanke.......................................................................................................................................
 Hal hal yang perludiperhatikan di rumah.............................................................................................
 Keterangan lain....................................................................................................................................

Malang,
 Pengkaji

__________________
ANALISA DATA

No. Data Etiologi Masalahkeperawatan

 ANALISA DATA

No. Data Etiologi Masalahkeperawatan

 DAFTAR PRIORITAS DIAGNOSA KEPERAWATAN

NAMA KLIEN :
NO.REG :

NO TANGGAL DIAGNOSA TANGGAL TANDA

MUNCUL KEPERAWATAN TERATASI TANGAN
 RENCANA ASUHAN KEPERAWATAN

Nama / Usia : Dx / No.Reg :

No Tgl Dx Keperawatan Tujuan&Kriteria Hasil Intervensi Rasional

 RENCANA ASUHAN KEPERAWATAN

Nama / Usia : Dx / No.Reg :

No Tgl Dx Keperawatan Tujuan&Kriteria Hasil Intervensi Rasional

 IMPLEMENTASI DAN EVALUASI

Nama : __________________ Ruangan : ______________________ RM No. : _____________________Dx medis : _____________________

No. Tanggal/
IMPLEMENTASI KEPERAWATAN EVALUASI
Dx Jam