FORMAT PENGKAJIAN

I. DATA UMUM

Nama : .................................................................................
Umur : .................................................................................
Jenis kelamin : .................................................................................
Alamat : .................................................................................
Pekerjaan : .................................................................................
Penghasilan : .................................................................................
Status : .................................................................................
Pendidikan Terakhir : .................................................................................
Golongan Darah : .................................................................................
Tanggal MRS : .................................................................................
Tanggal Pengkajian : .................................................................................
Diagnosa Medis : .................................................................................

II. DATA DASAR

Keluhan Utama :
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Alasan Masuk Rumah Sakit :

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MRS
Dari Rumah sendirian
Dari Rumah dengan keluarga
Jalan
Emergensi
Lain-lain (sebutkan) ...................................................................................

Alat yang digunakan :

Kursi roda
Ambulan
 Brankart
Lain-lain (sebutkan) ...................................................................................

Masuk Rumah Sakit terakhir tanggal :

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Alasan, ............................................................................................................
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Riwayat Penyakit Sekarang :

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Riwayat Penyakit Sebelumnya :

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Riwayat Pengobatan Sebelumnya :

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III. POLA FUNGSI KESEHATAN

1. Persepsi terhadap Kesehatan–Manajemen Kesehatan

Mengkonsumsi :
Tembakau (merokok) : Ya Tidak
Kalau ya berapa batang sehari .......................................................
Alkohol : Ya
Tidak
Kalau ya sebutkan jenis, jumlah dan lama mengkonsumsi alkohol:
.........................................................................................................
Alergi : Obat
Makanan
Kalau ya sebutkan jenis obat dan makanan serta reaksinya ...............
.............................................................................................................
.............................................................................................................

2. Pola Aktivitas dan Latihan

Kemampuan Perawatan Diri
Skor 0 : mandiri, 1 : dibantu sebagian, 2 : perlu bantuan orang lain,
3 : perlu bantuan orang lain dan alat, 4 : tergantung pada orang lain/
tidak mampu.
 Aktivitas 0 1 2 3 4
Mandi
Berpakaian
Eleminasi
Mobilisasi di tempat tidur
Pindah
Ambulansi
Naik tangga
Makan dan minum
Gosok gigi

Keterangan : .............................................................................................
..................................................................................................................
..................................................................................................................

3. Pola Istirahat dan Tidur :

Waktu tidur : ...............................................................................
Kualitas : ...............................................................................
Kuantitas : ...............................................................................
Frekwensi : ...............................................................................
Gangguan tidur : ...............................................................................
Tanda-tanda gangguan tidur : .............................................................
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4. Pola Nutrisi–Metabolik
Diet khusus : ...............................................................................
Anjuran diet sebelumnya : .................................................................
Nafsu makan : Normal
Meningkat Menurun
Mual Muntah
Stomatitis
BB naik turun 6 bulan terakhir : Ya
: Tidak
Berapa kg ............................................................................................
Kesulitan menelan : .............................................................................
.............................................................................................................
.............................................................................................................

5. Pola Eliminasi
Kebiasaan BAB : ..................x/hari; .............tgl. BAB terakhir : ........
 Normal; ................ Konstipasi; ................diare; ...............inkontinent;
................lainnya.
Kebiasaan BAB : ........................normal; ..........................frekwensi;
..........disuri; ..........................nokturi; ...................tidak bisa ditahan;
.............hematuri; ......................retensi.
Inkontinen: ..............tidak; .........ya; ......total ........siang ........malam;
..............kadang-kadang; ..............kesulitan menahan; ................tidak
sampai di toilet.
Penggunaan bantuan : .....................kateter; ........................................

6. Pola Kognitif–Perseptual
Status mental : .................sadar; ..................afasia; ..........orientasi;
........................bingung; ...................tidak ada respon.
Bicara : ............normal; ............gagap; ............afasia; ..........blocking
Bahasa yang digunakan : .........Jawa; ........Madura; ...........Indonesia;
..................lainnya.
Kemampuan membaca : ............................bisa; .........................tidak;
.................................mengartikan : ................bisa; .....................tidak.
Kemampuan interaksi : ............sesuai; ..................tidak, sebutkan
..............................................
Pendengaran : ...................normal; ................terganggu (kanan/kiri);
............................tuli (kanan/kiri); ....................alat bantu
pendengaran; .................tinitus (nging).
Penglihatan : ......................normal; ..................kaca mata; .................
lensa kontak ....................terganggu (kanan/kiri); .........................buta
(kanan/kiri); .............kabur (kanan/kiri); .................lainnya, sebutkan
........................................
Vertigo : ...............................ya ............; .....................tidak ...............
Manajemen nyeri : ...............................................................................

7. Pola Konsep Diri

Harga diri : .......... tidak terganggu .......... terganggu, sebutkan ..........
Ideal diri : ............ tidak terganggu .......... terganggu, sebutkan ..........
Identitas diri : .......... tidak terganggu ........ terganggu, sebutkan ........
Gambaran diri : .......... tidak terganggu ....... terganggu, sebutkan ......
Peran diri : .......... tidak terganggu .......... terganggu, sebutkan ...........

8. Pola Koping
Masalah utama selama masuk Rumah Sakit (keuangan, Perawatan diri,
lainnya) .........................................................................................
Kehilangan/perubahan yang terjadi sebelumnya ......tidak; ......ya.......
Takut terhadap kekerasan : ..........tidak; .........ya, siapa ......................
Pandangan terhadap masa depan : ..........(rata-rata dari 1 = pesimistis
s/d optimistis).
 9. Pola Seksual–Reproduksi
Menstruasi Terakhir (LMP) .................................................................
Masalah Menstruasi : ...................tidak; .............ya ............................
Papsmen terakhir : ................normal; ................tidak, sebutkan ........
Perawatan payudara setiap bulan : ...............ya; ...........tidak .............
Pola seks selama masuk rumah sakit ...................................................

10. Pola Peran Berhubungan

Status perkawinan : ..............................................................................
Pekerjaan : ............................................................................................
Kualitas bekerja : ............ sebulan berhenti : ............... tidak bekerja :
.................. lama
Sistem dukungan : .................... pasangan : ....................... tetangga /
teman : ................................. tidak : ........................................ lainnya
...............................................................................................................
Dukungan keluaga selama masuk RS ..................................................

11. Pola Nilai dan Kepercayaan

Agama ..................................................................................................
Larangan agama .................. tidak : ................. ya (sebutkan) ............
Permintaan rohaniawan selama masuk RS ....tidak : .....ya (sebutkan)
...............................................................................................................

IV. PEMERIKSAAN FISIK

1. Keadaan umum
a. Kesadaran : .............................................................................
b. Tanda-tanda vital :
Tekanan darah : .............................................................................
Nadi : .............................................................................
Suhu : .............................................................................
Pernafasan : .............................................................................
c. Tinggi badan : .............................................................................
2. Kepala dan Leher
a. Kepala :
Bentuk .......................... Massa ..................................................
Distribusi rambut ...........Warna kulit kepala ..............................
Keluhan : pusing/sakit kepala/migren/lainnya, sebutkan ……...
b. Mata :
Bentuk .............................. Kongjungtiva ...................................
Pupil : ( ) Reaksi terhadap cahaya ( ) Isokor ( ) Miosis
( ) Pin Point ( ) Midriasis
Tanda-tanda radang : ..................................................................
Fungsi penglihatan : ( ) Baik ( ) Kabur
Penggunaan alat bantu : ( ) Ya ( ) Tidak
Apabila ya menggunakan : ( ) Kacamata ( ) Lensa kontak
( ) Minus....ka/.....ki ( ) Plus....ka/....ki ( ) Silinder....ka/....ki
 Pemeriksaan mata terakhir : .......................................................
Riwayat operasi : ........................................................................
c. Hidung :
Bentuk ........... Warna ................ Pembengkakan ......................
Nyeri tekan..............Perdarahan...................Sinus......................
Riwayat Alergi............Cara mengatasinya..................................
Penyakit yang pernah terjadi.......................................................
Frekuensi...........................Cara mengatasi..................................
d. Mulut dan Tenggorokan :
Warna bibir.................Mukosa...............Ulkus...........................
Lesi..................Massa....................Warna lidah..........................
Perdarahan gusi.....................Caries............................................
Kesulitan menelan.................Gigi geligi.....................................
Sakit tenggorok......................Gangguan bicara..........................
Pemeriksaan gigi terakhir............................................................
e. Telinga :
Bentuk...................Warna.......................Lesi..............................
Massa....................Nyeri.........................Nyeri............................
Fungsi pendengaran.................Alat bantu pendengaran..............
Masalah yang pernah terjadi .......................................................
Upaya untuk mengatasi ..............................................................
f. Leher :
Kekakuan................Nyeri/Nyeri tekan........................................
Benjolan/massa..................Keterbatasan gerak...........................
Vena jugularis...................Tiroid.....................Limfe..................
Trakea.......................Keluhan.....................................................
Upaya untuk mengatasi...............................................................
g. Dada :
Bentuk...................................Pergerakan dada............................
Nyeri/nyeri tekan................Massa...............Peradangan.............
Taktil Fremitus...................Pola nafas.........................................
Jantung : Perkusi..........................................................................
Auskultasi....................................................................
Paru : Perkusi...............................................................................
Auskultasi..........................................................................
h. Payudara dan Ketiak :
Benjolan/Massa.....................Nyeri/Nyeri Tekan........................
Bengkak.................................Kesimetrisan.................................
i. Abdomen :
Inspeksi........................................................................................
Palpasi..........................................................................................
Perkusi.........................................................................................
Auskultasi....................................................................................
j. Genetalia :
Inspeksi........................................................................................
Palpasi..........................................................................................
 Perempuan : Siklus menstruasi....................................................
Kontrasepsi.............................................................
Kehamilan..............................................................
Keluhan..................................................................
Pria : Keluhan..............................................................................
k. Ekstremitas :
Kekuatan otot..............................................................................
Kontraktur............................Pergerakan......................................
Deformitas............................Pembengkakan...............................
Edema..................................Nyeri/Nyeri tekan...........................
Pus/luka.......................................................................................
Refleks-refleks : Sensasi
– Bisep : – Raba/ sentuhan :
– Trisep : – Panas :
– Brakioradialis : – Dingin :
– Patelar : – Tekanan/tusuk :
– Achiles :
– Plantar (babinski) :
l. Kulit dan Kuku :
Kulit : Warna......................Jaringan Parut..................................
Lesi.....................Suhu....................Tekstur.....................
Turgor...............................................................................
Kuku : Warna...................................Bentuk................................
Lesi.................................Pengisian kapiler......................

V. HASIL PEMERIKSAAN PENUNJANG

Laboratorium

Radiologi

VI. PENGOBATAN

VII. PERSEPSI KLIEN TERHADAP PENYAKITNYA

VIII. KESIMPULAN

IX. PERENCANAAN PULANG

Tujuan pulang : ( ) Ke rumah ( ) Tidak ada tujuan ( ) Lain-lain, sebutkan..
Transportasi pulang : ( ) Mobil ( ) Taksi ( ) Lain-lain, sebutkan
Transportasi pulang : ( ) Ambulans ( ) Belum dapat ditentukan sekarang
Dukungan keluarga : ( ) Ada ( ) Tidak ada
Antisipasi bantuan biaya setelah pulang : ( ) Ada ( ) Tidak ada
Antisipasi masalah perawatan diri setelah pulang : ( ) Ya ( ) Tidak
Pengobatan :.................................................................................................
......................................................................................................................
Rawat jalan ke :.........................Waktu...............Frekuensi.........................
Hal-hal yang perlu diperhatikan di rumah :.................................................
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Keterangan lain :..........................................................................................
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 ANALISA DATA

NO TANGGAL SIMPTOMA ETIOLOGI PROBLEM

 NURSING CARE PLANNING

NO TANGGAL DIAGNOSA KEPERAWATAN TUJUAN KRITERIA HASIL INTERVENSI RASIONAL

 IMPLEMENTASI
DIAGNOSA TINDAKAN TANDA
NO TANGGAL/JAM
KEPERAWATAN KEPERAWATAN TANGAN
 EVALUASI
DIAGNOSA CATATAN TANDA
NO TANGGAL/JAM
KEPERAWATAN PERKEMBANGAN TANGAN