FORMAT PENGKAJIAN ASUHAN KEPERAWATAN

KEPERAWATAN DASAR PROFESI

IKesT MUHAMMADIYAH PALEMBANG

Nama Mahasiswa : ………………………………

Tempat Praktek : ………………………………
Tanggal Praktek : ………………………………
Pengkajian Dilakukan Tanggal................jam................WIB

1. Identitas Klien
Inisial : No RM :
Usia : Tgl Masuk :
Jenis kelamin : Tgl Pengkajian :
Alamat : Sumber Informasi :
Alamat : Keluarga Terdekat :
No Telepon : status :
Status : Alamat :
Agama : No Telepon :
Suku : Pendidikan :
Pekerjaan : Pekerjaan :
Lama Bekerja :
2. Riwayat Kesehatan
a. Keluhan Utama (saat masuk RS)
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b. Keluhan utama (saat pengkajian)
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c. Riwayat Kesehatan Saat Ini
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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)
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3. Imunisasi (tambahan; flu, pneumonia, tetanus, dll)
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4. Kebisasaan
Jenis Frekuensi Jumlah Lamanya
a. Merokok ………………… …………………… ……………....……
b. Kopi ………………… …………………… ……………....……
c. Alkohol ………………… …………………… ……………....……

5. Obat-obatan yang digunakan

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

3. Riwayat Keluarga
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4. Catatan Penanganan Kasus (Dimulai saat pasien di rawat di ruang
rawat sampai pengambilan kasus kelolaan)
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5. Pengkajian Keperawatan
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:
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Masalah keperawatan:
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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 ( ),
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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
:........................................................................
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Intake Cairan
:........................................................................
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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 :
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Masalah keperawatan:
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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:
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Masalah keperawatan:
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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):
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Kekuatan Otot :
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Kelainan Otot:
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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 :
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Masalah keperawatan:
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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
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Masalah keperawatan:
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6. Persepsi Diri
Perasaaan klien terhadap penyakit yang dideritanya
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Persepsi klien terhadap
dirinya....................................................................................
Konsep
diri..................................................................................................................
Tingkat
kecemasan.......................................................................................................
Citra Diri/Bodi
image:.................................................................................................
Data tambahan
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Masalah keperawatan:
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7. Peran Hubungan
Budaya:
Suku:
Agama yang di anut:
Bahasa yang digunakan :
Masalah sosial yang penting:
Hubungan dengan orang tua:
Hubungan dengan saudara kandung:
Hubungan dengan lingkungan sekitar
 Data Tambahan
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Masalah keperawatan:
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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
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Masalah keperawatan:
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9. Toleransi/Koping Stress
GCS :.......
E :........................................................................................
V : .......................................................................................
M :.......................................................................................

Data Tambahan:
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 Masalah keperawatan:
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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:
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Data Tambahan
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Masalah keperawatan:
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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
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 Masalah keperawatan:
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12. Kenyamanan
Provaiking :
Quality :
Regio :
Scala :
Time :
Data Tambahan:
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Masalah keperawatan:
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Terapi
Tanggal Terapi :
Cara Golongan Kontra
No Nama Terapi Dosis Indikasi
Pemberian Obat Indikasi

Pemeriksaan Penunjang :
Laboratorium ( Tanggal Pemeriksaan )
USG ( Tanggal Pemeriksaan )
EKG ( Tanggal Pemeriksaan )
Rontsen ( Tanggal Pemeriksaan )
EEG ( Tanggal Pemeriksaan )
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ANALISA DATA

NO DATA/PROBLEM ETIOLOGI MASALAH KEPERAWATAN

DS: Pathway
DO:

DAFTAR MASALAH KEPERAWATAN

1. .....................................................................................................................

2. ......................................................................................................................

3. .......................................................................................................................

PRIORITAS MASALAH KEPERAWATAN

1. ......................................................................................................................

2. ......................................................................................................................

3. ...................................................................................................................... .
DIAGNOSA KEPERAWATAN (PES)
1. ......................................................................................................................

2. ......................................................................................................................

3. ...................................................................................................................... .
 WRENCANA KEPERAWATAN

Nama pasien :
Umur :
Jenis kelamin:
Rencana keperawatan
No Diagnosa Keperawatan
Tujuan dan Kriteria Hasil Intervensi Rasional
:................................................................ 1. 1.
2. 2.
No Kriteria Awal Tujuan 3. 3.
1 4. 4.
2 5. 5.
3
4
5

Indikator :
1 Gangguan ekstrem
2 Berat
3 Sedang
4 Ringan
5 Tidak ada gangguan
 IMPLEMENTASI& EVALUASI KEPERAWATAN

Nama pasien :
Umur :

Hari, Tgl Hari, Tgl

No. DIAGNOSA KEP. IMPLEMENTASI EVALUASI PARAF
&Jam &Jam
S:

O:

A:

P:

I:
EVALUASI / CATATAN PERKEMBANGAN

Nama pasien :
Umur :
Jenis kelamin :
No RM :

TANGGAL &
DIAGNOSA EVALUASI PARAF
WAKTU

S :
O :
A :
P :