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JURUSAN KEPERAWATAN FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA PENGKAJIAN DASAR KEPERAWATAN Nama Mahasiswa: NIM : Tempat Praktik: Tgl. Praktek : A. Identitas Klien Nama : No.RM : Usia : Tgl. Masuk : Jenis Kelamin : Tgl. Pengkajian : Alamat : Sumber Informasi : No. Telepon : - Nama klg. Dekat yng bisa dihubungi : Status Pernikahan : .......................................................................... . Agama : Status : Suku : Alamat :....................................... Pendidikan : - No. Telepon :....................................... Pekerjaan : - Pendidikan :....................................... Lama Bekerja : - . Pekerjaan :....................................... B. Status Kesehatan Saat Ini 1. Keluhan utama : 2. Diagnosa Medis : Riwayat Kesehatan Saat Ini Keluhan Saat pengkajian : Riwayat Kesehatan Terdahulu 3. Penyakit yang pernah dialami :

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JURUSAN KEPERAWATANFAKULTAS KEDOKTERAN

UNIVERSITAS BRAWIJAYAPENGKAJIAN DASAR KEPERAWATANNama Mahasiswa: NIM : Tempat Praktik: Tgl. Praktek :

A. Identitas KlienNama

:

No.RM

: Usia

:

Tgl. Masuk

: Jenis Kelamin:

Tgl. Pengkajian: Alamat

:

Sumber Informasi: No. Telepon: -

Nama klg. Dekat yng bisa dihubungi :Status Pernikahan:

...........................................................................Agama

:

Status

: Suku

:

Alamat

:.......................................Pendidikan: -

No. Telepon

:.......................................Pekerjaan

: -

Pendidikan

:.......................................Lama Bekerja: -

.Pekerjaan

:.......................................B. Status Kesehatan Saat Ini1. Keluhan utama

: 2. Diagnosa Medis:

Riwayat Kesehatan Saat IniKeluhan Saat pengkajian :

Riwayat Kesehatan Terdahulu

3. Penyakit yang pernah dialami:a. Kecelakaan (jenis & waktu): tidak adab. Operasi (jenis & waktu): tidak adac. Penyakit:

Akut: Kronis: -4. Alergi (obat, makanan, plester, dll):

Tidak ada

5. Imunisasi ( ) BCG

( ) Hepatitis

( ) Polio

( ) Campak

( ) DPT

6. Obat-obatan yang digunakan

Jenis

Lamanya

Dosis

.........................

.................................................. ..........................................

C. Riwayat Keluarga

GENOGRAMKeterangan :

: Laki-laki

: Perempuan

X: Meninggal

: Pasien

: Tinggal Serumah

: Menikah

: Garis Keturunan

D. Riwayat LingkunganJenis

Rumah

Pekerjaan

Kebersihan

.......................................................................................................

Bahaya kecelakaan.......................................................................................................

Polusi

.......................................................................................................

Ventilasi

......................................................................................................

Pencahayaan

......................................................................................................

................................................................................................................................

E. Pola Aktivitas-Latihan

Jenis

Rumah

Rumah Sakit

Makan/Minum........................................................................................................................ Mandi

...................................................................................................................... Berpakaian..................................................................................................................... Toiletting....................................................................................................................... Mobilitas...................................................................................................................... Berpindah...................................................................................................................... Berjalan

...................................................................................................................... Naik tangga.......................................................................................................................Pemberian Skor: 0=mandiri, 1=alat bantu, 2=dibantu orang lain (1 orang), 3=dibantu orang lain (>1 orang), 4=tidak mampuF. Pola NutrisiJenis

Rumah

Rumah Sakit

Makan

Jenis diit/makanan.......................................................................................................

Frekuensi/pola

......................................................................................................

Porsi yang dihabiskan......................................................................................................

Komposisi menu......................................................................................................

Pantangan

......................................................................................................

Nafsu makan

......................................................................................................

Fluktuasi BB 6 bl trhr......................................................................................................

Minum

Jenis minuman

......................................................................................................

Frekuensi/pola minum......................................................................................................

Gelas yang dihabiskan......................................................................................................

Sukar menelan

......................................................................................................

Pemakaian gigi palsu......................................................................................................

Riw.masalah

penyembuhan luka......................................................................................................

G. Pola Eliminasi

Jenis

Rumah

Rumah Sakit

BAB

Frekuensi/pola

.......................................................................................................

Konsistensi

.......................................................................................................

Warna & bau

.......................................................................................................

Kesulitan

.......................................................................................................

Upaya mengetasi.......................................................................................................

BAK

Frekuensi/pola.......................................................................................................

Konsistensi

.......................................................................................................

Warna & bau

.......................................................................................................

Kesulitan

.......................................................................................................

Upaya mengetasi.......................................................................................................

H. Pola Tidur-Istirahat

Rumah

Rumah Sakit

Tidur siang: Lamanya...........................................

..................................................- Jam .....s/d.................................................

...................................................

- Kenyamanan stl tidur...........................................

................................................... Tidur malam: Lamanya...........................................

...................................................- Jam .....s/d.................................................

...................................................

- Kenyamanan stl tidur...........................................

...................................................- Kebiasaan sbl tidur...........................................

...................................................

- Kesulitan

...........................................

...................................................

- Upaya mengatasi...........................................

...................................................

I. Pola Kebersihan DiriRumah

Rumah Sakit

Mandi: Frekuensi...........................................

.................................................. Penggunaan sabun...........................................

...................................................

Keramas: Frekuensi...........................................

...................................................- Penggunaan Shampo...........................................

................................................... Gosok gigi: Frekuensi...........................................

...................................................- Penggunaan odol...........................................

................................................... Ganti baju: Frekuensi...........................................

................................................... Memotong kuku: Frekuensi.....................................

.................................................... Kesulitan

...........................................

................................................... Upaya yang dilakuan...........................................

...................................................J. Pola Toleransi Koping Stress

1. Pengembilan keputusan: ( ) sendiri, ( ) dibantu orang lain, ........................................................2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri, dll)...........................................................................................................................................................

3. Yang biasa dilakukan apabila stres/mengalami masalah ..........................................................4. Harapan setelah menjalani perawatan.......................................................................................

5. Perubahan yang dirasa setelah sakit.........................................................................................

K. Pola peran & Hubungan

1. Peran dalam keluarga................................................................................................................2. Sistem pendukung: suami/istri/tetangga/teman/keluarga/tidak ada, sebutkan ..........................3. Kesulitan dalam keluarga( ) Hub. dgn orang tua

( ) Hub.dgn pasangan( ) Hub. dgn sanak saudara( ) Hub. dgn anak

( ) Lain-lain sebutkan4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS .............................................................................................................................................................................5. Upaya yang dilakukan untuk mengatasi.....................................................................................L. Pola Komunikasi

1. Bicara:( ) Normal

( ) Bahasa utama: jawa

( ) Tidak Jelas

( ) Bahasa daerah

( ) Bicara berputar-putar

( ) Rentang perhatian

( ) Mampu mengerti pembicaraan orang lain ( ) Afek........................................2. Tempat tinggal:( ) Sendiri

( ) Kos/asrama

( ) Bersama orang lain, yaitu: ...............................................................3. Kehidupan Keluarga

a. Adat istiadat yag dianut: ......................................................................................................

b. Pantangan adat dan agama yang dianut: ...........................................................................

c. Penghasilan Keluarga:( ) < Rp 250.000

( ) Rp 1 juta 1,5 juta

( ) Rp 250.000 500.000

( ) Rp 1,5 juta 2 juta

( ) Rp 500.000 1 juta

( ) > 2 juta

M. Pola Seksualitas

1. Masalah dalam hubungan seksual selama sakit: ( ) Tidak ada( ) Ada2. Upaya yang dilakukan pasangan: ( ) Perhatian ( ) Sentuhan

( ) Lain-lain, seperti ...................................................................................................................N. Pola Nilai & Kepercayaan

1. Apakah tuhan dan agama penting untuk anda: ( ) Ya

( ) Tidak

2. Kegiatan keagamaan yang dilakukan di rumah (jenis dan frekuensi):.....................................

..................................................................................................................................................

3. Kegiatan keagamaan yang tidak dapat dilakukan di RS: ........................................................4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya: .........................................O. Pemeriksaan fisik1. Keadaan umum:.......................................................................................................................

a. Kesadaran: ........................................................................................................................b. Tanda tanda vital:Tek.darah : ..........mmHg

Suhu

: ..............oC

Nadi

: ..........x/m

Pernapasan: ..............x/m2. Kepala dan leher

a. Kepala:

Bentuk.......... Massa..........Distribusi Rambut ...................Warna kulit kepala............ Keluhan: pusing/sakit kepala/migren/lainnya, sebutkan .............................................b. Mata

Bentuk .................................

Konjungtiva ........................................

Pupil: ( ) Reaksi terhadap cahaya ( ) Isokor ( ) Meiosis ( ) Pin Point ( ) Midriasis

Tanda radang:............................................................................................................... Fungsi penglihatan:

( ) Baik

( ) Kabur

Penggunaan alat bantu:( ) ya

( ) tidak

Apabila ya: ( ) kaca mata ( ) lensa kontak( ) minus.....ka/ki( ) plus....ka/ki

Pemeriksaan mata terakhir: ...................................................................................................... Riwayat operasi: .......................................................................................................................c. Hidung

Bentuk......................... Warna ............................... Pembengkakan...........Nyeri tekan........ Pendarahan......... Sinus ............... Riwayat Alergi......... Cara mengatasi ....................................................................................... Penyakit yang pernah terjadi ....................................................................................................d. Mulut dan tenggorokan

Warna bibir ...................... Mukosa.................. Ulkus.........Lesi............ Massa...................... Warna lidah............................Perdarahan gusi .............Karies...................................

Gangg bicara................................................ Pemeriksaan gigi terakhir.............................................................................................e. Telinga

Bentuk .................Warna ...................Lesi......... Massa ......... Nyeri.......... Nyeri Tekan...........

Fungsi Pendengaran ......... ....Alat bantu pendengaran .............................................. Masalah Yang Pernah Terjadi: ...................................................................................f. Leher

Kekakuan.......... .....................Nyeri/nyeri tekan................................... Benjolan/ Massa....................Keterbatasan gerak........................ Vena jugularis : ..................Tiroid...............Limfe................. Trakea........................ Keluhan: ...................................................................................................................... Upaya untuk mengatasi ...............................................................................................

3. Dada Bentuk ..........................................Pergerakan Dada .......................................................... Nyeri/nyeri tekan......Massa.........Peradangan......Taktil Fremitus ........................................Pola Nafas ................................................................. JantungInspeksi................................................................................................................................Palpasi .................................................................................................................................Perkusi .................................................................................................................................Auskultasi ............................................................................................................................. Paru:

Inspeksi................................................................................................................................Palpasi ..................................................................................................................................Perkusi ................................................................................................................................Auskultasi ............................................................................................................................4. Payudara dan ketiak Benjolan/Massa: .............................Nyeri/nyeri tekan ......................................................... Bengkak ........................................Kesimetrisan: ................................................................5. Abdomen

Inspeksi: .............................................................................................................................. .... Auskultasi : .......................................................................................................................... Perkusi: ............................................................................................................................... Palpasi: ................................................................................................................................... ...6. Genitalia Inspeksi

: ............................................................................................................ Palpasi

: ............................................................................................................ Keluhan ...............................................................................................................................7. Ekstremitas Kekuatan otot: ............................................................................................................. Kontraktur ..............Pergerakan .........................Deformitas .......... Pembengkakan ...........

Edema ............... Nyeri/nyeri tekan ..............Pus/luka ........................................................8. Kulit dan Kuku

Kulit : Warna .................Jaringan parut: .............

Lesi........... Suhu........... Tekstur .............Turgor....................................................... Kuku : Warna .....................................Bentuk .................................................Lesi ........................................Pengisian Kapiler ..................................P. Hasil pemeriksaan penunjang

Radiologi

.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Q. Pengobatan................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Hasil pemeriksaan laboratorium

No.Jenis PemeriksaanHasilNilai Normal

ANALISA DATA

No.DataEtiologiMasalah keperawatan

DAFTAR DIAGNOSA KEPERAWATAN

(Berdasarkan Prioritas)

Ruang

:

Nama Pasien:

Diagnosa:

No.Tanggal

MunculDiagnosa MunculTanggal TeratasiTanda Tangan

Rencana Asuhan KeperawatanDiagnosa keperawatan No.

Tujuan

:

Kriteria hasil

:

NOC :

No.Indikator12345

Keterangan penilaian :

1:

2:

3:

4:

5:

NOC : No.Indikator12345

Keterangan penilaian :

1:

2:

3:

4:

5:

Intervensi NIC

IMPLEMENTASI

Nama Klien

:

Tanggal Pengkajian:

Diagnosa Medis:

TglNo. Dx. KepJamTindakan KeperawatanRespon KlienTTD & Nama Terang

TglNo. Dx. KepJamTindakan KeperawatanRespon KlienTTD & Nama Terang

CATATAN PERKEMBANGAN (PROGRES NOTE)Diagnosa keperawatan No.NOC :

NoIndikatorTanggal Observasi Dan Hasil

1234S1234S1234S

Diagnosa keperawatan No.

NOC :

NoIndikatorTanggal Observasi Dan Hasil

1234S1234S1234S

Diagnosa keperawatan No.

NOC :

NoIndikatorTanggal Observasi Dan Hasil

1234S1234S1234S

Keterangan penilaian:

-: Tidak sesuai

+: Sesuai dengan diharapkan

S: Scoring

Keterangan Skoring:

1: -

2: 1+

3: 2+ 4: 3+

5: 4+

EVALUASI

Hari/ Tanggal/ JamNo. Dx. Kep.EvaluasiTanda tangan

S :

O :

NOC :

IndikatorScore

Awal

Trgt

Akhir

A : Masalah sesuai dengan NOC sudah teratasi/belum teratasi

P : Intervensi dihentikan / dilanjutkan dan didelegasikan

Kepada perawat dinas .................. :

1. NIC :

2. NIC :

S :

O :

NOC :

IndikatorScore

Awal

Trgt

Akhir

A : Masalah sesuai dengan NOC sudah teratasi/belum teratasi

P : Intervensi dihentikan / dilanjutkan dan didelegasikan

Kepada perawat dinas .................. :

1. NIC :

2. NIC :

*coret yang tidak perlu