Askep(format Pengkajian).docx

PEMERINTAH KABUPATEN MINAHASA

DINAS KESEHATAN UPT PUSKESMAS TOMPASO Alamat : Desa Talikuran Kecamatan Tompaso, Kode Pos 95693 Email : [email protected]

FORMAT PENGKAJIAN DATA DASAR SEWAKTU MASUK PUSKESMAS I.

II.

IDENTIFIKASI KLIEN Inisial nama : .................................................................................... Tempat/Tgl Lahir (umur) : .................................................................................... Jenis Kelamin : Laki-laki Perempuan Status Perkawinan : .................................................................................... Agama : .................................................................................... Kebangsaan/Suku : .................................................................................... Pendidikan : .................................................................................... Pekerjaan : .................................................................................... Alamat Rumah : .................................................................................... Dx. Medis : .................................................................................... DATA UMUM  Tgl..........Jam.......... Keluarga yang dapat dihubungi .............Telp ......................  Masuk di ruangan ............... dari rumah sendirian .......... dari rumah dengan keluarga ...... jalan ........ Jalan .......... Emergensi ........... lainnya  Alat yang digunakan : Kursi Rodan ....... brankard ........ ambulans  Alasan masuk rumah sakit/keluhan utama .................................................................................................................................................. .................................................................................................................................................. ..................  Riwayat Keluhan Utama .................................................................................................................................................. ..................................................................................................................................................  Faktor Pencetus .................................................................................................................................................. .........  Lamanya Keluhan...............................................................................................................................  Timbulnya keluhan : ( ) bertahap ( ) mendadak  Faktor yang memperberat ................................................................................................................  Upaya yang dilakukan untuk mengatasinya sendiri ..................................................................................................................................................  Riwayat Pengobatan sebelumnya Jenis Obat

III.

Dosis

Dosis Sebelumnya

KEADAAN UMUM A. Keadaan Sakit : Klien tampak sakit ringan / sedang / berat / tidak tampak sakit Alasan : Tak bereaksi / baring lemah / duduk / aktif / gelisah / posisi tubuh B. Tanda-Tanda Vital : 1. Kesadaan  Kualitatif : compos mentis Apatis

Frekuensi

IV.

 Kuantitatif : Skala coma glasgow : Respon motorik : - Respon verbal : - Respon membuka mata : 2. Tekanan Darah : ............ mmHg 3. Suhu : ........... °C 4. Nadi : ............ x/mnt (kuat/lemah; teratur/tidak) 5. Pernafasan : Frekuensi .............. x/mnt C. ANTROPOMETRI: 1. Lingkar lengan atas : ............. cm 2. Tinggi badan : ............. cm 3. Berat Badan : ............. kg PENGKAJIAN POLA FUNGSI KESEHATAN 1. PERSEPSI TERHADAP KESEHATAN MANAJEMEN KESEHATAN  Riwayat Penyakit yang dialami : ................................................................................................................................... ................................................................................................................................... ..................  Riwayat penggunaan Tembakau : Alkohol : Alergi (Obat / Makanan / lainnya ) Data Objektif Observasi Penapilan Umun Klien - Kebersihan Rambut : ..................................................... - Kulit Kepala : ..................................................... - Kebersihan Kulit : ..................................................... - Higiene rongga mulut : ..................................................... - Kebersihan Genitalia : ..................................................... - Kebersihan Anus : ..................................................... 2. NUTRISI METABOLIK A. Data Subjektif - Diet Kusus ......................................... - Anjuran diet sebelumnya ........................ ya ; ...................... tidak - Nafsu Makan : ............. normal ............meningkat ............. menurun ............ mual........... muntah : ........... stomatis - Perubahan BB dalam 6 bulan terakhir : ....... tidak; ........ ya ....... kg (naik/turun) - Kesulitan Menelan : ........ tidak, ........ ya B. Data Objektif  Pemeriksaan Fisik - Keadaan rambut ..................................................................................................... - Hidrasi kulit ............................................................................................................. - Kuku ....................................................................................................................... - Palpebrae .................................................Conjungtiva........................................... - Sclera ..................................................................................................................... - Hidung .................................................................................................................... - Rongga mulut ..........................................Gusi....................................................... - Gigi geligi ............................................... Gigi Palsu .............................................. - Kemampuan mengunyah ...................................................................................... - Lidah ......................................................... Tonsil .................................................. - Kelenjar getah bening leher .................................................................................... - Kelenjar parotis .......................................... Kelenjar thyroid ................................... - Abdomen Inspeksi : ......................................................................................................... Auskultasi : ......................................................................................................... Palpasi : .......................................................................................................... Kulit : ..........................................................................................................  Pemeriksaan Diagnostik : - Laboratorium : ......................................................................................................................................

...................................................................................................................................... ...................................................................................................................................... ..................................................................................................................................... 3. POLA ELIMINASI A. Data Subjektif a. Kebiasaan BAK - Normal ........... , Frekuensi ........... - Karakteristik Urine ..................................................................................................... - Masalah berkemih ..................................................................................................... b. Kebiasaan BAB …......................................................................................................... B. Data Objektif  Pemeriksaan Fisik - Peristaltik usus : ........... x/mnt - Palpasi suprapubika : Kandung kemih penuh kosong - Nyeri ketuk ginjal : Kiri : Negatif Positif Kanan : Negatif Positif 4. POLA AKTIVITAS DAN LATIHAN A. Observasi - Kemampuan perawatan diri Skor : 0= mandiri, 1= dibantu sebagian, 2= perlu bantuan orang lain, 3= perlu bantuan orang lain dan alat, 4= tergantung/tidak mampu Makan : Mandi : Berpakaian : Eliminasi : Mobilisasi di tempat tidur : 5. POLA ISTIRAHAT DAN TIDUR ..................................................................................................................................................... ....................................................................................................................................................