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JURUSAN KEPERAWATAN FAKULTAS KESEHATAN UNIVERSITAS TRIBHUWANA TUNGGADEWI

PENGKAJIAN DASAR KEPERAWATAN Nama Mahasiswa

:

Tempat Praktik

:

NIM

:

Tgl. Praktik

:

A. IdentitasKlien Nama

: ...................................................

No. RM

: ............................................

Usia

: ................tahun

Tgl. Masuk

: ............................................

Jeniskelamin

: ...................................................

Tgl. Pengkajian

: ............................................

Alamat

: ...................................................

Sumberinformasi

: ............................................

No. telepon

: ...................................................

Namaklg. dekatygbisadihubungi:.............................

Status pernikahan

: ...................................................

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

Agama

: ...................................................

Status

: ............................................

Suku

: ...................................................

Alamat

: ............................................

Pendidikan

: ...................................................

No. telepon

: ............................................

Pekerjaan

: ...................................................

Pendidikan

: ............................................

Lama berkerja

: ...................................................

Pekerjaan

: ............................................

B. Status kesehatanSaatIni

1. Keluhan Utama a. Saat MRS

:......... ................................................................................................... .....……………………………………………............................................ ........... ..............................................................................................

....

.…………………………………………………………………………… …. b. Saat Pengkajian

: ............................... .……………………………………………………………………….. ..............................................................................................................

……………………………………………………………………………….. .………………………………………………………………………………. ................................................................................................................ 2. Riwayat Kesehatan Saat ini ................................................................ ……………………………………………………………………………….. ................................................................. ………………………………………………………………………………. ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... .........................................................................................................................................................................................

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

C. RiwayatKesehatanTerdahulu

1. Penyakitygpernahdialami: a. Kecelakaan (jenis&waktu)

: ....................................................................................................................

b. Operasi (jenis&waktu)

: ....................................................................................................................

c. Penyakit:  Kronis

: ...................................................................................................................................................

 Akut

: ...................................................................................................................................................

d. Terakhirmasuki RS

: ....................................................................................................................

2. Alergi (obat, makanan, plester, dll): Tipe ...............................................................

Reaksi ........................................................

Tindakan ...................................................

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

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

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

3. Imunisasi: ( ) BCG ( ) Polio ( ) DPT

( ) Hepatitis ( ) Campak ( ) .....................

4. Kebiasaan: Jenis Merokok

Frekuensi ..........................................

Jumlah .................................................

Lamanya ........................................

Kopi

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

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

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

Alkohol

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

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

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

5. Obat-obatanygdigunakan: Jenis ...............................................................

Lamanya ........................................................

Dosis ...................................................

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

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

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

D. RiwayatKeluarga ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... . ........................................................................................................................................................................................ . ........................................................................................................................................................................................ GENOGRAM

E. RiwayatLingkungan Jenis  Kebersihan

Rumah ...................................................................

Pekerjaan ..........................................................

 Bahayakecelakaan

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

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

 Polusi

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

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

 Ventilasi

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

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

 Pencahayaan

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

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

F. PolaAktifitas-Latihan  Makan/minum

Rumah ...............................................................

RumahSakit ......................................................

 Mandi

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

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

 Berpakaian/berdandan

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

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

 Toileting

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

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

 Mobilitas di tempattidur

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

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

 Berpindah

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

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

 Berjalan

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

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

 Naiktangga

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

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

PemberianSkor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang lain, 4 = tidakmampu G. PolaNutrisiMetabolik  Jenisdiit/makanan

Rumah ........................................................

RumahSakit ...................................................

 Frekuensi/pola

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

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

 Porsiygdihabiskan

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

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

 Komposisi menu

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

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

 Pantangan

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

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

 Napsumakan

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

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

 Fluktuasi BB 6 bln. terakhir

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

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

 Jenisminuman

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

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

 Frekuensi/polaminum

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

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

 Gelasygdihabiskan

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

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

 Sukarmenelan (padat/cair)

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

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

 Pemakaiangigipalsu (area)

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

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

 Riw. masalahpenyembuhanluka

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

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

H. PolaEliminasi Rumah

RumahSakit

 BAB: - Frekuensi/pola

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

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

- Konsistensi

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

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

- Warna&bau

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

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

- Kesulitan

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

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

- Upayamengatasi

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

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

- Frekuensi/pola

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

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

- Warna&bau

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

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

- Kesulitan

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

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

- Upayamengatasi

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

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

 BAK:

I. PolaTidur-Istirahat  Tidursiang:Lamanya

Rumah ........................................................

RumahSakit ......................................................

- Jam …s/d…

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

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

- Kenyamananstlh. tidur

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

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

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

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

- Jam …s/d…

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

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

- Kenyamananstlh. tidur

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

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

- Kebiasaansblm. tidur

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

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

- Kesulitan

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

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

- Upayamengatasi

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

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

 Tidurmalam: Lamanya

J. PolaKebersihanDiri Rumah ............................................................

RumahSakit ...................................................

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

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

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

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

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

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

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

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

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

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

 Gantibaju:Frekuensi

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

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

 Memotong kuku: Frekuensi

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

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

 Kesulitan

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

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

 Upayaygdilakukan

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

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

 Mandi:Frekuensi - Penggunaansabun  Keramas: Frekuensi - Penggunaan shampoo  Gosokgigi: Frekuensi - Penggunaan pasta gigi

K. PolaToleransi-KopingStres

1. Pengambilankeputusan:

( ) sendiri

( ) dibantu orang lain, sebutkan, ...............................................................

2. Masalahutamaterkaitdenganperawatan di RS ataupenyakit (biaya, perawatandiri, dll): ............................................ ……………………………………………………………………………………………………………

3. Yang biasadilakukanapabila stress/mengalamimasalah: ............................................................................................ 4. Harapansetelahmenjalaniperawatan: .......................................................................................................................... 5. Perubahan yang dirasa setelah sakit: .......................................................................................................................... L. KonsepDiri

1. Gambarandiri: ............................................................................................................................................................

2. Ideal diri:.................................................................................................................................................................... 3. Hargadiri: ................................................................................................................................................................... 4. Peran: 5. Identitasdiri ................................................................................................................................................................ M. PolaPeran&Hubungan

1. Perandalamkeluarga ................................................................................................................................................... 2. Sistem pendukung:suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain, sebutkan: ...................................... ......................................................................................................................................................

3. Kesulitan dalam keluarga:

( ) Hub. dengan orang tua

( ) Hub.dengan pasangan

( ) Hub. dengan sanak saudara

( ) Hub.dengan anak

( ) Lain-lain sebutkan, ......................................................................................

4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS: ........................................................... ...................................................................................................................................................................................

5. Upaya yg dilakukan untuk mengatasi: ....................................................................................................................... N. PolaKomunikasi

1. Bicara:

( ) Normal

( )Bahasautama: ..........................................

( ) Tidakjelas

( ) Bahasadaerah: ........................................

( ) Bicaraberputar-putar

( ) Rentangperhatian: ..................................

( ) Mampumengertipembicaraan orang lain(

) Afek: ..........................................................

2. Tempattinggal:

( ) Sendiri

(

) Kos/asrama

(

) Bersama orang lain, yaitu: ................................................................................................

3. Kehidupankeluarga a. Adatistiadatygdianut: ........................................................................................................................................... b. Pantangan& agama ygdianut:............................................................................................................................... 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

O. PolaSeksualitas

1. Masalahdalamhubungan seksual selama sakit: ( ) tidak ada

( ) ada

2. Upaya yang dilakukanpasangan: ( ) perhatian

( ) sentuhan

( ) lain-lain, seperti, .....................................................................

P. PolaNilai&Kepercayaan

1. ApakahTuhan, agama, kepercayaanpentinguntukAnda, Ya/Tidak 2. Kegiatan agama/kepercayaanygdilakukandirumah (jenis&frekuensi): ...................................................................... ...................................................................................................................................................................................

3. Kegiatan agama/kepercayaantidakdapatdilakukan di RS: ......................................................................................... 4. Harapanklienterhadapperawatuntukmelaksanakanibadahnya: ...................................................................................

Q. PemeriksaanFisik

1. KeadaanUmum: ......................................................................................................................................................... ................................................................................................................................................................................... . ..................................................................................................................................................................................

 Kesadaran: ............................................................................................................................................................  Tanda-tanda vital:

- Tekanandarah :……… mmHg - Nadi

:……...x/menit

 Tinggibadan: .................................................. cm

- Suhu :………oC - RR

:……… x/menit

BeratBadan: ....................................kg

2. Kepala&Leher a. Kepala: ............................................................................................................................................................. b. Mata: ............................................................................................................................................................. c. Hidung: ............................................................................................................................................................. d. Mulut&tenggorokan: ............................................................................................................................................................. e. Telinga: ............................................................................................................................................................. f. Leher: .............................................................................................................................................................

3. Thorak& Dada:  Jantung - Inspeksi:.......................................................................................................................................................... - Palpasi: ........................................................................................................................................................... - Perkusi: ........................................................................................................................................................... - Auskultasi: ......................................................................................................................................................

 Paru - Inspeksi:.......................................................................................................................................................... - Palpasi: ........................................................................................................................................................... - Perkusi: ........................................................................................................................................................... - Auskultasi: ......................................................................................................................................................

4. Payudara&Ketiak .........................................................................................................................................................................

5. Punggung&TulangBelakang .........................................................................................................................................................................

6. Abdomen  Inspeksi: ............................................................................................................................................................... .............................................................................................................................................................................

 Palpasi: .................................................................................................................................................................

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

 Perkusi: ................................................................................................................................................................ .............................................................................................................................................................................

 Auskultasi: ........................................................................................................................................................... .............................................................................................................................................................................

7. Genetalia& Anus  Inspeksi: ............................................................................................................................................................... ............................................................................................................................................................................. .............................................................................................................................................................................

 Palpasi: ................................................................................................................................................................. 8. Ekstermitas  Atas: ..................................................................................................................................................................... ............................................................................................................................................................................. .............................................................................................................................................................................

 Bawah: ................................................................................................................................................................. ............................................................................................................................................................................. .............................................................................................................................................................................

9. SistemNeurologi ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. ............................................................................................................................................................................. 10. Kulit& Kuku

 Kulit: ................................................................................................................................................................... ………………………………………………………………………………………………………... ………………………………………………………………………………………………………...

 Kuku: ………………………………………………………………………………………………… …………………………………………………………………………………..……………………. ………………………………………………………………………………………………………… R. HasilPemeriksaanPenunjang ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... .........................................................................................................................................................................................

......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... S. Terapi ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... T. PersepsiKlienTerhadapPenyakitnya ......................................................................................................................................................................................... .........................................................................................................................................................................................

2. Analisa Data A. ANALISA DATA NamaPasien

:

Umur

:

No. Register

:

DATA PENUNJANG

ETIOLOGI

MASALAH KEPERAWATAN

B. DIAGNOSA KEPERAWATAN DAFTAR DIAGNOSA KEPERAWATAN BERDASARKAN PRIORITAS No

DiagnosaKeperawatan

TanggalDitemukan

TanggalTeratasi

C. PERENCANAAN RENCANA ASUHAN KEPERAWATAN

DiagnosaKeperawatan No.

Tujuan

KriteriaHasil

NOC No.

KeteranganPenilaian : 1 :idaksesuai 2 :g tidaksesuai 3 :adangtidaksesuai 4 :angtidaksesuai 5 :esuai Intervensi NIC

Indikator

1

2

3

4

5

2. Tujuan, KriteriaStandar, Interensi, Rasional

IMPLEMENTASI NamaKlien

:

TanggalPengkajian

No Reg

:

DiagnosaMedis :

:

TTD &NamaTerang Tgl

No. Dx. Kep.

Jam

TindakanKeperawatan

ResponKlien

D. PELAKSANAAN CATATAN PERKEMBANGAN (PROGRESS NOTE)

DiagnosaKeperawatan No. NOC : No.

Indikator

TanggalObservasidanHasil

1

KeteranganPenilaian : -

: tidaksesuai

+

: sesuai yang diharapkan

S

: Skoring

KeteranganSkoring : 1:2 : 1+ 3 : 2+ 4 : 3+ 5 : 4+

2

3

4

S

1

2

3

4

S

1

2

3

4

S

E. EVALUASI EVALUASI

Hari/Tanggal Jam

No. DxKep

Evaluasi

TTD

RESUME KEPERAWATAN NAMA KLIEN : NO. REG :

S

TANGGAL DX. MEDIS

O

A

: :

P

I

E