Pengkajian Dasar Keperawatan Msn

8/18/2019 Pengkajian Dasar Keperawatan Msn

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PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Tempat Praktik :

NIM : Tgl. Praktik :

A.Identitas Klien

Nama :..................................... No. RM :....................................

Usia :........... Tgl. Masuk :....................................

Jenis kelamin :..................................... Tgl. Pengkajian :....................................

Alamat :..................................... Sumber inormasi...................................:

No. telepon :..................................... Nama klg. !ekat "g bisa !ihubungi:.......

Status pernikahan : ...................................

Agama :..................................... Status :....................................

Suku : .................................... Alamat :....................................

Pen!i!ikan :..................................... No. telepon :....................................Pekerjaan :..................................... Pen!i!ikan :....................................

#ama berkerja :..................................... Pekerjaan :....................................

B.Status kesehatan Saat Ini

1. $eluhan utama :

2. #ama keluhan :...................................................................................................

3. $ualitas keluhan :...................................................................................................

4. %aktor pen&etus :...................................................................................................

5. %aktor pemberat :...................................................................................................

6. Upa"a "g. telah !ilakukan.............................................................................................. :

7. 'iagnosa me!is :

a. .......................................................................... Tanggal..................................

b. .......................................................................... Tanggal..................................

&. .......................................................................... Tanggal..................................

C.Riwayat Kesehatan Saat Ini

D.Riwayat Kesehatan Terdahulu



1. Pen"akit "g pernah !ialami:

a. $e&elakaan (jenis ) waktu* :...............................................................................

b. +perasi (jenis ) waktu* :...............................................................................

&. Pen"akit:

• $ronis :..................................................................................................

• Akut :..................................................................................................

!. Terakhir masuki RS :..................................................................................................

2. Alergi (obat, makanan, plester, !ll*:

3. Imunisasi:

( * -/ ( * 0epatitis

( * Polio ( * ampak

( * 'PT ( * ...............

4. $ebiasaan:

Jenis %rekuensi Jumlah #aman"a

Merokok .............................. .................................... ....................................

$opi .............................. .................................... ....................................

Alkohol .............................. .................................... ....................................

5. +bat1obatan "g !igunakan:

E. Riwayat Keluara

/2N+/RAM

!. Riwayat "inkunan

Jenis Rumah Pekerjaan

• $ebersihan bersih, rumah !isapu 34 sehari ............................&ukup bersih

• -aha"a ke&elakaan ti!ak a!a tangga5lantai li&in.. .. ter!apat lantai li&in !ari genangan

air

• Polusi jauh !ari pabrik !an jalan ra"a &ukup, !itengah kota...............



• 6entilasi &ukup....................................... baik, !itempat terbuka............

• Pen&aha"aan baik, siang hari tanpa lampu.. . baik..........................................

G.P#la Akti$tas%"atihan

Rumah Rumah Sakit

•

Makan5minum 7............................................ 3............................................• Man!i 7............................................ 8............................................

• -erpakaian5ber!an!an 7............................................ 3............................................

• Toileting 7............................................ 8............................................

• Mobilitas !i tempat ti!ur 7............................................ 9

• -erpin!ah .............................................. 9............................................

• -erjalan .............................................. 9............................................

•Naik tangga 7............................................ 9............................................Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain, 3 = dibantu orang

lain, 4 = tidak mampu

&.P#la Nutrisi 'eta(#lik

Rumah Rumah Sakit

• Jenis !iit5makanan pa!at................................ pa!at..................................

• %rekuensi5pola 8194 sehari....................... 84 sehari.............................

• Porsi "g !ihabiskan porsi.............................. porsi................................

• $omposisi menu nasi, sa"ur, lauk, buah..... nasi, sa"r, lauk, buah..........

• Pantangan ti!ak a!a.......................... ti!ak a!a.............................

• Napsu makan baik.................................. menurun.............................

• %luktuasi -- ; bln. terakhir sebelum MRS <= kg.......... saat MRS <7kg....................

• Jenis minuman air putih !an jus............... air putih, susu, we!ang jahe

• %rekuensi5pola minum sering............................... sering.................................

• /elas "g !ihabiskan >17 gelas........................ <1; gelas.............................

• Sukar menelan (pa!at5&air* ti!ak a!a.......................... ti!ak a!a.............................

• Pemakaian gigi palsu (area* ti!ak a!a.......................... ti!ak a!a.............................

• Riw. masalah pen"embuhan luka.......................ti!ak a!a .............................ti!ak a!a

I. P#la Eli)inasi

Rumah Rumah Sakit

• -A-:

- %rekuensi5pola 4 sehari............................... 34 sehari.............................

- $onsistensi lembek.................................. pa!at...................................

- ?arna ) bau kuning ke&oklatan, bau khas eses......................................

ke&oklatan, bau khas eses.. .



- $esulitan ti!ak a!a............................... ti!ak a!a.............................

- Upa"a mengatasi ti!ak a!a............................... ti!ak a!a.............................

• -A$:

- %rekuensi5pola <1;4 sehari............................ 8194 sehari..........................

- $onsistensi &air........................................ &air......................................

-?arna ) bau kuning jernih, bau khas urin.. kuning jernih, bau khas urin

- $esulitan ti!ak a!a............................... ti!ak a!a.............................

- Upa"a mengatasi ti!ak a!a............................... ti!ak a!a.............................

-

J. P#la Tidur%Istirahat

Rumah Rumah Sakit

• Ti!ur siang:#aman"a 3 jam................................ jam.....................................

- Jam @s5!@ 3.7719.77..................... 3.7718.77.........................

- $en"amanan stlh. ti!ur n"aman........................... n"aman...............................

• Ti!ur malam: #aman"a jam................................ 9 jam.....................................

- Jam @s5!@ 38.7717;.77..................... 77.77179.77.........................

- $en"amanan stlh. ti!ur n"aman........................... ti!ak n"aman, sering terbangun

- $ebiasaan sblm. ti!ur merokok.......................... ti!ak a!a.............................

- $esulitan ti!ak a!a......................... terasa n"eri.........................

-Upa"a mengatasi ti!ak a!a......................... ti!ak a!a.............................

K.P#la Ke(ersihan Diri

Rumah Rumah Sakit

• Man!i:%rekuensi 34 sehari............................. 34 seminggu, setiap hari

!iseka

- Penggunaan sabun menggunakan sabun......... menggunakan sabun.........

• $eramas: %rekuensi 84 seminggu....................... 34 seminggu.......................

- Penggunaan shampoo menguunakan sampo........ menggunakan sampo........

• /ososok gigi: %rekuensi 34 sehari............................. 4 sehari.............................

- Penggunaan o!ol menggunakan o!ol............ menggunakan o!ol............

• /anti baju:%rekuensi 34 sehari............................. ti!ak menggunakan baju... .

• Memotong kuku: %rekuensi 4 seminggu....................... belum memotong kuku.......

• $esulitan ti!ak a!a............................. ti!ak !apat melakukan man!iri

• Upa"a "g !ilakukan ti!ak a!a............................. !ibantu perawat.................

". P#la T#leransi%K#*in Stres

1. Pengambilan keputusan: ( * sen!iri ( * !ibantu orang lain, sebutkan,....................



2. Masalah utama terkait !engan perawatan !i RS atau pen"akit (bia"a, perawatan !iri,

!ll*:

3. Bang biasa !ilakukan apabila stress5mengalami masalah:...............................................

4. 0arapan setelah menjalani perawatan:............................................................................

5. Perubahan "ang !irasa setelah sakit ...............................................................................

'. K#nse* Diri

1. /ambaran !iri:..................................................................................................................

2. I!eal !iri:..........................................................................................................................

3. 0arga !iri:.........................................................................................................................

4. Peran:...............................................................................................................................

5. I!entitas !iri:....................................................................................................................

N.P#la Peran + &u(unan

1. Peran !alam keluarga.......................................................................................................

2. Sistem pen!ukung:suami5istri5anak5tetangga5teman5sau!ara5ti!ak a!a5lain1lain,sebutkan:

3. $esulitan !alam keluarga:

( *0ub. !engan orang tua ( * 0ub.!engan pasangan

( * 0ub. !engan sanak sau!ara ( * 0ub.!engan anak

( * #ain1lain sebutkan,.................................................

4. Masalah tentang peran5hubungan !engan keluarga selama perawatan !i RS:................

5. Upa"a "g !ilakukan untuk mengatasi:..............................................................................

,.P#la K#)unikasi

1. -i&ara: ( * Normal ( *-ahasa utama:..............................

( * Ti!ak jelas ( *-ahasa !aerah:...........................

( * -i&ara berputar1putar ( *Rentang perhatian:......................

( * Mampu mengerti pembi&araan orang lain(.......................................... *

Aek:

2. Tempat tinggal: ( * Sen!iri

( *$os5asrama

( *-ersama orang lain, "aitu:............................................................

3. $ehi!upan keluarga

a. A!at istia!at "g !ianut: Jawa......................................................................................

b. Pantangan ) agama "g !ianut: Pantangan !alam agama islam................................

&. Penghasilan keluarga: ( * C Rp. 3<7.777 ( * Rp. juta D

.< juta

( * Rp. 3<7.777 D <77.777..........( *

Rp. .< juta D 3 juta

( * Rp. <77.777 D juta..............( *

E 3 juta

P. P#la Seksualitas



$lien belum menikah

-.P#la Nilai + Ke*erayaan

1. Apakah Tuhan, agama, keper&a"aan penting untuk An!a, Ba5Ti!ak

2. $egiatan agama5keper&a"aan "g !ilakukan !irumah (jenis ) rekuensi*:.......................

3. $egiatan agama5keper&a"aan ti!ak !apat !ilakukan !i RS: ............................................

4. 0arapan klien terha!ap perawat untuk melaksanakan iba!ahn"a:..................................

R.Pe)eriksaan !isik

1. $ea!aan Umum:...............................................................................................................

• $esa!aran:....................................................................................................................

• Tan!a1tan!a Fital:

• Tinggi ba!an: ................................. -erat -a!an:...................kg

2. $epala ) #eher

a. $epala:

b. Mata:

&. 0i!ung:

!. Mulut ) tenggorokan:

e. Telinga:

. #eher:

3. Thorak ) 'a!a:

• Jantung



• Paru

4. Pa"u!ara ) $etiak

5. Punggung ) Tulang -elakang

6. Ab!omen

7. /enetalia ) Anus

8. 2kstermitas

9. Sistem Neorologi

10. $ulit ) $uku

S. &asil Pe)eriksaan Penun/an

T. Tera*i



0.Perse*si Klien Terhada* Penyakitnya

1. Kesi)*ulan

W. Perenanaan Pulan

• Tujuan pulang: .................................................................................................................

• Transportasi pulang:.........................................................................................................

• 'ukungan keluarga:..........................................................................................................

• Antisipasi bantuan bia"a setelah pulang..........................................................................

• Antisipasi masalah perawatan !iri setalah pulang:..........................................................

• Pengobatan:.....................................................................................................................

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

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

• Rawat jalan ke:.................................................................................................................

...................................................................................................................................• 0al1hal "ang perlu !iperhatikan !i rumah:.....................................................................

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

• $eterangan lain:...............................................................................................................

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Pengkajian Dasar Keperawatan Msn