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Format Pengkajian Kep.dewasa i

Format Pengkajian Kep.dewasa i

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Published by Leiya Luu

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Categories:Types, School Work
Published by: Leiya Luu on Sep 26, 2011
Copyright:Attribution Non-commercial

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11/22/2012

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PENGKAJIANKEPERAWATAN DEWASA ISTIKES A.YANI YOGYAKARTA
Nama Mahasiswa
:……………………..
 NPM
:……………………..
 INFORMASI UMUM
Nam
a……………………………………………Usia………………………………………….tanggal Lahir…………………………………….Jenis Kelamin……………………………….
 
Suku Bangsa…………………………………….
Tanggal
Masuk……………………………...
 
Waktu……………………………………………Dari…………………………………………
 Sumber Informasi
………………………………..
 
AKTIVITAS / ISTIRAHAT
 
Gejala (Subjektif)
Pekerjaan…….............................
.....................Aktivitas/hobi
………...………………………
..Aktivitas di
waktu luang…………………
 
Perasaan Bosan/tidak puas :……………………………………………………………………
 
Keterbatasan karena kondisi :…………………………………………………………………..
 
Tidur Jam………………………Tidur siang :……………………….Kebiasaan tidur….…….
 
Insomnia……………………….Berhubungan dengan…………………………………………
 Rasa Segar Saat
Bangun…………………………
 Lain-
lain………………………………………………………………………………………...
 
Tanda (objektif)
Respon terhadap aktivitas yang teratasi :
Kardivaskuler…………………………………………………………………………………...
 
Pernafasan………………………………………………………………………………………
 Status mental
……………………………………………………………………………………
 
Pengkajian neouskuler…………………………………………………………………………..
 
Massa/tonus otot :………………………………………………………………………………
 
 
Postur :…………………………………………Tremor :……………………………………...
 
Rentan gerak :………………………………….Kekuatan :……………………………………
 
Deformitas :……………………………………………………………………………………..
 
SIRKULASI
 
Gejala (subjektif)
Riwayat TentangHipertensi
:………………………………………………..
 
Masalah jantung :………..………………………………………
 
Demam rematik :…………………………………..Edema mata/kaki :………………………..
 
Flebitis :……………………………………………Penyembuhan lambat
 
:…………………...
 
Ekstermitas : Kesemutan :………………………...Kebas :…………………………………….
 
Batuk/hemoptisis………………………………………………………………………………..
 
Perubahan frekuensi/jumlah urine :……………………………………………………………..
 
Tanda (Objektif)
 
TD :Ka. Dan. Ki : baring/duduk/berdiri :……………………………………………………….
 
 Nadi :………………………………….
 
Jantung :………………………………
 
Bunyi Jantung : Frekuensi :………………Irama :…………………..Kualitas :………………
 
Friksi gesek :……………………………..Murmur :…………………………………………..
 
Bunyi Nafas :………………………….
 
Desiran vaskuler :……………………….Distensi vena jugularis……………………………
..
Ekstermitas : suhu :…………………….Warna :………………………………………………
 
Tanda Roman’s :………………………..Varises :…………………………………………….
 
Abnormalitas kuku :…………………………………………………………………………….
 
Penyebaran /Kualitas rambut :………………………………………………………………….
 
Warna :………………………………..Membran mukosa :………………bibir :……………..
 
Punggung kuku :………………………Konjungtiva :…………………....Sklera :……………
 
Deforesis :………………………………………………………………………………………
 
 
INEGRITAS EGO
 
Gejala (Subjektif)
Factor stress :……………………………………………………………………………………
 
Cara Mengatasi stress :………………………………………………………………………….
 Maslah-
masalah financial :……………………………………………………………………..
 
Status hubungan :……………………………………………………………………………….
 Factor-
faktor Budaya :………………………………………………………………………….
 
Agama :……………………………………..Kegiatan keagamaan :…………………………
..
Gaya hidup :………………………………..
Perubahan t
erahir :………………………………
 Perasaan
 –perasaan : Ketidakberdayaan :………………………................................................
 
Keputusasaan :…………………………………………………………………………..
 
Tanda (Objektif)
Status emosional
Tenang :……………………….Cemas :.…………………………Marah :……………………
 
Menarik Diri :……………........Takut :…………………………
 
Mudah Tersinggung ;……………………Tidak Sabar :……………………………………….
 
Euforik :…………………………………………………………………………………………
 Respon-
respon fisiologik yang terobservasi :…………………………………………………..
 
ELIMINASI
 
Gejala (Subjektif)
Pola BAB :………………………………Penggunaan laktasif :……………………………….
 
Karakter feses :…………………………..BAB terahir :……………………………………….
 
Riwayat Perdarahan :……………………hemoroid :………………………………………….
 
Konstipasi :………………………………Diare :………………………………………………
 
Pola BAK :………………………………Inkontimensia/kapan :………………………………
 
Dorongan :………………………..Frekuensi :…………………………Retensi :……………..
 
Karakter urine :………………………………………………………………………………….
 
 Nyeri/rasa terbakar/kesulitan BAK :……………………………………………………………
 
Riwayat penyakit ginjal/kandung kemih :………………………………………………………
 

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