You are on page 1of 10

JURUSAN KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Tempat Praktik :
NIM : Tgl. Praktik :

A. Identitas Klien
Nama : Ny. N................................ No. RM :.........................................
Usia : 23........ tahun Tgl. Masuk :.........................................
Jenis kelamin : perempuan ...................... Tgl. Pengkajian :.........................................
Alamat :.......................................... Sumber informasi :.........................................
No. telepon :.......................................... Nama klg. dekat yg bisa dihubungi:................
Status pernikahan : menikah............................ ..........................................
Agama :.......................................... Status :.........................................
Suku :.......................................... Alamat :.........................................
Pendidikan :.......................................... No. telepon :.........................................
Pekerjaan :.......................................... Pendidikan :.........................................
Lama berkerja :.......................................... Pekerjaan :.........................................

B. Status kesehatan Saat Ini
1. Keluhan utama : nyeri di area kemaluan karena benjolan, nyeri bertambah
jika dipakai duduk
2. Lama keluhan : 2 minggu yang lalu...................................................................................
3. Kualitas keluhan : nyeri pada skala 7....................................................................................
4. Faktor pencetus : .................................................................................................................
5. Faktor pemberat : .................................................................................................................
6. Upaya yg. telah dilakukan
7. Keluhan saat pengkajian : ..................................................................................................
8. Diagnosa medis :
a. .................................................................................... Tanggal.......................................
b. .................................................................................... Tanggal.......................................
c. .................................................................................... Tanggal.......................................

1

.............................................. Kecelakaan (jenis & waktu) :.................................................................................................................................................... ................................ ........................................................ c................................................ b........................... 2 ....... Kebiasaan: Jenis Frekuensi Jumlah Lamanya Merokok .... ........................................................................... ............. Riwayat Kehamilan : G2P1001Ab000 D........................................................................................ …………………………………………………………………………………………………………..Penyakit yg pernah dialami: a.Alergi (obat.. Imunisasi: ( ) BCG ( ) Hepatitis ( ) Polio ( ) Campak ( ) DPT ( ) ...................... 3.................................................................................................................................................................................. .................................................................... 4......................... 2.... Benjolan timbul sejak 2 minggu yang lalu dan sekarang sudah sebesar kelereng...... ............ Penyakit:  Kronis :........................ Riwayat Kesehatan Saat Ini nyeri di area kemaluan karena benjolan............... ..........................C.... ................................................................... Kopi ............ plester.............................................. dll): Tipe Reaksi Tindakan ........ Operasi (jenis & waktu) :...................................................... ............................... ...................................................................................................................................... d............................................................................................................................................................................................................................................................................  Akut :...........................Riwayat Kesehatan Terdahulu 1.......... .............................................................................................. nyeri bertambah jika dipakai duduk.................................................................................. makanan........................................................ ................ ........................................................................................ Terakhir masuki RS :................................ ................................................. ............................................. ......................................................................... ..................................................

............. .............. ..................................................... ......................................... ................................................................................. E................................................................................................................................................................................................................................................. ...............................................................................  Toileting .................. .......................................................................... ......................................................................  Pencahayaan ............ . ................................................. ........................................ F........... .......................................................................................... G....................... ..................................................................................................................................................... .......................... ...... 3 ........................................................................................................................................................................................................................ ............................................. ......... ...................................................................................................................................................................... ........................ .........................................................Riwayat Lingkungan Jenis Rumah Pekerjaan  Kebersihan .................................................................Pola Aktifitas-Latihan Rumah Rumah Sakit  Makan/minum ...... 5................................................................................................................................. ........................................................................  Polusi .................................................................................................................... .......................................................................  Mandi ............................................. ..............................................................................  Berpindah ...................................................................................................................... ................  Mobilitas di tempat tidur ............... ..............................................................................................................  Ventilasi ..... .....................................................................  Berpakaian/berdandan .....  Naik tangga ..................................... ................................................................................... Obat-obatan yg digunakan: Jenis Lamanya Dosis ...............................................................................................................................Riwayat Keluarga ............... ....................................................  Bahaya kecelakaan ............................ ................................... Alkohol ...........................................................  Berjalan ................................................... ........................................................ ............................... ..........................

.................................Frekuensi/pola ......................................... ....................................................................................... I........................................................................ ............... .... ................................................................................................................................ terakhir ........Konsistensi ........................................Konsistensi ......... 4 = tidak mampu H...................................... .................Kesulitan .............................................  Frekuensi/pola .......... .................................................................................. ..... .................................................... ............................. J.......... .....................................................................  Sukar menelan (padat/cair) ......................................Kesulitan ......................... ............................ ..... ................................. 1 = alat bantu..........Warna & bau ...................... .................. ................................  Riw........................... ................................................... ............................. .................................Pola Tidur-Istirahat 4 ......... ............................................................................  BAK: ......... 2 = dibantu orang lain partial............... .......................................................................................................................................... .............. ..................................................... ........................................................ masalah penyembuhan luka ................................. .........................................................................Warna & bau .......................................................................................... ..................................................  Napsu makan ........Upaya mengatasi ..........................Frekuensi/pola ........................................  Fluktuasi BB 6 bln............... ................... .................................... .......... .......  Pantangan ..........................................................................  Jenis minuman ........Pola Nutrisi Metabolik Rumah Rumah Sakit  Jenis diit/makanan ........................................................................Upaya mengatasi ....  Gelas yg dihabiskan ..................... .......................Pola Eliminasi Rumah Rumah Sakit  BAB: ..................  Komposisi menu .......................... Pemberian Skor: 0 = mandiri.........  Porsi yg dihabiskan ...............  Pemakaian gigi palsu (area) .... 3 = dibantu orang lain total............................. ..................................  Frekuensi/pola minum ......

.......... ....................................... perawatan diri.......................Kebiasaan sblm.............. ........................................................................................................ Harapan setelah menjalani perawatan:............................................... .................Kesulitan ........... Rumah Rumah Sakit  Tidur siang:Lamanya .......... 5........................................................................... Perubahan yang dirasa setelah sakit:........................Upaya mengatasi ................................................................... K............................ 5 .............................  Kesulitan .......................................................................................... tidur ...... ..................................... L.................................................................. Pola Kebersihan Diri Rumah Rumah Sakit  Mandi:Frekuensi ............................................................... ................. . ...... ... ........  Tidur malam: Lamanya ............................................................................. 2....................................................................... sebutkan.....Kenyamanan stlh....... ... Pengambilan keputusan: ( ) sendiri ( ) dibantu orang lain...................................................................................................... Gambaran diri : ............................................... ...............Penggunaan sabun ........ . tidur .............  Gosok gigi: Frekuensi ....................................................................................  Memotong kuku: Frekuensi ............................................................. .. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya............................ ............. .................................... .......................... ..................... ................................................................................................................................................Penggunaan shampoo ......................... .....................Pola Toleransi-Koping Stres 1..................................................... ......................... ...................Jam …s/d… .....................................  Ganti baju:Frekuensi ............................................................................................Jam …s/d… .....................................................................................  Upaya yg dilakukan ..........Kenyamanan stlh............... .... ........................................................................................................... Konpep Diri 1...................... ..................  Keramas: Frekuensi ...... ................. M.................................. tidur ........ ............... dll): …………………………………………………………………………………………… 3.... ...................... Ideal diri : . 4............................... .............. Yang biasa dilakukan apabila stress/mengalami masalah:......................................................................................... 2............................Penggunaan odol ......

................ 4...dengan pasangan ( ) Hub.. ( ) Bicara berputar-putar ( ) Rentang perhatian:.......................................................... Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS:....................................... Penghasilan keluarga: ( ) < Rp..... Tempat tinggal: ( ) Sendiri ( ) Kos/asrama ( ) Bersama orang lain..............000 ( ) Rp.......... Identitas diri :.....................000 – 1 juta ( ) > 2 juta P............................................................................................................ c..... b... 500............................... 3.............................. Masalah dalam hubungan seksual selama sakit: ( ) tidak ada ( ) ada 2....dengan anak ( ) Lain-lain sebutkan. Adat istiadat yg dianut:.................................................. ........ sebutkan:.. 250............... Bicara: ( ) Normal ( )Bahasa utama:.............. 1 juta – 1... 1........... ( ) Mampu mengerti pembicaraan orang lain( ) Afek:..................................................................................Pola Peran & Hubungan 1............................ O.........................................................................000 ( ) Rp.................................................................... Kesulitan dalam keluarga: ( ) Hub............................ Kehidupan keluarga a................................................ 6 ....... 250..................................................................................... N........... Sistem pendukung:suami/istri/anak/tetangga/teman/saudara/tidak ada/lain-lain............. 4..............................000 – 500...................................... Pantangan & agama yg dianut:......... dengan sanak saudara( ) Hub.............................................. Upaya yg dilakukan untuk mengatasi:............................................................. dengan orang tua ( )Hub........................... Peran dalam keluarga.........................Pola Seksualitas 1............... 3...Pola Komunikasi 1................ 5.. Upaya yang dilakukan pasangan: ( ) perhatian ( ) sentuhan ( ) lain-lain............ 2....................... Peran : .3................................................................... seperti..... 2..............................................................................5 juta – 2 juta ( ) Rp....................... .................................... 5................................ yaitu:.......................................................................... Harga diri : .......... ( ) Tidak jelas ( ) Bahasa daerah:...............................................5 juta ( ) Rp.......

. Sinus …………… Riw.. Alergi ……… Cara mengatasinya …………………………….. Frekuensi ………................ Mata : Bentuk Konjungtiva Pupil : ( ) reaksi terhadap cahaya ( ) isokor ( )Miosis ( ) Pin point ( ) Midriasis Tanda-tanda radang : Funsi penglihatan : ( ) Baik ( ) Kabur Penggunaan alat bantu : ( ) Ya ( ) Tidak Apabila ya menggunakan : ( ) Kaca mata ( ) Lensa kontak ( ) Minus….. Penyakit yg pernah terjadi ……………………………………………... e.......... Upaya untuk mengatasi…………………………………………… 3.......... 3... Kegiatan agama/kepercayaan yg dilakukan dirumah (jenis & frekuensi):.. Harapan klien terhadap perawat untuk melaksanakan ibadahnya:.. Masalah yg pernah terjadi………………………………………… Upaya untuk mengatasi………………………………………………... f.. Keadaan umum : a...... Cara mengatasi ………………………………… d........ Leher : Kekakuan………………..Nadi : 85x/menit Pernafasan : 18x/menit .... Tanda-tanda vital : . 4. Kegiatan agama/kepercayaan tidak dapat dilakukan di RS:.. Riwayat Operasi :……………………………………………………… c..... Fs............ Gangguan bicara ……… Pemeriksaan gigi terakhir …………………………………………….. R.Nyeri/Nyeri tekan………………………… Benjolan/massa……………Keterbatasan gerak……………………..DJJ : 145x/menit c... Apakah Tuhan. Mulut dan Tenggorokan : Warna bibir ……… Mukosa …………… Ulkus ………………….... Perdarahan …………........ Ya/Tidak 2. Sakit tenggorok …………………………...limfe…………... Kepala : Bentuk Massa Distribusi rambut Warna kulit kepala b...TD : 120/80 mmHg Suhu : 36.. Warna Lidah …………… Perdarahan gusi ………………………….... Peradangan …… Taktil fremitus ………… Pola nafas ……………………………… Jantung : Inspeksi perkusi 7 .... Vena jugularis……………Tiroid………………......ka/ ki ( ) Plus…........Dada : Bentuk ………………… Pergerakan Dada …………………… Nyeri/nyeri tekan ……… Massa ………….. Kepala dan Leher a..... Kesadaran : compos mentis b......... Warna ………….. Trakea……………………Keluhan………………………………... Nyeri …………………………………………... Karies …………………... kepercayaan penting untuk Anda........... Lesi …………………… Massa ……………. Hidung : Bentuk …………... Pembengkakan ………… Nyeri tekan ……......Pola Nilai & Kepercayaan 1.Alat bantu pendengaran……………….. Tinggi badan : Berat badan : 2. agama.....5 C . Lesi ……………… Massa ……………... Kesulitan menelan ……………………… Gigi geligi ……………..ka/ki( ) silinder…ka/ki Pemeriksaan mata terakhir : ………………………………………….... Pendengaran……………. Telinga : Bentuk …………… Warna ……………....Q.Pemeriksaan Fisik 1......

.................................... Bengkak ………………………… Kesimetrisan ………………….......................................................................... Genetalia : Inspeksi terdapat benjolan di labia mayora kanan berwarna merah Palpasi ……………………………………………………………….................................... Kontrasepsi ………………………………………… Kehamilan 34-36 minggu……………………………........ 5..Abdomen : Inspeksi ………………………………………………………………...................... Paru : Inspeksi perkusi palpasi……………………………………………………..... ..................... Pus/luka ………………………… Refleks-refleks Sensasi Bisep : Raba/sentuhan: Trisep : panas : Brakioradialis : dingin : Patella : tekanan/tusuk : Achiles: Plantar (babinski) : 8............... MRI) ........................ Keluhan nyeri ketika duduk atau dipakai berjalan Pria : Keluhan …………………………………………….............................. Auskultasi ………………………………………………… 4.................... Payudara dan ketiak : Benjolan/massa ………………..................................................................... Palpasi ………………………………………………………………........................................... Lesi ……………………................................................................................................... Perkusi ………………………………………………………………..... Deformitas ……………………………Pembengkakan …………….................................. .............................................................................. Rontgen.. Nyeri/nyeri tekan ……………........ palpasi……………………………………………………… Auskultasi ………………………………………………….......................... Lesi ………………suhu……………tekstur ………………… Turgor …………… Kuku : warna …………………… bentuk …………………………............................................................... 8 ......... ......................................................................................................... 6................ 7.............................. Perempuan : Siklus mentruasi …………………………………............ Ekstremitas : Kekuatan otot ……………………………………………………… Kontraktur ……………………………Pergerakan ………………..................................................... Auskultasi ……………………………………………………………...................................... S.... Kulit dan kuku : Kulit : warna …………………… jaringan parut …………………...... .............................. USG...................................................... Hasil Pemeriksaan Penunjang (Laboratorium.... Edema ………………………… nyeri/nyeri tekan ……………….................................. ............ pengisian kapiler ………………...... ......

.......................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................................................................................ Nutrisi) .................................................................................................................................  Pengobatan:............................................................................................................Persepsi Klien Terhadap Penyakitnya ........................................................................................................................................ ..................................................................................... ...........................................................................................................................................  Antisipasi masalah perawatan diri setalah pulang:.......Terapi ( Medis.... T.................................................................................................................... U................................... V.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. Rawat jalan ke:........................................................... Rehabmedis................  Dukungan keluarga:... . . ......................................................................................................Kesimpulan ......................................................................................................................................................................................................................................... ...................................................... ................................................................................  Hal-hal yang perlu diperhatikan di rumah:............................................................................................................................  Transportasi pulang:............................................................................ 9 ..................................................................................................................... .......  Antisipasi bantuan biaya setelah pulang:...................................................................................................................................................................................................... W......................................................................................................................................................................................................................................... ........................................................................................................................................................................................................................................................................................................................................................ ......................................................................................................Perencanaan Pulang  Tujuan pulang:................. .... .................... ................................................................................................................. ......................................................

......... ....................................................................................................................................  Keterangan lain:............................................................................................................................................................................................................................. 10 ............. ........................................................