JURUSAN KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYA

PENGKAJIAN DASAR KEPERAWATAN

Nama Mahasiswa : Tempat Praktik :

NIM : Tgl. Praktik :

A. Identitas Klien
Nama : Tn Budi ............................ No. RM : ........................................
Usia : 40 thn.. Tgl. Masuk : ........................................
Jenis kelamin : Laki-Laki .......................... Tgl. Pengkajian : ........................................
Alamat : ........................................ Sumber informasi : ........................................
No. telepon : ......................................... Nama klg. dekat yg bisa dihubungi: ...............
Status pernikahan : Belum menikah ................ .........................................
Agama : ......................................... Status : .......................................
Suku : ......................................... Alamat : ........................................
Pendidikan : ......................................... No. telepon : ........................................
Pekerjaan : ......................................... Pendidikan : ........................................
Lama berkerja : ......................................... Pekerjaan : ........................................

B. Status kesehatan Saat Ini

1. Keluhan utama : Klien mengeluh kepala pusing, mukosa kering dan diare
selama 4 minggu, tidak sembuh setelah diobati. Klien juga
mengeluh gatal-gatal dan panas pada ujung penis kurang
lebih 1 minggu.
2. Lama keluhan : diare 4 minggu, gatal di penis seminggu ..................................................
3. Kualitas keluhan : ................................................................................................................
4. Faktor pencetus : ................................................................................................................
5. Faktor pemberat : ................................................................................................................
6. Upaya yg. telah dilakukan
7. Keluhan saat pengkajian : ..................................................................................................
8. Diagnosa medis :
a. ................................................................................... Tanggal .......................................
b. ................................................................................... Tanggal .......................................
c. ................................................................................... Tanggal .......................................

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C. Riwayat Kesehatan Saat Ini
.Klien mengeluh kepala pusing, mukosa kering, diare selama 4 minggu , tidak sembuh
setelah diobati, adanya garis-garis putih vertical pada sisi lidah, mengeluh gatal-gatal pada
ujung penis kurang lebih seminggu. Riwayat berpacaran dengan seorang pria 5 tahun lalu.
Klien rajin berolahraga fitness. ..........................................................................................................
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D.Riwayat Kesehatan Terdahulu
1.Penyakit yg pernah dialami:
a. Kecelakaan (jenis & waktu) : ........................................................................................
b. Operasi (jenis & waktu) : ........................................................................................
c. Penyakit:
Kronis :..............................................................................................................
Akut :..............................................................................................................
d. Terakhir masuki RS : ........................................................................................
2.Alergi (obat, makanan, plester, dll):
Tipe Reaksi
Tindakan
................................................... .............................................. .................................................
................................................... .............................................. .................................................
3. Imunisasi:
( ) BCG ( ) Hepatitis
( ) Polio ( ) Campak
( ) DPT ( ) ................

4. Kebiasaan:
Jenis Frekuensi Jumlah Lamanya
Merokok .................................. ....................................... ........................................
Kopi .................................. ....................................... ........................................
Alkohol .................................. ....................................... ........................................
.............................. .................................. ....................................... ........................................

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 5. Obat-obatan yg digunakan:
Jenis Lamanya Dosis
................................................... .............................................. .................................................
................................................... .............................................. .................................................

E.Riwayat Keluarga
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F.Riwayat Lingkungan
Jenis Rumah Pekerjaan
Kebersihan ...................................................... ......................................................
Bahaya kecelakaan ...................................................... ......................................................
Polusi ...................................................... ......................................................
Ventilasi ...................................................... ......................................................
Pencahayaan ...................................................... ......................................................
............................... ................................................... .........................................................

G.Pola Aktifitas-Latihan
Rumah Rumah Sakit
Makan/minum ...................................................
Mandi ................................................... ...................................................
Berpakaian/berdandan ................................................... ...................................................
Toileting ................................................... ...................................................
Mobilitas di tempat tidur ...................................................
Berpindah ................................................... ...................................................
Berjalan ................................................... ...................................................
Naik tangga ................................................... ...................................................
Pemberian Skor: 0 = mandiri, 1 = alat bantu, 2 = dibantu orang lain partial, 3 = dibantu
orang lain total, 4 = tidak mampu

H.Pola Nutrisi Metabolik

Rumah Rumah Sakit

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 Jenis diit/makanan .............................................. .................................................
Frekuensi/pola .............................................. .................................................
Porsi yg dihabiskan .............................................. .................................................
Komposisi menu .............................................. .................................................
Pantangan .............................................. .................................................
Napsu makan .............................................. .................................................
Fluktuasi BB 6 bln. terakhir .............................................. .................................................
Jenis minuman .............................................. .................................................
Frekuensi/pola minum .............................................. .................................................
Gelas yg dihabiskan .............................................. .................................................
Sukar menelan (padat/cair) .............................................. .................................................
Pemakaian gigi palsu (area) .............................................. .................................................
Riw. masalah penyembuhan luka .............................................. .................................................

I.Pola Eliminasi
Rumah Rumah Sakit
BAB:
- Frekuensi/pola ................................................... .................................................
- Konsistensi ................................................... .................................................
- Warna & bau ................................................... .................................................
- Kesulitan ................................................... .................................................
- Upaya mengatasi ................................................... .................................................
BAK:
- Frekuensi/pola ................................................... .................................................
- Konsistensi ................................................... .................................................
- Warna & bau ................................................... .................................................
- Kesulitan ................................................... .................................................
- Upaya mengatasi ................................................... .................................................

J.Pola Tidur-Istirahat
Rumah Rumah Sakit
Tidur siang:Lamanya .............................................
- Jam s/d ............................................. ..............................................
- Kenyamanan stlh. tidur ............................................. ..............................................
Tidur malam: Lamanya ............................................. ...............................................
- Jam s/d ............................................. ..............................................

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 - Kenyamanan stlh. tidur ............................................. ..............................................
- Kebiasaan sblm. tidur ............................................. ..............................................
- Kesulitan ............................................. ..............................................
- Upaya mengatasi ............................................. ..............................................

K. Pola Kebersihan Diri

Rumah Rumah Sakit
Mandi:Frekuensi ................................................ .................................................
- Penggunaan sabun ............................................... ...............................................
Keramas: Frekuensi ................................................ .................................................
- Penggunaan shampoo ............................................... ...............................................
Gosok gigi: Frekuensi ................................................ .................................................
- Penggunaan odol ................................................. ...............................................
Ganti baju:Frekuensi ................................................ .................................................
Memotong kuku: Frekuensi ................................................ .................................................
Kesulitan ................................................ .................................................
Upaya yg dilakukan ................................................ .................................................

L.Pola Toleransi-Koping Stres

1. Pengambilan keputusan: ( ) sendiri ( ) dibantu orang lain, sebutkan, ......................................
2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri,
dll):
3. Yang biasa dilakukan apabila stress/mengalami masalah:................................................................
4. Harapan setelah menjalani perawatan: .............................................................................................
5. Perubahan yang dirasa setelah sakit: ...............................................................................................
M. Konpep Diri
1. Gambaran diri : .....................................................................................................................................
2. Ideal diri : ..............................................................................................................................................
3. Harga diri : ............................................................................................................................................
4. Peran : ................................................................................................................................................
5. Identitas diri :..........................................................................................................................................

N.Pola Peran & Hubungan

1. Peran dalam keluarga .......................................................................................................................

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 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: ...............................................................................................
O.Pola Komunikasi
1. Bicara: ( ) Normal ( )Bahasa utama:.....................................
( ) Tidak jelas ( ) Bahasa daerah: .................................
( ) Bicara berputar-putar ( ) Rentang perhatian: ............................
( ) Mampu mengerti pembicaraan orang lain( ) Afek: ..................................................
2. Tempat tinggal: ( ) Sendiri
( ) Kos/asrama
( ) Bersama orang lain, yaitu:.............................................................................
3. Kehidupan keluarga
a. Adat istiadat yg dianut: ...............................................................................................................
b. Pantangan & agama yg dianut: ..................................................................................................

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

P.Pola Seksualitas
1. Masalah dalam hubungan seksual selama sakit: ( ) tidak ada ( ) ada
2. Upaya yang dilakukan pasangan:
( ) perhatian ( ) sentuhan ( ) lain-lain, seperti, ...........................................................

Q.Pola Nilai & Kepercayaan

1. Apakah Tuhan, agama, kepercayaan penting untuk Anda, Ya/Tidak
2. Kegiatan agama/kepercayaan yg dilakukan dirumah (jenis & frekuensi): ........................................
3. Kegiatan agama/kepercayaan tidak dapat dilakukan di RS: ..............................................................
4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya: ....................................................
R.Pemeriksaan Fisik

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1. Keadaan umum : klien mengeluh pusing
a. Kesadaran : GCS.
b. Tanda-tanda vital : - Tekanan darah : Suhu :
- Nadi : Pernafasan :
c. Tinggi badan : 165 cm
Berat badan : awal : 60 kg, setelah sakit: 53kg
2. Kepala dan Leher
a. Kepala : Bentuk Massa
Distribusi rambut Warna kulit kepala
b. 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..ka/ ki ( ) Plus.ka/ki ( ) silinderka/ki
Pemeriksaan mata terakhir : ...
Riwayat Operasi :
c. Hidung : Bentuk .. Warna . Pembengkakan
Nyeri tekan .. Perdarahan .. Sinus
Riw. Alergi Cara mengatasinya ..
Penyakit yg pernah terjadi .
Frekuensi .. Cara mengatasi
d. Mulut dan Tenggorokan :
Warna bibir Mukosa : kering Ulkus
Lesi Massa .. Warna Lidah ada garis-
garis warna putih vertical pada sisi lidah
Perdarahan gusi . Karies ..
Kesulitan menelan Gigi geligi ...
Sakit tenggorok . Gangguan bicara
Pemeriksaan gigi terakhir .
e. Telinga : Bentuk Warna . Lesi
Massa . Nyeri ..
Fs. Pendengaran.Alat bantu pendengaran.
Masalah yg pernah terjadi
Upaya untuk mengatasi..

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 f. Leher : Kekakuan..Nyeri/Nyeri tekan
Benjolan/massaKeterbatasan gerak.
Vena jugularisTiroid..limfe..
TrakeaKeluhan.
Upaya untuk mengatasi
3.Dada : Bentuk Pergerakan Dada
Nyeri/nyeri tekan Massa . Peradangan
Taktil fremitus Pola nafas
Jantung : Inspeksi
perkusi
palpasi
Auskultasi ..
Paru : Inspeksi
perkusi
palpasi.
Auskultasi
4. Payudara dan ketiak :
Benjolan/massa .. Nyeri/nyeri tekan ..
Bengkak Kesimetrisan .
5.Abdomen :
Inspeksi .
Auskultasi .
Palpasi ..
Perkusi .
6. Genetalia :
Inspeksi
Palpasi ..
Perempuan : Siklus mentruasi ...
Kontrasepsi
Kehamilan .
Keluhan ..
Pria : Keluhan : mengeluh gatal-gatal dan panas di ujung
penis..
7. Ekstremitas : Kekuatan otot
Kontraktur Pergerakan .
Deformitas Pembengkakan .
Edema nyeri/nyeri tekan .

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 Pus/luka
Refleks-refleks Sensasi
Bisep : Raba/sentuhan:
Trisep : panas :
Brakioradialis : dingin :
Patella : tekanan/tusuk :
Achiles :
Plantar (babinski) :
8. Kulit dan kuku :
Kulit : warna jaringan parut .
Lesi suhutekstur
Turgor
Kuku : warna bentuk ..
Lesi .. pengisian kapiler .

S. Hasil Pemeriksaan Penunjang (Laboratorium, USG, Rontgen, MRI)

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T.Terapi ( Medis, Rehabmedis, Nutrisi)

Dokter merencanakan pemeriksaan CD4. ...........................................................................................

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U.Persepsi Klien Terhadap Penyakitnya

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V.Kesimpulan
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W.Perencanaan Pulang
Tujuan pulang: ..................................................................................................................................
Transportasi pulang: .........................................................................................................................
Dukungan keluarga: ..........................................................................................................................
Antisipasi bantuan biaya setelah pulang: ..........................................................................................
Antisipasi masalah perawatan diri setalah pulang: ............................................................................
Pengobatan: .....................................................................................................................................
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Rawat jalan ke: ....................................................................................................................................
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Hal-hal yang perlu diperhatikan di rumah: .......................................................................................
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Keterangan lain: ................................................................................................................................

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