PEMERINTAH KABUPATEN BLITAR

DINAS KESEHATAN
UPT PUSKESMAS KADEMANGAN
Jl. Raya Trisula No.78 Kademangan Telp. (0342) 801613
email : pusk.kdm@gmail.com
BLITAR

PENGKAJIAN KEPERAWATAN DASAR PADA KELOMPOK

Nama Pengkaji :
Instansi :
A. PENGKAJIAN
1. Data Inti
- Jumlah Penduduk : ...................................................................................................................................................
Laki-laki : ...................................................................................................................................................
Perempuan : ...................................................................................................................................................
- Jumlah lansia : ...................................................................................................................................................
Laki-laki : ...................................................................................................................................................
Perempuan : ...................................................................................................................................................
- Pekerjaan Penduduk : ...................................................................................................................................................
- Suku Bangsa : ...................................................................................................................................................
- Status Perkawinan : ...................................................................................................................................................
- Nilai dan Kepercayaan : ...................................................................................................................................................
- Agama Penduduk : ...................................................................................................................................................
2. Data Subsistem
a. Lingkungan Fisik
- Kualitas Udara : ...................................................................................................................................................
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- Kualitas Air : ...................................................................................................................................................
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- Tingkat Kebisingan : ...................................................................................................................................................
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- Kepadatan Penduduk : ...................................................................................................................................................
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b. Pendidikan
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c. Keamanan dan Transportasi
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d. Politik dan Pemerintahan
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e. Pelayanan Sosial dan Kesehatan
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 f. Komunikasi
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g. Ekonomi
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h. Rekreasi
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B. ANALISA DATA
a. Diagnosa Keperawatan

No. Data Problem Etiologi

1 DS : ...............................................................
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DO : ...............................................................
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2 DS : ...............................................................
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DO : ...............................................................
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3 DS : ...............................................................
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DO : ...............................................................
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Diagnosa :
1. .......................................................................................................................................................................................................................
2. .......................................................................................................................................................................................................................
3. .......................................................................................................................................................................................................................

b. Kriteria Penapisan

Dx. Kep Kriteria penapisan

1 2 3 4 5 6 7 8 9 10 11 12 Jumlah
Diagnosa 1
Diagnosa 2
Diagnosa 3

Keterangan :
1. Sesuai dengan peran Perawat Komunitas
2. Jumlah yang beresiko
3. Besarnya resiko
4. Kemungkinan untuk Pendidikan Kesehatan
5. Minat Masyarakat
6. Kemungkinan untuk diatasi
7. Sesuai Program Pemerintah
8. Sumber daya tempat
9. Sumber daya waktu
10. Sumber daya dana
11. Sumber daya peralatan
12. Sumber daya manusia

Skor :
1 = sangat rendah
2 = rendah
3 = cukup
4 = tinggi
5 = sangat tinggi

c. Rencana Tindakan

Diagnosa Tujuan jangka pendek Tujuan jangka panjang

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