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    Pengkajian

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    8 views17 pages

    Askep Stemi.... Hakam

    Uploaded by

    Nindia Setyaningrum
    Pengkajian

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 17

    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR

    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    PENGKAJIAN DASAR KEPERAWATAN


    Nama : Tempat Praktik :
    NIM : Tgl. Praktik :

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

    B. Status kesehatan Saat Ini


    1. Keluhan utama
    Saat MRS : ……………………………………………………………………………………............
    ……………………………………………………………………………………..............
    ……………………………………………………………………………………..............
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    ................................................................................................................................

    Saat Pengkajian : ……………………………………………………………………………………............


    ……………………………………………………………………………………..............
    ……………………………………………………………………………………..............
    ................................................................................................................................
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    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    2. Lama keluhan : .............................................................................................................................


    .............................................................................................................................
    3. Kualitas keluhan : .............................................................................................................................
    .............................................................................................................................
    4. Faktor pencetus : .............................................................................................................................
    .............................................................................................................................
    5. Faktor pemberat : .............................................................................................................................

    6. Upaya yg. telah dilakukan : …………………………..........................................................................................


    ............................................................................................................................
    7. Diagnosa medis
    a. .........................................................................Tanggal .................................................................
    b. .........................................................................Tanggal .................................................................
    c. .........................................................................Tanggal .................................................................
    d. .........................................................................Tanggal .................................................................
    e. .........................................................................Tanggal .................................................................
    f. .........................................................................Tanggal .................................................................

    8. Riwayat Kesehatan Saat Ini


    .......................................................................................................................................................................
    .......................................................................................................................................................................
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    C. Riwayat Kesehatan Terdahulu


    1. Penyakit yg pernah dialami:
    a. Kecelakaan (jenis & waktu) :...................................................................................................
    b. Operasi (jenis & waktu) :...................................................................................................
    c. Penyakit:
     Kronis :...........................................................................................................................
    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    ............................................................................................................................
    ............................................................................................................................
    ............................................................................................................................
     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 ...................................... ............................................. .............................................

    5. Obat-obatan yg digunakan:
    Jenis Lamanya Dosis
    ......................................................... ................................................... ......................................................
    ......................................................... ................................................... ......................................................
    ......................................................... ................................................... ......................................................
    D. Riwayat Keluarga
    ..............................................................................................................................................................................
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    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

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

    GENOGRAM
    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

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

    F. 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 1 orang, 3 = dibantu >1 orang, 4 = tidak mampu

    G. Pola Nutrisi Metabolik


    Rumah Rumah Sakit
     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 ................................................... ......................................................

    H. Pola Eliminasi
    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    Rumah Rumah Sakit


     BAB:
    - Frekuensi/pola ......................................................... .......................................................
    - Konsistensi ......................................................... .......................................................
    - Warna & bau ......................................................... .......................................................
    - Kesulitan ......................................................... .......................................................
    - Upaya mengatasi ......................................................... .......................................................
     BAK:
    - Frekuensi/pola ......................................................... .......................................................
    - Konsistensi ......................................................... .......................................................
    - Warna & bau ......................................................... .......................................................
    - Kesulitan ......................................................... .......................................................
    - Upaya mengatasi ......................................................... .......................................................

    I. Pola Tidur-Istirahat
    Rumah Rumah Sakit
     Tidur siang:Lamanya ................................................... .........................................................
    - Jam …s/d… .................................................. .......................................................
    - Kenyamanan stlh. tidur .................................................. .......................................................
     Tidur malam: Lamanya ................................................... .........................................................
    - Jam …s/d… .................................................. .......................................................
    - Kenyamanan stlh. tidur .................................................. .......................................................
    - Kebiasaan sblm. tidur .................................................. .......................................................
    - Kesulitan .................................................. .......................................................
    - Upaya mengatasi .................................................. .......................................................

    J. Pola Kebersihan Diri


    Rumah Rumah Sakit
     Mandi:Frekuensi ...................................................... ......................................................
    - Penggunaan sabun ..................................................... .....................................................
     Keramas: Frekuensi ...................................................... ......................................................
    - Penggunaan shampoo ..................................................... .....................................................
     Gososok gigi: Frekuensi ...................................................... ......................................................
    - Penggunaan odol ..................................................... .....................................................
     Ganti baju:Frekuensi ...................................................... ......................................................
     Memotong kuku: Frekuensi ...................................................... ......................................................
     Kesulitan ...................................................... ......................................................
     Upaya yg dilakukan ...................................................... ......................................................
    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    K. 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:.................................................................................
    ............................................................................................................................................................................
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    4. Harapan setelah menjalani perawatan:...............................................................................................................
    ............................................................................................................................................................................
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    5. Perubahan yang dirasa setelah sakit:.................................................................................................................
    ............................................................................................................................................................................
    ............................................................................................................................................................................

    L. Konsep Diri
    1. Gambaran diri:....................................................................................................................................................
    ..................................................................................................................................................................
    ..................................................................................................................................................................
    2. Ideal diri:.............................................................................................................................................................
    ..................................................................................................................................................................
    ..................................................................................................................................................................
    3. Harga diri:...........................................................................................................................................................
    ..................................................................................................................................................................
    ..................................................................................................................................................................
    4. Peran:.................................................................................................................................................................
    ..................................................................................................................................................................
    ..................................................................................................................................................................
    5. Identitas diri........................................................................................................................................................
    ..................................................................................................................................................................
    ..................................................................................................................................................................

    M. Pola Peran & Hubungan


    1. Peran dalam keluarga.........................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    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
    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    ( ) Lain-lain sebutkan,
    4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS:..................................................
    ......................................................................................................................................................................... . .
    5. Upaya yg dilakukan untuk mengatasi:................................................................................................................

    N. 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
    O. Pola Seksualitas
    1. Masalah dalam hubungan seksual selama sakit: ( ) tidak ada ( ) ada
    2. Upaya yang dilakukan pasangan:
    ( ) Perhatian ( ) Sentuhan ( ) lain-lain, seperti, .....................................................................

    P. 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:.....................................................................

    Q. Pemeriksaan Fisik
    1. Keadaan Umum:.................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    - Kesadaran:....................................................................................................................................................
    - Tanda-tanda vital: - Tekanan darah :……… mmHg - Suhu :………oC
    - Nadi :……... x/meni - RR :……… x/menit
    - Tinggi badan: ...........................................cm Berat Badan:..............................kg

    2. Kepala & Leher


    a. Kepala :
    - Bentuk : ........................................................................................................................................................
    - Massa: ..........................................................................................................................................................
    - Distribusi rambut : .........................................................................................................................................
    - Warna kulit kepala : ......................................................................................................................................
    - Keluhan : pusing/ sakit kepala/ migraine/ lainya, sebutkan…........................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
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    .......................................................................................................................................................................
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    .......................................................................................................................................................................
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    b. Mata:
    - Bentuk:………………………….
    - Konjungtiva:………………………….
    - Pupil : ( ) reaksi terhadap cahaya ( )isokor ( ) miosis ( )pin point ( )midriasis

    - Tanda radang :………………………….


    - Fungsi penglihatan : ( ) baik ( ) kabur

    - Penggunaan alat bantu : ( ) ya ( ) tidak


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    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    c. Hidung:
    - Bentuk :………………………….
    - Warna:………………………….
    - Pembengkakan:………………………….
    - Nyeri tekan:………………………….
    - Pendarahan:………………………….
    - Sinus:………………………….
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................

    d. Mulut & tenggorokan:


    - Warna bibir:………………………….
    - Mukosa:………………………….
    - Ulkus:………………………….
    - Lesi:………………………….
    - Massa:………………………….
    - Warna lidah:………………………….
    - Perdarahan gusi:………………………….
    - Karies:………………………….
    - Gangguan bicara:………………………….
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................

    e. Telinga:
    - Bentuk:………………………….
    - Warna :………………………….
    - Lesi:………………………….
    - Massa:………………………….
    - Nyeri:………………………….
    - Nyeri tekan:………………………….
    .......................................................................................................................................................................
    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
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    f. Leher:
    - Kekakuan:………………………….
    - Benjolan / massa : :………………………….
    - Vena junggulris:………………………….
    - Nyeri:………………………….
    - Nyeri tekan:………………………….
    - Keterbatasan gerak:………………………….
    - Keluhan lain:………………………….
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................
    .......................................................................................................................................................................

    3. Thorak & Dada:


    - Jantung
    - Inspeksi:.................................................................................................................................................
    ...............................................................................................................................................................
    - Palpasi:..................................................................................................................................................
    ...............................................................................................................................................................
    - Perkusi:..................................................................................................................................................
    ...............................................................................................................................................................
    - Auskultasi:..............................................................................................................................................
    ...............................................................................................................................................................
    ......................................................................................................................................................................
    ......................................................................................................................................................................
    ......................................................................................................................................................................
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    - Paru
    - Inspeksi:.................................................................................................................................................
    ...............................................................................................................................................................
    - Palpasi:..................................................................................................................................................
    ...............................................................................................................................................................
    - Perkusi:..................................................................................................................................................
    ...............................................................................................................................................................
    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    - Auskultasi:..............................................................................................................................................
    ...............................................................................................................................................................
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    -

    4. Payudara & Ketiak


    - Benjolan / massa:………………………….
    - Bengkak:………………………….
    - Nyeri:………………………….
    - Nyeri tekan:………………………….
    - Kesimetrisan :………………………….
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    5. Punggung & Tulang Belakang


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    6. Abdomen
    - Inspeksi:......................................................................................................................................................
    ....................................................................................................................................................................
    - Palpasi:.......................................................................................................................................................
    ....................................................................................................................................................................
    - Perkusi:.......................................................................................................................................................
    ....................................................................................................................................................................
    - Auskultasi:...................................................................................................................................................
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    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

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

    7. Genetalia & Anus


    - Inspeksi:......................................................................................................................................................
    ....................................................................................................................................................................
    - Palpasi:.......................................................................................................................................................
    ....................................................................................................................................................................
    ............................................................................................................................................................................
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    8. Ekstermitas ( kekuatan otot, kontraktur, deformitas, edema, luka, nyeri/ nyeri tekan, pergerakan)
    - Atas:............................................................................................................................................................
    ....................................................................................................................................................................
    - Bawah:........................................................................................................................................................
    ....................................................................................................................................................................
    ............................................................................................................................................................................
    ............................................................................................................................................................................
    ............................................................................................................................................................................
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    9. Sistem Neorologi (SSP : I –XII, reflek, motorik,sensorik)


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    10. Kulit & Kuku


    - Kulit (warna, lesi, turgor, jaringan, parut, suhu, tkstur, diaphoresis)
    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    ....................................................................................................................................................................
    ....................................................................................................................................................................
    ............................................................................................................................................................................
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    - Kuku: (warna, lesi, bentuk, pengisian kapiler)
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    ............................................................................................................................................................................
    ............................................................................................................................................................................
    ............................................................................................................................................................................
    R. Hasil Pemeriksaan Penunjang (Laboratorium, USG, Rontgen, MRI)
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    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

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    S. Terapi (Medis, Rehabmedik, nutrisi)
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    T. Persepsi Klien Terhadap Penyakitnya


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    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

    U. Kesimpulan
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    V. 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:.........................................................................................................................................
     Hal-hal yang perlu diperhatikan di rumah:................................................................................................
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     Keterangan lain:........................................................................................................................................
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    [PENDIDIKAN DAN PELATIHAN KARDIOLOGI DASAR
    Oktober 2018 PERAWAT RSUD DR. SAIFUL ANWAR MALANG - 2018

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