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LAMPIRAN FORMAT PENGKAJIAN PROGRAM STUDI S1 KEPERAWATAN



SEKOLAH TINGGI ILMU KESEHATAN (STIKES) BHAKTI HUSADA MULIA MADIUN FORMAT PENGKAJIAN



Pengkajian tanggal :...................................



Jam



:.................................................



Tanggal MRS



No. Registrasi



:.................................................



Diagnosa Masuk



:.................................................



Ruang



:.................................... : ...................................



I. IDENTITAS PASIEN Nama



: …………………..…….



Umur



: …………………….......



Jenis kelamin



: ………………………...



Agama



: ………………………...



Pendidikan



: ………………………...



Pekerjaan



: ………………………...



Suku /bangsa



: ………………………...



Alamat



: ………………………... …………………………



Status perkawinan



Penanggung jawab pasien : Nama : …………………….. Umur



: ……………………..



Jenis kelamin



: ……………………..



Pendidikan



: ……………………..



Pekerjaan



: ……………………..



Hubungan dengan pasien



: ……………………..



Alamat



: …………………….. ..……………………..



: ………………………...



II. PENGKAJIAN RIWAYAT KESEHATAN Keluhan Utama



:



....................................................................................................................................................................................................... Riwayat Penyakit Sekarang



:



...................................................................................................................................................................................................... ..................................................................................................................................................................................................... ....................................................................................................................................................................................................... ....................................................................................................................................................................................................... ....................................................................................................................................................................................................... ....................................................................................................................................................................................................... ....................................................................................................................................................................................................... Riwayat Penyakit Dahulu : 10



1. Pernah di rawat



:



Ya



Tidak



Kapan :.........................



Diagnosa :........................................................ 2. Riwayat penyakit kronik dan menular :



Ya



Tidak



Jenis : ................................................... Riwayat kontrol : ............................................................................................ Riwayat penggunaan obat : ........................................................................... Riwayat operasi



:



Ya



Tidak



Kapan :........................



Riwayat alergi



:



Ya



Tidak



Kapan :........................



3. Riwayat Kesehatan Keluarga :.............................................................................................................................. ......................................................................................................................................................................................... ............................................................................................................................................................................................ 4. Genogram Keterangan :



III. PEMERIKSAAN FISIK 1.



TANDA-TANDA VITAL Suhu :...........°C



Nadi : ..........x/mnt



Kesadaran pasien :



Tensi : ....../......mmHg



Composmentis



Apatis



Sopor



Resp : ....... x/mnt



Somnolen



Koma



2.



PENGKAJIAN PERNAPASAN (B1) a.



Keluhan :



Sesak



Nyeri



waktu nafas Batuk :



Produktif



Tidak produktif



Sekret : ................ Warna : ................... Konsistensi : .................... Bau : ...................... b.



Inspeksi Irama pernafasan :



Teratur



Kedalaman : .......................



Tidak teratur Kesimetrisan : .........................



Penggunaan otot bantu nafas : ...................... Jenis pernafasan :



Dispnoe



Kusmaul



Cuping hidung : ......................... Chyne Stoke 11



c. Palpasi Fokal Fremitus : ........................ Nyeri tekan:



Ya



tidak



d. Auskultasi Suara napas :



Vesikuler



Bronko Vesikuler



Bronkial



Trakeal



Penggunaan alat bantu napas : Jenis oksigen : .................................... WSD :



Ya



Tidak



Ronkhi



Wheezing



Crackles



Ya



Tidak



Flowmeter : ......................................



Jumlah cairan yang keluar :.......cc Warna :................



Lain-lain : ................................................................................................................................... .................................................................................................................................................... Masalah Keperawatan : .......................................................................................................... 3. PENGKAJIAN SIRKULASI/ KARDIOVASKULAR (B2) a. Inspeksi dan Palpasi Pergerakan dada : ............................................. Keluhan nyeri dada :



Ya



Pembesaran Vena Jugularis :



Tidak Ya



Jelaskan : ............................................... Tidak



b. Auskultasi Irama jantung :



Reguler



S1 / S2 tunggal :



Ya



Suara Jantung :



Ireguler Tidak



Normal



Jelaskan : .........................................



Murmur



Friction Rub



Gallop Lain-lain :.........



c. CRT : ........ detik Akral :



a. Dingin



Kering



b. Pengukuran JVP :



Basah Normal



Hangat



Panas



Pucat Meningkat



Menurun



c. Pengukuran CVP :



Nilai : ....................



Ada



Tidak



Jelaskan : ..................... mmH2O Lain-lain : .............................................................................................................................. ................................................................................................................................................ Masalah Keperawatan : ...................................................................................................... 4. PENGKAJIAN NEURO SENSORI / PERSYARAFAN (B3) a.



GCS : E : ................ V : .................... M: ....................



b. Keluhan pusing : c. Pupil :



Isokor



Ya



Tidak Unisokor



Jelaskan : .................................... Diameter : ................................... 12



d.



Sclera : Ikterus



Anemis



Normal



e. Konjungtiva :



Anemis



Ikterus



f. Gangguan pandangan :



Ya



g. Gangguan pendengaran :



Tidak Ya



h. Gangguan penciuman :



Normal Tidak Jelaskan : ..................................



Ya



Tidak Jelaskan : ..................................



i. Triceps



Jelaskan : ..................................



Reflek fisiologis :



Patella



Refleks patologis :



Babinsky



Biceps



j. Budzinsky



Kernig



k.



Istirahat / tidur : .................. jam/hari Ganguan Tidur : ............................................... Lain-lain : .............................................................................................................................. ................................................................................................................................................ Masalah Keperawatan : ......................................................................................................



5. PENGKAJIAN ELIMINASI (BLADER DAN BOWEL) (B4) Blader a. Inspeksi Kebersihan :



Bersih



Keluhan miksi :



Kotor



Tidak ada/normal



Nokturia



Inkontinensia



Poliuri



Retensi



Oliguri



Disuria



Gross hematuri



Frekuensi miksi : ......................x/hari Warna : ..............................................



Anuria



Produksi urine : ....................... cc/hari Bau : ...................................................



b. Palpasi Kandung kemih : membesar Nyeri tekan Ginjal



Ya



Tidak



Ya



Tidak



Ya



Tidak



Ya



Tidak



: membesar Nyeri tekan



c. Alat bantu kateter :



Ya



Tidak



Terpasang sejak : ..........................



Jenis : .....................................



Produksi urine : ..............cc/........



Warna : ..................................



Bau : .............................................



Bowel a. Inspeksi dan Palpasi Area perianal :



Hemoroid



b. BAB : .................................x/hari



Kutil



Kanker



Normal



Terakhir tanggal : ............................................ 13



Konsistensi :



Lunak



Keras



Cair



Berlendir



Berdarah



Warna : ................................................. Gangguan :



Tidak ada/ normal



Diare



Konstipasi



Inkontinensia



Lain-lain : .............................................................................................................................. ................................................................................................................................................ Masalah Keperawatan : ...................................................................................................... 6. PENGKAJIAN MAKANAN DAN CAIRAN / PENCERNAAN / ABDOMEN (B5) a. Mulut :



Bersih



Kotor



Berbau



b. Mukosa :



Lembab



Kering



Stomatitis



c. Tenggorokan :



Sakit saat menelan



Kesulitan menelan



Pembesaran tonsil d. Inspeksi Abdomen :



Nyeri tekan



Tegang



Nyeri tekan :



Kembung Ya



Luka operasi :



Jelaskan : ................... Acites



Tidak



Ada



Tidak



Keadaan : .................................. Drain :



Tanggal operasi : .....................



Ada



Tidak



Jumlah : ............. cc Warna : ...................... Kondisi area sekitar insersi : ........................ Auskultasi Abdomen : Peristaltik : ................................x/menit Perkusi dan Palpasi Abdomen : Hepar :



Ya



Tidak



Jelaskan : ......................................................



Limpa :



Ya



Tidak



Jelaskan : ......................................................



Nyeri Tekan :



e. Diet :



Padat



Lunak



Cair



Jenis diet : ...................................................... f. Nafsu makan :



Baik



Menurun



Frekuensi : .............................. x/hari Porsi makan :



Habis



Tidak habis



Keterangan : .....................................



g. Intake cairan : oral .................................... cc/hari Parenteral : ........................... cc/hari Jelaskan : ........................................................................................................ h. Terpasang NGT :



Ya



Tidak



Terpasang sejak :...........................



Lain-lain : .............................................................................................................................. 14



................................................................................................................................................ Masalah keperawatan : ...................................................................................................... 7.



PENGKAJIAN MUSKULOSKELETAL DAN INTEGUMEN (B6) a.



Pergerakan sendi :



Bebas



Terbatas b.



Kekuatan otot :



c.



Kelainan ekstremitas : Tidak



Ya



Jelaskan : ....................................



d.



Kelainan tulang belakang : Tidak



Ya



Jelaskan : ....................................



e.



Fraktur :



Ya



Tidak



Jelaskan : .................................... f.



Traksi / spalk / Gips : Tidak



Ya



Jelaskan : ....................................



g.



Kompartemen syndrome : Tidak



Ya



Jelaskan : ....................................



h.



Kulit : Kemerahan



Ikterik



Sianosis



Hiperpigmentasi



i.



Turgor :



Baik



Kurang



Jelek j.



Luka : Jenis : ......................... Luas : ..........................



Bersih



Kotor



Lain-lain : ................................................................................................................................... .................................................................................................................................................... Masalah Keperawatan : .......................................................................................................... 8. PENGKAJIAN ORGAN GENETALIA Ada kelainan :



Ya



Tidak



Jelaskan : .........................................



Lain-lain : ................................................................................................................................... .................................................................................................................................................... Masalah keperawatan : ........................................................................................................... 9. PENGKAJIAN SISTEM ENDOKRIN 15



a. Pembesaran Kelenjar Thyroid :



Ya



b. Pembesaran kelenjar getah bening :



Tidak Ya



Tidak



c. Hipoglikemia :



Ya



Tidak



Nilai : ............................



d. Hiperglikemi :



Ya



Tidak



Nilai : ............................



e. Luka gangren :



Ya



Tidak



Lokasi : ..................................



Lain-lain : ................................................................................................................................... .................................................................................................................................................... Masalah keperawatan : ........................................................................................................... 10.



PERSONAL HYGIENE DAN KEBIASAAN



a. Mandi : .................................. x/hari



f. Ganti



pakaian : ................................x/hari b. Keramas : ............................... x/hari



g. Sikat gigi : ....................................



x/hari c. Memotong kuku : ....................................... d. Merokok :



Ya



Tidak Keterangan : ..............................................



e. Alcohol :



Ya



Tidak Keterangan : ..............................................



Lain-lain ..................................................................................................................................... .................................................................................................................................................... Masalah keperawatan : ..........................................................................................................



11. PENGKAJIAN PSIKOSOSIAL a.



Persepsi klien terhadap sakit yang diderita : Cobaan tuhan Lainnya



b.



Hukuman Jelaskan : ...............................................................................



Ekspresi perilku klien terhadap penyakit yang diderita : Murung/diam



Gelisah/cemas



c.



Reaksi saat interaksi :



Kooperatif



d.



Gangguan konsep diri :



Ya



Tegang Tidak kooperatif



Mudah/menangis Curiga



Tidak



Lain-lain : ................................................................................................................................... ..................................................................................................................................................... Masalah keperawatan : ........................................................................................................... 12. PENGKAJIAN SPIRITUAL Kebiasaan beribadah : a.



Selama sakit : ........................................................................................................................ 16



b.



Sebelum sakit : ......................................................................................................................



Masalah keperawatan : ........................................................................................................... 13. TERAPI OBAT .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... 14. TINDAKAN PEMBEDAHAN Rencana akan dilaksanakan operasi tanggal :………………. Jam :………………WIB Nama / jenis operasi :…………………………………………………………………. 1. Pre operasi …………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………… ………………………………………… 2. Post operasi …………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………… ………………………………………… 15. PEMERIKSAAN PENUNJANG 1. Laboratorium ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... 2. X-Ray ................................................................................................................................................... ................................................................................................................................................... 17



................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... 3. USG ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... 4. Lain-lain ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... .........................., ......-.......-20......



(...................................................) ANALISA DATA Tanggal



Data



Etiologi



Masalah



18



PRIORITAS DIAGNOSA KEPERAWATAN 1. ................................................................................................................................................ 2. ................................................................................................................................................ 3. ................................................................................................................................................ 4. ................................................................................................................................................



19



20



INTERVENSI KEPERAWATAN



NO



HARI/ TANGGAL



DIAGNOSA KEPERAWATAN (NOC dan kriteria hasil)



INTERVENSI



IMPLEMENTASI DAN EVALUASI KEPERAWATAN Hari Ke-........ (Tgl/Bln/Thn), ..........................................



21



Shift



Hari / Tgl



Diagnosa Keperawatan



Jam



Implementasi



Jam



Evaluasi (Soap)



Paraf



22