PENGKAJIAN-STIKes Maharani [PDF]

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Format Pengkajian Keperawatan STIKes Maharani Malang Jl. Akordion Selatan 8B Malang www.stikesmaharani.ac.id Nama Mahasiswa : Binti NIM :



Tempat Praktek: Tgl. Praktek :



A. Identitas Klien Nama :Tn M No.RM : 11525958 Usia : 71 tahun Tgl. Masuk : 06-12-2021 Jenis Kelamin : Laki-laki Tgl. Pengkajian : 06-12-2021 Alamat : pajajaran rt6, poncokusumo Sumber Informasi : anak No. Telepon : 08313443108 Nama klg. Dekat yng bisa dihubungi: anak Status Pernikahan: Kawin Agama :Islam Status : kawin Suku : Jawa Alamat : pajajran, poncokusumo Pendidikan : SD No. Telepon : 082131876227 Pekerjaan : Swasta (jualan) Pendidikan : SMP Lama Bekerja : Sampai sekarang bekerja Pekerjaan : Penyanyi B. Status Kesehatan Saat Ini 1. Keluhan utama : a.Saat MRS : Pasien mengatakan nyeri pada daerah kepala b. Saat Pengkajian : nyeri pada tulang rahang atas 2. Lama Keluhan : 10-15 menit 3. Kualitas Keluhan : nyeri seperti di tusuk-tusuk 4. Faktor Pencetus : fraktur patah tulang 5. Faktor Pemberat : ketika di buat gerak 6. Upaya yg telah dilakukan: meminimalkan gerakan 7. Diagnosa Medis : 1. Fr mandibula+ fr maxila= zigoma tanggal 06-12- 2021 2. ..................................................................... tanggal................................................... 3. ..................................................................... tanggal................................................... C. Riwayat Kesehatan Saat Ini Pasien saat pulang berdagang di tabrak oleh motor dari depan pada jalan yang menikung pada malam hari didaerah tumpang,malang.



D. Riwayat Kesehatan Terdahulu 1. Penyakit yang pernah dialami : 1. Kecelakaan (jenis & waktu) : kecelakaan sepedah motor 2. Operasi (jenis & waktu) : rencana pro debridrmrnt+ repair + repair palatum 3. Penyakit:  Akut : tidak ada  Kronis : tidak ada 2. Alergi (obat, makanan, plester, dll): tidak ada riwayat alergi makanan atau obat dll Tipe Reaksi Lamanya ........................................... .................................................. .......................................... ........................................... .................................................. .......................................... ........................................... .................................................. ..........................................



3. Kebiasaan Jenis Frekuensi Jumlah Merokok sehari 3 kali 2-3 batang Kopi sehari 2 kali 2 gelas Alkohol tidak mengkomsumsi Obat-obatan yang digunakan : tidak menggunakan Jenis Lamanya ........................................... .................................................. ........................................... .................................................. ........................................... .................................................. ........................................... ..................................................



Lamanya bertahun-tahun bertahun-tahun Dosis .......................................... .......................................... .......................................... ..........................................



E. Riwayat Keluarga Keluarga pasien tidak mempunyai riwayat penyakit menurun dan menular GENOGRAM



Keterangan: : Laki-laki : Perempuan : Garis keturunan : Hubungan pernikahan : Klien : Tinggal dalam satu rumah : Meninggal dunia



F. Riwayat Lingkungan Jenis  Kebersihan  Bahaya kecelakaan  Polusi  Ventilasi  Pencahayaan



Rumah .................................................... ................................................... ................................................... ................................................... ...................................................



G. Pola Aktivitas-Latihan Jenis Rumah  Makan/Minum ........................................................ .  Mandi .......................................................  Berpakaian .......................................................  Toiletting .......................................................  Mobilitas .......................................................  Berpindah ...................................................... .  Berjalan .......................................................  Naik tangga ....................................................... ................................................................



Pekerjaan ................................................... ................................................... ................................................... ................................................... ...................................................



Rumah Sakit ............................................................... ............................................................... .............................................................. ............................................................... .............................................................. ............................................................... ...............................................................



Pemberian Skor: 0=mandiri, 1=alat bantu, 2=dibantu orang lain (1 orang), 3=dibantu orang lain (>1 orang), 4=tidak mampu



Masalah kep



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H. Pola Nutrisi Jenis Rumah Makan  Jenis diit/makanan ....................................................  Frekuensi/pola ...................................................  Porsi yang dihabiskan ...................................................  Komposisi menu ...................................................  Pantangan ...................................................  Nafsu makan ...................................................  Fluktuasi BB 6 bl trhr ................................................... Minum  Jenis minuman ...................................................  Frekuensi/pola minum ...................................................  Gelas yang dihabiskan ...................................................  Sukar menelan ...................................................  Pemakaian gigi palsu ...................................................  Riw.masalah penyembuhan luka ................................................... I.



Pola Eliminasi Jenis BAB  Frekuensi/pola  Konsistensi  Warna & bau  Kesulitan  Upaya mengetasi BAK  Frekuensi/pola  Konsistensi  Warna & bau  Kesulitan  Upaya mengetasi



Rumah



Rumah Sakit ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... Rumah Sakit



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J. Pola Tidur-Istirahat Rumah  Tidur siang: Lamanya ........................................... - Jam .....s/d...... ........................................... - Kenyamanan stl tidur ...........................................  Tidur malam: Lamanya ........................................... - Jam .....s/d...... ........................................... - Kenyamanan stl tidur ........................................... - Kebiasaan sbl tidur ........................................... - Kesulitan ........................................... - Upaya mengatasi ...........................................



Rumah Sakit .................................................. ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ................................................... ...................................................



K. Pola Kebersihan Diri     



Rumah Mandi: Frekuensi ........................................... - Penggunaan sabun ........................................... Keramas: Frekuensi ........................................... - Penggunaan Shampo........................................... Gosok gigi: Frekuensi ........................................... - Penggunaan odol ........................................... Ganti baju: Frekuensi ........................................... Memotong kuku: Frekuensi..................................... ....................................................



Rumah Sakit .................................................. ................................................... ................................................... ................................................... ................................................... ................................................... ...................................................



 Kesulitan  Upaya yang dilakuan



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L. Pola Toleransi Koping Stress 1. Pengembilan keputusan: ( ) sendiri, ( ) dibantu orang lain, ........................................................ 2. Masalah utama terkait dengan perawatan di RS atau penyakit (biaya, perawatan diri, dll)....... ................................................................................................................................................... . 3. Yang biasa dilakukan apabila stres/mengalami masalah .......................................................... 4. Harapan setelah menjalani perawatan....................................................................................... 5. Perubahan yang dirasa setelah sakit......................................................................................... M. Pola peran & Hubungan 1. Peran dalam keluarga................................................................................................................ 2. Sistem pendukung: suami/istri/tetangga/teman/keluarga/tidak ada, sebutkan .......................... 3. Kesulitan dalam keluarga ( ) Hub. dgn orang tua ( ) Hub.dgn pasangan ( ) Hub. dgn sanak saudara ( ) Hub. dgn anak ( ) Lain-lain sebutkan 4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS ......................... ................................................................................................................................................... . 5. Upaya yang dilakukan untuk mengatasi..................................................................................... N. Pola Komunikasi 1. Bicara: ( ) Normal Bahasa utama: ( ) Tidak Jelas ( ) Bahasa daerah ( ) Bahasa Indonesia ( ) 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 yag dianut: ...................................................................................................... b. Pantangan adat dan agama yang dianut: ........................................................................... c. Penghasilan Keluarga: ( ) < Rp 500.000 ( ) Rp 2 juta – 3 juta ( ) Rp 500.000 – 1 juta ( ) Rp 3 juta – 4 juta ( ) Rp 1 juta – 2 juta ( ) > 4 juta O. Pola Seksualitas 1. Masalah dalam hubungan seksual selama sakit: ( ) Tidak ada ( ) Ada 2. Upaya yang dilakukan pasangan: ( ) Perhatian ( ) Sentuhan ( ) seperti ...................................................................................................................



Lain-lain,



P. Pola Nilai & Kepercayaan 1. Apakah Tuhan dan agama penting untuk anda: ( ) Ya ( ) Tidak 2. Kegiatan keagamaan yang dilakukan di rumah (jenis dan frekuensi):..................................... ................................................................................................................................................. . 3. Kegiatan keagamaan yang tidak dapat dilakukan di RS: ........................................................



4. Harapan klien terhadap perawat untuk melaksanakan ibadahnya: ......................................... Q. Konsep Diri a. Citra tubuh : ……………………………………………………………………………….......... ……………………………………………………………………………………………………. …………………………………………………………….......................................................... .... b. Identitas : ………………………………………………………………………....………...... …………………………………………………………………………………………………........ ...................................................………………………………………………………………… c. Peran : …………………………………………………………………………....……...... ………………………………………………………………………………................................. ………………………………………………………………………………................................. d. Ideal diri : …………………………………………………………....……………………...... ……………………………………………………………………………. ………………………………………………………………………………………...................... .................................... e. Hargadiri : ………………………………………………………....... ………………………… ………………………………………………………………………. …………………………………………………………………………………………................... .......................................… R. Pemeriksaan fisik 1. Keadaan umum:....................................................................................................................... a. Kesadaran: ........................................................................................................................ b. Tanda tanda vital: Tek.darah : ..........mmHg Suhu o : .............. C Nadi : ..........x/m Pernapasan : ..............x/m 2. Kepala dan leher a. Kepala:  Bentuk.......... Massa..........Distribusi Rambut ...................Warna kulit kepala............  Keluhan: pusing/sakit kepala/migren/lainnya, sebutkan ............................................. ..................................................................................................................................... b. Mata  Bentuk ................................. Konjungtiva ........................................  Pupil: ( ) Reaksi terhadap cahaya ( ) Isokor ( ) Meiosis ( ) Pin Point ( ) Midriasis  Tanda radang:...............................................................................................................  Fungsi penglihatan: ( ) Baik ( ) Kabur  Penggunaan alat bantu: ( ) ya ( ) tidak Apabila ya: ( ) kaca mata ( ) lensa kontak ( ) minus.....ka/ki ( ) plus....ka/ki  Pemeriksaan mata terakhir: .........................................................................................  Riwayat operasi: ......................................................................................................... c. Hidung  Bentuk......................... Warna ............................... Pembengkakan...........Nyeri tekan........ Pendarahan......... Sinus ...............  Riwayat Alergi......... Cara mengatasi .........................................................................  Penyakit yang pernah terjadi ......................................................................................  Frekuensi.......................................... Cara mengatasi ................................................ d. Mulut dan tenggorokan  Warna bibir ...................... Mukosa.................. Ulkus.........Lesi............ Massa........... Warna lidah............................Perdarahan gusi .............Karies................................... Gangg bicara................................................  Pemeriksaan gigi terakhir............................................................................................. e. Telinga



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Bentuk .............................Warna ......................Lesi......... Massa ......... Nyeri.......... Nyeri Tekan...........  Fungsi Pendengaran ......... ....Alat bantu pendengaran ..............................................  Masalah Yang Pernah Terjadi: ................................................................................... f. Leher  Kekakuan.......... .....................Nyeri/nyeri tekan...................................  Benjolan/ Massa........ ............Keterbatasan gerak........................  Vena jugularis : ..................Tiroid...............Limfe................. Trakea........................ Keluhan: ......................................................................................................................  Upaya untuk mengatasi ............................................................................................... 3. Dada  Bentuk .......................................... Pergerakan Dada ..........................................................  Nyeri/nyeri tekan......Massa.........Peradangan......Taktil Fremitus ........................................ Pola Nafas .................................................................  Jantung Inspeksi................................................................................................................................ Palpasi ................................................................................................................................. Perkusi ................................................................................................................................ . Auskultasi ............................................................................................................................ .  Paru: Inspeksi................................................................................................................................ Palpasi ................................................................................................................................. . Perkusi ................................................................................................................................ Auskultasi ............................................................................................................................ 4. Payudara dan ketiak  Benjolan/Massa: .........................Nyeri/nyeri tekan ..............................................  Bengkak ....................... ...Kesimetrisan: ................................................................ 5. Abdomen  Inspeksi: .............................................................................................................................  Palpasi: ...............................................................................................................................  Perkusi: ..............................................................................................................................  Auskultasi: ........................................................................................................................... . 6. Genitalia  Inspeksi : .................................................................................... .......  Palpasi : .................................................................................... .......  Perempuan: Siklus Menstruasi ..........................................................................  Kontrasepsi ........................................................................................................  Kehamilan ..........................................................................................................  Keluhan ..............................................................................................................  Pria: Keluhan ...................................................................................................... 7. Ekstremitas  Kekuatan otot: ............................................................................................................. Kontraktur ..............Pergerakan .........................Deformitas .......... Pembengkakan ........... Edema ............... Nyeri/nyeri tekan ..............Pus/luka ........................................................ 8. Kulit dan Kuku  Kulit : Warna .................Jaringan parut: ............. Lesi........... Suhu........... Tekstur ............. Turgor.......................................................



 Kuku :



Warna ..................................... Bentuk ................................................. Lesi ........................................ Pengisian Kapiler ..................................



Hasil pemeriksaan penunjang ................................................................................................................................................. . ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. .. .............................................................................................................................................. ... ............................................................................................................................................. ................................................................................................................................................. ...... ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. .. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. .. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. .. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. .. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. .. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. .. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. .. ................................................................................................................................................. ................................................................................................................................................. ................................................................................................................................................. .. S. Pengobatan ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... T.



Perencanaan Pulang  Tujuan Pulang:.......................................................................................................................  Transportasi Pulang:...............................................................................................................  Dukungan Keluarga:...............................................................................................................  Antisipasi bantuan biaya setelah pulang:................................................................................  Antisipasi masalah perawatan diri setalah pulang:..................................................................



 Pengobatan:........................................................................................................................... ................................................................................................................................................ ................................................................................................................................................  Hal-hal yang perlu diperhatikan di rumah:.............................................................................. ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................  Keterangan lain:......................................................................................................................