format pengkajian ub
DESCRIPTION
MEDICALTRANSCRIPT
JURUSAN KEPERAWATANFAKULTAS KEDOKTERAN
UNIVERSITAS BRAWIJAYAPENGKAJIAN DASAR KEPERAWATANNama Mahasiswa: NIM : Tempat Praktik: Tgl. Praktek :
A. Identitas KlienNama
:
No.RM
: Usia
:
Tgl. Masuk
: Jenis Kelamin:
Tgl. Pengkajian: Alamat
:
Sumber Informasi: No. Telepon: -
Nama klg. Dekat yng bisa dihubungi :Status Pernikahan:
...........................................................................Agama
:
Status
: Suku
:
Alamat
:.......................................Pendidikan: -
No. Telepon
:.......................................Pekerjaan
: -
Pendidikan
:.......................................Lama Bekerja: -
.Pekerjaan
:.......................................B. Status Kesehatan Saat Ini1. Keluhan utama
: 2. Diagnosa Medis:
Riwayat Kesehatan Saat IniKeluhan Saat pengkajian :
Riwayat Kesehatan Terdahulu
3. Penyakit yang pernah dialami:a. Kecelakaan (jenis & waktu): tidak adab. Operasi (jenis & waktu): tidak adac. Penyakit:
Akut: Kronis: -4. Alergi (obat, makanan, plester, dll):
Tidak ada
5. Imunisasi ( ) BCG
( ) Hepatitis
( ) Polio
( ) Campak
( ) DPT
6. Obat-obatan yang digunakan
Jenis
Lamanya
Dosis
.........................
.................................................. ..........................................
C. Riwayat Keluarga
GENOGRAMKeterangan :
: Laki-laki
: Perempuan
X: Meninggal
: Pasien
: Tinggal Serumah
: Menikah
: Garis Keturunan
D. Riwayat LingkunganJenis
Rumah
Pekerjaan
Kebersihan
.......................................................................................................
Bahaya kecelakaan.......................................................................................................
Polusi
.......................................................................................................
Ventilasi
......................................................................................................
Pencahayaan
......................................................................................................
................................................................................................................................
E. Pola Aktivitas-Latihan
Jenis
Rumah
Rumah Sakit
Makan/Minum........................................................................................................................ Mandi
...................................................................................................................... Berpakaian..................................................................................................................... Toiletting....................................................................................................................... Mobilitas...................................................................................................................... Berpindah...................................................................................................................... Berjalan
...................................................................................................................... Naik tangga.......................................................................................................................Pemberian Skor: 0=mandiri, 1=alat bantu, 2=dibantu orang lain (1 orang), 3=dibantu orang lain (>1 orang), 4=tidak mampuF. Pola NutrisiJenis
Rumah
Rumah Sakit
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......................................................................................................
G. Pola Eliminasi
Jenis
Rumah
Rumah Sakit
BAB
Frekuensi/pola
.......................................................................................................
Konsistensi
.......................................................................................................
Warna & bau
.......................................................................................................
Kesulitan
.......................................................................................................
Upaya mengetasi.......................................................................................................
BAK
Frekuensi/pola.......................................................................................................
Konsistensi
.......................................................................................................
Warna & bau
.......................................................................................................
Kesulitan
.......................................................................................................
Upaya mengetasi.......................................................................................................
H. Pola Tidur-Istirahat
Rumah
Rumah Sakit
Tidur siang: Lamanya...........................................
..................................................- Jam .....s/d.................................................
...................................................
- Kenyamanan stl tidur...........................................
................................................... Tidur malam: Lamanya...........................................
...................................................- Jam .....s/d.................................................
...................................................
- Kenyamanan stl tidur...........................................
...................................................- Kebiasaan sbl tidur...........................................
...................................................
- Kesulitan
...........................................
...................................................
- Upaya mengatasi...........................................
...................................................
I. Pola Kebersihan DiriRumah
Rumah Sakit
Mandi: Frekuensi...........................................
.................................................. Penggunaan sabun...........................................
...................................................
Keramas: Frekuensi...........................................
...................................................- Penggunaan Shampo...........................................
................................................... Gosok gigi: Frekuensi...........................................
...................................................- Penggunaan odol...........................................
................................................... Ganti baju: Frekuensi...........................................
................................................... Memotong kuku: Frekuensi.....................................
.................................................... Kesulitan
...........................................
................................................... Upaya yang dilakuan...........................................
...................................................J. 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.........................................................................................
K. 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 sebutkan4. Masalah tentang peran/hubungan dengan keluarga selama perawatan di RS .............................................................................................................................................................................5. Upaya yang dilakukan untuk mengatasi.....................................................................................L. Pola Komunikasi
1. Bicara:( ) Normal
( ) Bahasa utama: jawa
( ) 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 yag dianut: ......................................................................................................
b. Pantangan adat dan agama yang 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
M. Pola Seksualitas
1. Masalah dalam hubungan seksual selama sakit: ( ) Tidak ada( ) Ada2. Upaya yang dilakukan pasangan: ( ) Perhatian ( ) Sentuhan
( ) Lain-lain, seperti ...................................................................................................................N. 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: .........................................O. Pemeriksaan fisik1. Keadaan umum:.......................................................................................................................
a. Kesadaran: ........................................................................................................................b. Tanda tanda vital:Tek.darah : ..........mmHg
Suhu
: ..............oC
Nadi
: ..........x/m
Pernapasan: ..............x/m2. 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 ....................................................................................................d. Mulut dan tenggorokan
Warna bibir ...................... Mukosa.................. Ulkus.........Lesi............ Massa...................... Warna lidah............................Perdarahan gusi .............Karies...................................
Gangg bicara................................................ Pemeriksaan gigi terakhir.............................................................................................e. Telinga
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 ................................................................. JantungInspeksi................................................................................................................................Palpasi .................................................................................................................................Perkusi .................................................................................................................................Auskultasi ............................................................................................................................. Paru:
Inspeksi................................................................................................................................Palpasi ..................................................................................................................................Perkusi ................................................................................................................................Auskultasi ............................................................................................................................4. Payudara dan ketiak Benjolan/Massa: .............................Nyeri/nyeri tekan ......................................................... Bengkak ........................................Kesimetrisan: ................................................................5. Abdomen
Inspeksi: .............................................................................................................................. .... Auskultasi : .......................................................................................................................... Perkusi: ............................................................................................................................... Palpasi: ................................................................................................................................... ...6. Genitalia Inspeksi
: ............................................................................................................ Palpasi
: ............................................................................................................ 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 ..................................P. Hasil pemeriksaan penunjang
Radiologi
.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Q. Pengobatan................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Hasil pemeriksaan laboratorium
No.Jenis PemeriksaanHasilNilai Normal
ANALISA DATA
No.DataEtiologiMasalah keperawatan
DAFTAR DIAGNOSA KEPERAWATAN
(Berdasarkan Prioritas)
Ruang
:
Nama Pasien:
Diagnosa:
No.Tanggal
MunculDiagnosa MunculTanggal TeratasiTanda Tangan
Rencana Asuhan KeperawatanDiagnosa keperawatan No.
Tujuan
:
Kriteria hasil
:
NOC :
No.Indikator12345
Keterangan penilaian :
1:
2:
3:
4:
5:
NOC : No.Indikator12345
Keterangan penilaian :
1:
2:
3:
4:
5:
Intervensi NIC
IMPLEMENTASI
Nama Klien
:
Tanggal Pengkajian:
Diagnosa Medis:
TglNo. Dx. KepJamTindakan KeperawatanRespon KlienTTD & Nama Terang
TglNo. Dx. KepJamTindakan KeperawatanRespon KlienTTD & Nama Terang
CATATAN PERKEMBANGAN (PROGRES NOTE)Diagnosa keperawatan No.NOC :
NoIndikatorTanggal Observasi Dan Hasil
1234S1234S1234S
Diagnosa keperawatan No.
NOC :
NoIndikatorTanggal Observasi Dan Hasil
1234S1234S1234S
Diagnosa keperawatan No.
NOC :
NoIndikatorTanggal Observasi Dan Hasil
1234S1234S1234S
Keterangan penilaian:
-: Tidak sesuai
+: Sesuai dengan diharapkan
S: Scoring
Keterangan Skoring:
1: -
2: 1+
3: 2+ 4: 3+
5: 4+
EVALUASI
Hari/ Tanggal/ JamNo. Dx. Kep.EvaluasiTanda tangan
S :
O :
NOC :
IndikatorScore
Awal
Trgt
Akhir
A : Masalah sesuai dengan NOC sudah teratasi/belum teratasi
P : Intervensi dihentikan / dilanjutkan dan didelegasikan
Kepada perawat dinas .................. :
1. NIC :
2. NIC :
S :
O :
NOC :
IndikatorScore
Awal
Trgt
Akhir
A : Masalah sesuai dengan NOC sudah teratasi/belum teratasi
P : Intervensi dihentikan / dilanjutkan dan didelegasikan
Kepada perawat dinas .................. :
1. NIC :
2. NIC :
*coret yang tidak perlu