FORMAT PENGKAJIAN ASUHAN KEPERAWATAN
MODEL DOENGES
INFORMASI
UMUM
A. Identitas Klien.
Nama:................................................................
Usia:..................................................................
Jenis kelamin:....................................................
Agama :........................................................
Suku bangsa:.....................................................
Pendidikan:.......................................................
Pekerjaan:..........................................................
Alamat :........................................................
Tanggal masuk :................................................ Waktu
:................................................
No. Rekam Medik:...........................................
B. Identitas Penanggung Jawab.
C. Alasan Masuk Rumah Sakit :
D.
AKTIVITAS/ISTIRAHAT
Gejala
(subjektif)
Pekerjaan :......................................................... Aktivitas/hobby
:.................................
Aktivitas waktu luang:....................................................................................................
Perasaan bosan/tidak puas :............................................................................................
Keterbatasan karena kondisi :.........................................................................................
Tidur: Jam:........................................................ Tidur
Siang:.........................................
Alat bantu:......................................................................................................................
Insomnia:................................................. yang
berhubungan dengan:..................
................................................................. Rasa
segar saat bangun:.......................
Lain-lain :...............................................................................................................
Tanda (objektif)
Respon terhadap aktivitas yang teramati:
Kardiovaskuler :........................................... Pernafasan :
Status mental (y.i, menarik
diri/letargi):..........................................................................
Pengkajian neuromuskuler:.............................................................................................
Massa/tonus otot :..................................................................................................
Postur:....................................................................................................................
Tremor:...................................................................................................................
Rentang gerak:.......................................................................................................
Kekuatan :..............................................................................................................
Deformitas :...........................................................................................................
SIRKULASI
Gejala
(subjektif)
Riwayat
tentang : Hipertensi :........................................................................................
Masalah
Jantung :...........................................................................................................
Demam Rematik :..................................................................................................
Edema mata kaki/kaki :..........................................................................................
Flebitis :.................................................................................................................
Penyembuhan lambat :...........................................................................................
Klaudikasi :............................................................................................................
Ekstremitas : Kesemutan :....................... Kebas :.................................................
Batuk/hemoptisis :.................................................................................................
Perubahan frekwensi/jumlah urine :.......................................................................
Tanda
(objektif)
TD :
kanan dan kiri : baring/duduk/berdiri :...................................................................
Tekanan nadi :........................................................................................................
Gap auskultatori :...................................................................................................
Nadi
(palpasi) : Karotis :.................................................................................................
Temporaslis :............................................ Jugularis
:.............................................
Radialis :.................................................. Femoralis
:............................................
Popliteal :................................................. Postibial
:.............................................
Dorsalis Pedis :......................................................................................................
Jantung
(palpasi) :
Getaran :.................................................. Dorongan
:...........................................
Bunyi
Jantung : Frekuensi :.............................. Irama
:..................................................
Kualitas :.................................................. Friksi
Gesek :.......................................
Murmur :................................................................................................................
Bunyi
Nafas : Desiran Vascular :....................................................................................
Destensi vena Jugularis :........................................................................................
Ekstremitas : suhu :.......................................... Warna
:.................................................
Pengisian kapiler :.................................... Tanda Homan’s :..................................
Varises :................................................... Abnormalitas
kuku :.............................
Penyebaran/kualitas rambut :.................................................................................
Warna :.............................................................. Membran
mukosa :...............................
Bibir :....................................................... Punggung
kuku :..................................
Konjungtiva :........................................... Sklera
:.................................................
Diaforesis :.............................................................................................................
INTEGRITAS
EGO
Gejala
(subjektif)
Faktor
stress :..................................................................................................................
Cara
menangani stress :...................................................................................................
Masalah-masalah
finansial :............................................................................................
Status
hubungan :...........................................................................................................
Faktor-faktor
budaya :....................................................................................................
Agama :............................................................. Kegiatan
keagamaan :..........................
Perasaan-perasaan
: Ketidakberdayaan :.........................................................................
Keputusasaan :.......................................................................................................
Ketidakberdayaan :................................................................................................
Tanda
(objektif)
Status
emosional (beri tanda cek untuk yang sesuai) :
Tenang :................................................... Cemas
:................................................
Marah :..................................................... Menarik
diri :.......................................
Takut :...................................................... Mudah
tersinggung :............................
Tidak sabar :............................................. Euforik
:...............................................
Respon-respon
fisiologis yang terobsesi :.......................................................................
ELIMINASI
Gejala
(subjektif)
Pola BAB:......................................................... Penggunaan
laxatif :............................
Karakter
feses :................................................. BAB
terakhir :.....................................
Riwayat
perdarahan :........................................ Haemorrhoid
:......................................
Konstipasi
:....................................................... Diare
:..................................................
Pola BAK
:....................................................... Inkontinensia/kapan
:...........................
Dorongan :............................................... Frekuensi
:............................................
Retensi :.................................................................................................................
Karakter
urine :...............................................................................................................
Nyeri/rasa
terbakar/kesulitan BAK :...............................................................................
Riwayat
penyakit ginjal/kandung kemih :......................................................................
Penggunaan
Diuretik :....................................................................................................
Tanda
(objektif)
Abdomen :
Nyeri tekan :.................................. lunak/keras
:.........................................
Bising usus :...........................................................................................................
Haemorrhoid
:.................................................................................................................
Perabaan
kandung kemih :..............................................................................................
BAK
terlalu sering :........................................................................................................
MAKANAN/CAIRAN
Gejala
(subjektif)
Diit
biasa (tipe) : ............................................................................................................
Jumlah
makanan per hari : ..............................................................................................
Makan
terakhir/masukan : ................................ Pola
diit : .............................................
Kehilangan
selera makan :..............................................................................................
Mual/muntah
:.................................................................................................................
Nyeri ulu
hati/salah cerna :..............................................................................................
Yang berhubungan dengan : ................... Disembuhkan oleh : ............................
Alergi/intoleransi
makanan : ..........................................................................................
Masalah-masalah
mengunyah/menelan : ........................................................................
Gigi : .....................................................................................................................
Berat badan
biasa : ........................................... Perubahan
berat badan : ......................
Penggunaan
Diuretik :....................................................................................................
Tanda
(objektif)
Berat
badan sekarang : ..................................... Tinggi
badan : .....................................
Bentuk
tubuh : ................................................. turgor
kulit : ........................................
Kelembaban/kering
membran mukosa : .........................................................................
Edema :
Umum : .............................................. Dependen
: ..........................................
Periorbital : .............................................. Asites
: ................................................
Distensi
vena jugularis : .................................................................................................
Pembesaran
tiroid : .......................................... Hernia/massa
: .....................................
Halitosis
: .......................................................................................................................
Kondisi :
gigi/gusi :.........................................................................................................
Penampilan
lidah : ..........................................................................................................
Membran mukosa : ................................................................................................
Bising
usus : ...................................................................................................................
Bunyi
nafas : ..................................................................................................................
Urine S/A
atau kemstiks : ..............................................................................................
HIGIENE
Gejala
(subjektif)
Aktivitas
sehari-hari : tergantung/mandiri :....................................................................
Mobilitas : ............................................... Makan
: ...............................................
Higiene :................................................... Berpakaian
: ........................................
Toileting : ..............................................................................................................
Waktu mandi yang diinginkan : ............................................................................
Pemakaian alat bantu/prostetik : ...........................................................................
Bantuan diberikan oleh :........................................................................................
Tanda
(objektif)
Penampilan
umum :.........................................................................................................
Cara
berpakaian :.............................................. Kebiasaan
pribadi :..............................
Bau badan
: ...................................................... Kondisi
kulit kepala :...........................
Adanya
kutu : ................................................................................................................
NEUROSENSORI
Gejala
(subjektif)
Rasa
ingin pingsan/pusing : ............................................................................................
Sakit
kepala : lokasi nyeri : .............................. Frekuensi
:............................................
Kesemutan/kebas/kelemahan
(lokasi) :...........................................................................
Stroke
(gejala sisa) : .......................................................................................................
Kejang : ............................................................ Tipe
: ...................................................
Aura : ...................................................... Frekuensi
: ...........................................
Status postikal : ....................................... Cara mengontrol : ...............................
Mata :
Kehilangan penglihatan : ....................................................................................
Pemeriksaan terakhir : ...........................................................................................
Glaukoma : .............................................. Katarak
: .............................................
Telinga :
Kehilangan pendengaran : ...............................................................................
Pemeriksaan terakhir :............................................................................................
Epistaksis
: ....................................................... Indera
penghidu : ................................
Tanda
(objektif)
Status
mental : ...............................................................................................................
Terorientasi/disorientasi : Waktu :.........................................................................
Tempat : ......................................................................
Orang
: .......... ............................................................
Kesadaran : ............................................. Mengantuk
: ........................................
Letargi : ................................................... Stupor
: ...............................................
Koma : .................................................... Kooperatif
: .........................................
Menyerang : ............................................ Delusi
:.................................................
Halusinasi : .............................................. Afek
(gambarkan) : .............................
...............................................................................................................................
Memori :
Saat ini : ............................................ Yang
lalu : ...........................................
Kaca mata
: ...................................................... Kontan
lensa : .....................................
Alat
bantu dengar : ........................................................................................................
Ukuran/reaksi
pupil : kanan/kiri : ...................................................................................
Facial
droop : ................................................... Menelan
: ............................................
Genggaman
tangan/lepas : kanan/kiri : ..........................................................................
Postur : ............................................................. Reflek
tendon dalam : ........................
Paralisis
: ........................................................................................................................
NYERI/KETIDAKNYAMANAN
Gejala
(subjektif)
Lokasi : ............................................................ Intensitas
(1-10 di mana 10 sangat nyeri ) Frekwensi
:
Kualitas
: .......................................................... Durasi
: ................................................
Penjalaran
: ....................................................... faktor-faktor
pencetus : ......................
Cara
menghilangkan, faktor-faktor yang berhubungan : ...............................................
Tanda
(objektif)
Mengkerutkan
muka :....................................... Menjaga
area yang sakit : ....................
Respon
emosional : .......................................... Penyempitan
fokus : ...........................
PERNAFASAN
Gejala
(subjektif)
Dispnea,
yang berhubungan dengan batuk/sputum: ......................................................
Riwayat
bronkhitis : ......................................... Asthma
: ..............................................
Tuberkulosa :............................................ Emfisema
: ..........................................
Pneumonia kambuhan : ........................... Pemajanan terhadap udara berbahaya
:
Perokok :
.......................................................... Pak/hari
: .............................................
Lama dalam tahun : ..............................................................................................
Penggunaan
alat bantu pernafasan : ...............................................................................
Oksigen : ...............................................................................................................
Gejala
(objektif)
Pernafasan
: Frekuensi : ................................... Kedalaman
:.........................................
Simetris : ...............................................................................................................
Penggunaan
otot-otot asesoris : ....................... Nafas
cuping hidung : .........................
Fremitus
: .......................................................................................................................
Bunyi
nafas : ..................................................................................................................
Egofoni :
........................................................................................................................
Sianosis
: .......................................................... Jari
tubuh : ..........................................
Karakteristik
sputum : ....................................................................................................
Fungsi
mental/gelisah : ...................................................................................................
KEAMANAN
Gejala
(subjektif)
Alergi/sensivitas
: ............................................. Reaksi
: ...............................................
Perubahan
sistem imun sebelumnya : .............................................................................
Penyebab : .............................................................................................................
Riwayat
penyakit hubungan seksual (tanggal/tipe) : .....................................................
Perilaku
resiko tinggi : ...................................................................................................
Periksaan : .............................................................................................................
Transfusi
darah/jumlah : ................................... Kapan
: ................................................
Gambaran reaksi : .................................................................................................
Riwayat
cedera kecelakaan : ..........................................................................................
Fraktur/dislokasi
: ..........................................................................................................
Artritis/sendi
tak stabil : .................................................................................................
Masalah
punggung : .......................................................................................................
Perubahan
pada tahi lalat : ............................... Pembesaran
nodus : ............................
Kerusakan
penglihatan, pendengaran : ..........................................................................
Protese :
........................................................... Alat
ambulatori : .................................
Tanda
(objektif)
Suhu
tubuh : ..................................................... Diaforesis
: ..........................................
Integritas
kulit : ..............................................................................................................
Jaringan parut .......................................... Kemerahan
: ........................................
Laserasi : ................................................. Ulserasi
: .............................................
Ekimosis : ................................................ Lepuh
: ................................................
Luka bakar (derajat/persen) : .................. Drainase : ............................................
Tandai
lokasi pada diagram dibawah ini :
Muka
Belakang
Kekuatan
umum : ............................................. Tonus
otot : .........................................
Cara
berjalan : .................................................. ROM
: .................................................
Parestesia/paralisis
: ........................................................................................................
Hasil
kultur, pemeriksaan sistem imun : .........................................................................
SEKSUALITAS
: (Komponen dari Interaksi Sosial)
Aktif
melakukan hubungan seksual : .............................................................................
Penggunaan kondom : ..........................................................................................
Masalah-masalah/kesulitan seksual : .....................................................................
Perubahan terakhir dalam frekuensi/minat : ..........................................................
Wanita
Gejala
(subjektif)
Usia
menarke : ................................................. Lamanya
siklus : .................................
Durasi : ..................................................................................................................
Periode
menstruasi terakhir : ............................ Menopause
: ........................................
Rabas
vaginal : ................................................. Perdarahan
antar periode : ..................
Melakukan
pemeriksaan payudara sendiri/mammogram : .............................................
PAP smear
terakhir : ......................................................................................................
Tanda
(objektif)
Pemeriksaan
payudara : .................................................................................................
Kutil
genital/lesi : ...........................................................................................................
Pria
Gejala
(subjektif)
Rabas
penis : .................................................... Gangguan
prostat : ..............................
Sirkumsisi
: ....................................................... Vasektomi
: .........................................
Melakukan
pemeriksaan sendiri : ..................... Payudara/Testis
: .................................
Protoskopi/pemeriksaan
prostat terakhir : ......................................................................
Tanda
(objektif)
Pemeriksaan
: ................................................... Payudara/penis/testis
: .........................
Kutil
genital/lesi : ...........................................................................................................
INTERAKSI
SOSIAL
Gejala
(subjektif)
Status
perkawinan : .......................................... Lama
: .................................................
Hidup dengan : ....................................... masalah-masalah/stress
: ......................
Keluarga
besar : .............................................................................................................
Orang
pendukung lain : .................................................................................................
Peran
dalam struktur keluarga : .....................................................................................
Masalah-masalah
yang berhubungan dengan penyakit/kondisi : ...................................
Perubahan
bicara : Penggunaan alat bantu komunikasi : ...............................................
Adanya Laringektomi : .........................................................................................
Tanda
(objektif)
Bicara :
Jelas : .................................................. Tidak
jelas : .........................................
Tidak dapat dimengerti : ......................... Afasia : ................................................
Pola bicara tidak biasa/kerusakan : .......................................................................
Penggunaan alat bantu bicara : .............................................................................
Komunikasi
verbal/non verbal dengan keluarga/orang dekat lain : ...............................
Pola
interaksi keluarga (perilaku) : .................................................................................
PENYULUHAN/PEMBELAJARAN
Gejala
(subjektif)
Bahasa
dominan (khusus) : .............................. Melek
huruf : ......................................
Tingkat pendidikan
: ......................................................................................................
Ketidakmampuan
belajar (khusus) : ...............................................................................
Keterbatasan
kognitif : ..................................................................................................
Keyakinan
kesehatan/yang dilakukan : ..........................................................................
Orientasi
spesifik terhadap perawatan kesehatan (seperti dampak dari agama/kultural yang
dianut) : ..........................................................................
Faktor
resiko keluarga (tandai hubungan) : ...................................................................
Diabetes : ................................................ Tuberkulosis
: ......................................
Penyakit jantung : ................................... Stroke : ................................................
TD Tinggi : .............................................. Epilepsi
: .............................................
Penyakit ginjal : ...................................... Kanker : ..............................................
Penyakit jiwa : ........................................ Lain-lain :.............................................
Obat yang
diresepkan (lingkari dosis terakhir) : ............................................................
Obat Dosis Waktu Diminum secara teratur Tujuan
.......... .......... .......... ..................................... ............
.......... .......... .......... ...................................... ............
.......... .......... .......... ...................................... ............
Obat-obat
tanpa resep : obat-obat bebas : ........ .............................................................
Obat-obat jalanan : ................................................................................................
Tembakau : ............................................................................................................
Perokok tembakau : ..............................................................................................
Penggunaan
alkohol (jumlah/frekuiensi) : ......................................................................
Diagnosa
saat masuk per dokter : ..................................................................................
Alasan
dirawat per pasien : ............................................................................................
Riwayat
keluhan terakhir : .............................................................................................
Harapan
pasien terhadap perawatan ini : .......................................................................
Penyakit
dan/atau perawatan/pembedahan sebelumnya : ..............................................
Bukti
kegagalan untuk perbaikan : ................................................................................
Pemeriksaan
fisik lengkap terakhir : ..............................................................................
Pertimbanagan
Rencana Pulang
DRG yang
menunjukan lama dirawat rata-rata : ...........................................................
Tanggal
informasi didapatkan : .....................................................................................
1. Tanggal pulang yang diantisipasi : .....................................................................
2. Sumber-sumber yang tersedia : orang
:...............................................................
Keuangan : .........................................................................................................
3. Perubahan-perubahan yang
diantisipasi dalam situasi kehidupan setelah pulang :
4. Area yang mungkin membutuhkan
perubahan/bantuan : ...................................
Penyiapan
makanan :........................................ Berbelanja
: .........................................
Transportasi
: .................................................... Ambulasi
: ...........................................
Obat/terapi
IV : ................................................ Pengobatan
: .......................................
Perawatan
luka : ............................................... Peralatan
: ...........................................
Bantuan
perawatan diri (khusus) : .................................................................................
Gambaran
fisik rumah (khusus) : ...................................................................................
Bantuan
merapihkan/pemeliharaan rumah : ...................................................................
Fasilitas kehidupan selain rumah (khusus) : ..........................................................
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