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 :
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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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