RIWAYAT KEPERAWATAN DAN ALAT PENGKAJIAN

RIWAYAT KEPERAWATAN DAN ALAT PENGKAJIAN

INFORMASI UMUM

Nama Pasien    : ....................................                      Alergi    : ........…………..................................

Nomor Kamar    :.....................................                      Diet      : ...........…………...............................

Dokter              : ....................................                      TB/BB  : ..........…………................................

Usia                 : ....................................                      Tanda vital : S : N : P : TD .…………..............

Jenis Kelamin    : ....................................                      ......................................…………...................

Suku Bangsa     : ....................................                      Nama dan Nomor Telepone orang terdekat

Bahasa Dominan :.................................                        kat : kota tempat tinggal …………..................

Status Perkawinan :...............................                        .......................................…………..................

Keluhan Utama : ..................................             ........................................………….................

..............................................................                      Diagnose ( saat masuk dan saat ini )

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Kondisi Saat Penerimaan

Tanggal : ....................................          Waktu : .....................................................................................

Diantar oleh       : ..........................................................................................................................

Cara Penerimaan (kursi roda, berjalan, brankar ) : ......................................................................

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Dikirim dari        : ..........................................................................................................................

FAKTOR-FAKTOR PREDISPOSISI

Pengaruh Genetika        :

Susunan keluarga (gunakan genogram)

Asal keluarga    : ......................................        Keluarga Sekarang         : ..............................

Dinamika Keluarga (jelaskan hubungan-hubungan yang bermakna diatara para anggota keluarga) .......................................................................................................................................................

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Riwayat Medis/Psikiatri  :

Pasien              :  .........................................................................................................................

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Anggota Keluarga          : .............................................................................................................

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Pengaruh Genetik lain    yang mempengaruhi adaptasi pasien saat ini (Hal ini mungkin saja mencakup efek-efek yang spesifik terhadap jenis kelamin, ras, penampilan {seperti cacat fisik genetik} atau faktor-faktor yang lain yang berhubungan dengan genetik yang mempengaruhi adaptasi pasien yang belum diungkapkan dalam bagian manapun dari pengkajian ini)

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Pengalaman Masa Lalu

Latar Belakang Budaya dan Sosial

Faktor-faktor lingkungan (pengaturan tempat tinggal keluarga, type tetangga, kondisi kerja khusus) : .......................................................................................................................................

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Keyakinan dan Praktik Kesehatan (tangggung jawab pribadi untuk kesehatannya; praktik perawatan keluarga khusus ) : .....................................................................................................

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Praktik dan Keyakinan Religius : ..................................................................................................

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Latar belakang pendidikan          : ................................................................................................

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Perubahan atau kehilangan yag bermakna (cantumkan tanggal )    :............................................

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Hubungan teman sebaya/persahabatan : ....................................................................................

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Riwayat pekerjaan :.......................................................................................................................

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Pola koping sebelumnya terhadap stress : ...................................................................................

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Faktor kontribusi gaya hidup lain untuk adaptasi saat ini : ...........................................................

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Sumber-sumber saat ini

Tahapan perkembangan (Erikson)

Secara Teoritis : ...........................................................................................................................

Perilaku            : .......................................................................................................................................................

Rasional           : ..........................................................................................................................

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Sistem Pendukung         : .............................................................................................................

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Keamanan ekonomi       : .............................................................................................................

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Kesempatan produktivitas/Kontribusi: Status Pekerjaan Saat ini    : ...........................................

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Kontribusi Peran dan Tanggung  Jawab Lainnya : .......................................................................

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KEJADIAN PENCETUS

Jelaskan situasi/ kejadian yang mencetuskan terjadinya penyakit/perawatan di rumah sakit saat ini : ........................................................................................................................................

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PERSEPSI PASIEN TERHADAP STRESOR

Pasien dan atau anggota keluarga mengerti atau dapat menjelaskan stresor/penyakit dan harapan-harapannya tentang perawatan di rumah sakit : ............................................................

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RESPON-RESPON ADAPTASI

Psikososial

Tingkat ansietas (lingkari tingkatan dan periksa perilaku yang diterapkan ) :

Ringan ............... Sedang .............Berat .............. Oanik ............... Tenang .................Bersahabat ................................. Pasif ............................Waspada............................

Merasakan lingkungan dengan tepat .............. Kooperatif ..............Kerusakan perhatian ......................... “ gelisah “ ...................................................

Tidak mau berkonsentrasi..............Sangat waspada .................Tremor .............Berbicara cepat ...... Menarik diri.......... Bingung............Disorientasi...........Ketakutan...................Hiperventilasi..

Salah interprestasi terhadap lingkungan (halusinansi/delusi): ...........Dipersonalisasi .................

Obsesi .............................Kompulsif .................Keluhan-keluhan somatik ....................... Hiperaktivitas .................. Lain-lain...............................................................................................

Alam Perasaan/Apek

(Gambarkan sebanyak mungkin sesuai yang diperlihatkan) :

Kegembiraan :.......... Kesedihan ............ Kesal ...........Putus asa ..............Sangat gembira .........Euforia ................. Kecurigaan...........Apatis ..........(tonus emosi kecil) Marah/ bermusuhan ................................

Mekanisme Pertahanan Diri : (jelaskan bagaimana hal ini digunakan oleh pasien)

Projeksi                        : ..........................................................................................................................

Supresi             : ..........................................................................................................................

Merusak            : ..........................................................................................................................

Pengalihan        : ..........................................................................................................................

Intelektualisasi  : ..........................................................................................................................

Rasionalisasi     : ..........................................................................................................................

Menyangkal       : ..........................................................................................................................

Represi             : ..........................................................................................................................

Isolasi               : ..........................................................................................................................

Regresi             : ..........................................................................................................................

Pembentukan reaksi      : .............................................................................................................

Pemisahan        : ..........................................................................................................................

Religius                        : ..........................................................................................................................

Sublimasi          : ..........................................................................................................................

Kompensasi      : ..........................................................................................................................

Tigkat harga diri (lingkari salah satu) :

Rendah  ............ Sedang .............. Tinggi..............

Hal-hal yang pasien sukai dari dirinya      : ...................................................................................

Hal-hal yang ingin diubah dari dirinya       : ...................................................................................

Pengkajian objectig tentang Harga Diri    :

            Kontak mata                  : ................................................................................................

            Penampilan umum         : ................................................................................................

            Higiene diri                    : ................................................................................................

            Partisipasi dalam aktivitas kelompok/interaksi dengan oran lain : ..................…………..

Tahapan dan Manifestasi Berduka (lingkari salah satu) :

Mengingkari; ...... Marah ;....... Tawar-menawar;..... Depresi;....... Penerimaan;...........................................

Jelaskan perilaku pasien berkenaan dengan tahapan berduka dalam berespon terhadap kehilangan atau perubahan : ........................................................................................................

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Proses Pikir ( lingkari sebanyak mungkin sesuai dengan pasien ) :

Jelas ;     Logis;  Mudah diikuti;   Relevan;   Bingung ;    Terhambat  ;    Delusi ;        Alur pikir cepat ;   Kelambatan dalam asosiasi pikir ;        Kecurigaan ;

Memori jauh ;    Hilang                           ;  Utuh

Memori Terbaru ;  Hilang                             ; Utuh 

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

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Pola Komunikasi (Lingkari sebanyak mungkin yang sesuai dengan pasien )

Jelas;               Koheren ;                      Bicara  tak jelas ;           Inkoheren ;       Neologisme; Kehilangan asosiasi;                        Flight of idea;                Afasia;              Perseverasi;      Ruminasi; ;Bicara tangensial;     Suka bicara;                  Bicara lambat;               Miskin bicara;

Kesukaran bicara (gambarkan) ;              Lain-lain; .....................................................................

Pola Orientasi (gambarkan pola interaksi interpersonal pasien dengan staf dan sesama pasien dalam unit perawatan, misalnya manipulatif, menarik diri, isolasi, bermusuhan secara verbal maupun fisik, argumentattif, pasif. Asertif, agresif, fasif-agresif dll); .................................

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Orientasi Realita (Periksa hal ini bila sesuai):

Orientasi terhadap          : Waktu : ............................................  Orang   : ..............................................

                                      Tempat:............................................  Situasi  : ..............................

Ide Merusak Diri/Orang Lain ?     Ya  ....................  Tidak ...................

Jika ya, pertimbangkan rencana ; cara-cara yang tersedia .........................................................

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Fisiologis

Manifestasi Psikosomatik ( jekaskan beberapa keluhan yang mungkin berhubungan dengan stress yang dialami oleh pasien ): ................................................................................................

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Pengkajian dan Riwayat Pengobatan

Pengguinaan obat-obatan yang diresepkan :

Nama                           Dosis                            Resep                           Hasil

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Penggunaan obat yang dijual bebas :

Nama                           Dosis                            Penggunaan Untuk        Hasil

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Penggunaan Obat jalanan dan atau alkohol :

Jlh yg digunakan            Seberapa sering Kapan terakhir              Efek yang dihasilkan

                                    Digunakan                     Digunakan

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Pengkajian Fisik Yang Berhubungan:

Pernafasan: Normal :................... Kesukaran: ......................  Frekwensi..............Irama............

Kulit            :Hangat...........Kering..........Lembab..........Dingin..........Berkeringat..........Merah muda.....Sianosis......

                   Turgor buruk......Edema .............Tanda-tanda ........ Ruam......Memar....Bekas tusukan  jarum..............Hirsutisme ..............Kehilangan bulu badan........................

                   Lain-lain.....................................................................................................................

Status Muskuloskeletal  :

                   Lemah.............Tremor...............

                   Derajat rentang gerak  (gambarkan keterbatasan): .................................................

                   Nyeri (gambarkan) :..................................................................................................

                   Kelainan bentukl rangka (gambarkan) :....................................................................

                   Koordinasi (gambarkan keterbatasan) :....................................................................

Status Neurologis :

                   Riwayat ( periksa semua yang sesuai ):

                   Kejang       (jelaskan metode yang digunakan untuk mengontrol) : .......................

                   Sakit kepala (jelaskan lokasi dan frekwensianya) : .................................................

                   Pingsan      : ..............................................  Pusing            : ...........................................

                   Kebas/kesemuta (jelaskan lokasi)............................................................................

Kardiovaskuler :

Tekanan darah: ......................................           Nadi: ...........................................................................

Riwayat :

Hipertensi    : ...............................................                Palpitasi            :...............................

Murmur jantung :..........................................                  Nyeri dada        : ..............................

Sesak nafas      : .........................................                 Nyeri pada lengan          :..................

Plebitis            : .........................................                 Edema pergelangan kaki:..................

Kebas/kesemutan  pada ektremitas : ...........................................................................................

Varises vena     : ..................................................................................................................................

Gastrointestinal

Pola diet kebiasaan        : .............................................................................................................

Alergi makanan              : .............................................................................................................

Gigi palsu                      : atas .................................................. bawah ..................................

Masalah dalam mengunyah/menelan       : ...................................................................................

Perubahan BB terakhir   ; .............................................................................................................

Masalah dengan :

·             Pencernaan/nyeri ulu hati: .............. dihilangkan dengan ...............................................

·             Mual/muntah     .............................. dihilangkan dengan ................................................

·             Kehilangan nafsu makan            : ...................................................................................

·             Riwayat tukak lambung              :....................................................................................

·             Pola kebiasaan defekasi             : .............................Konstipasi ............Diare................

Tipe bantuan perawatan diri yang diberikan untuk setiap permaslahan di atas:...........................

Genitourinarius/Reproduktif :

Pola kebiasaan berkemih            : ................................................................................................

Keragu-raguan dalam berkemih ...................................................frekwensi : ..............................

Nokturia       : ...................................Nyeri/rasa terbakar :.............................................................

Inkontinensia     : ..........................................................................................................................

Lesi genital : .......................................................Rabas ................................Bau ........................

Riwayat penyakit hubungan kelamin        : .............................. Bila ya jelaskan ..........................

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Masalah-masalah tentang seksualitas/aktivitas seksual    : .........................................................

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Metode keluarga berencana yang digunakan        : ......................................................................

Wanita:

Tanggal siklus menstruasi terakhir          : ...................................................................................

Lamanya siklus menstruasi                    : ...................................................................................

Masalah berkenaan  dg menstruasi         : ...................................................................................

Payudara nyeri/nyeri tekan                     : ...................................................................................

Bengkak .......            Rabas ...........   Benjolan...............         Lekukan ...................

Praktek pemeriksaan payudara sendiri     : ................................................................Frekwensi

Pria:

Rabas penis      : ...........................................   Masalah prostat : ...........................................

Mata                             :           Ya                    Tidak                            Keterangan

Kaca mata                    :           .....                   ..........  ...............................................

Lensa kontak                 :           .....                   .........   ...............................................

Bengkak                       :           .....                   .........   ...............................................

Rabas                           :           .....                   .........   ...............................................

Gatal                            :           .....                   .........   ...............................................

Kabur                            :           .....                   .........   ...............................................

Penglihatan ganda         :           .....                   .........   ...............................................

Telinnga                        :           Ya                    Tidak                            Keterangan

Nyeri                            :           .....                   ..........  ...............................................

Drainase                       :           .....                   ..........  ...............................................

Kesulitan mendengar      :           .....                   ..........  ...............................................

Alat bantu dengar           :           .....                   ..........  ...............................................

Tinitus                          :           .....                   ..........  ...............................................

Efek Samping Pengobatan :

Gejala yang mungkin menyertai pemakaian obat-obatan saat ini : ..............................................

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Perubahan nilai-nilai laboratorium dan kemungkinan bermakna :

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Pola aktivitas Istirahat

Latihan (jumlah, type, frekwensi) ................................................................................................

Waktu senggang diantara kegiatan          : ..................................................................................

Pola tidur     :

         Jumlah waktu tidur setiap malam   : ...................................................................................

         Menggunakan alat bantu tidur        : ...................................................................................

         Pola bangun dimalam hari              : ...................................................................................

         Merasa segar saat terbangun         : ...................................................................................

Higiene pribadi/Aktivitas Kehidupan Sehari-hari/AKS        :

Pola perawatan diri : mandiri : ................................................................................................

Membutuhkan bantuan untuk:

                   Mobilitas    : ...........................................

                   Higiene      : ...........................................

                   Toileting     : ...........................................

                   Makan        : ...........................................

                   Berpakaian : ...........................................

                   Lain-lain jelaskan higiene pribadi dan penampilan umum         ; ..............................

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Pengkajian Fisik lainnya yang berkaitan : ................................................................................

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RINGKASAN PENGKAJIAN PSIKOSOSIAL/FISIK AWAL :

Kurang Pengetahuan Yang Teridentifikasi :

Diagnose Keperawatan yang Teridentifikasi :