Kamis, 10 Maret 2011

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 )
..............................................................                      ..........................................…………...............
..............................................................                      ......................................…………...................

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) : .......................................................................................................................................
..............................................................................................................................................................................................................................................................................................................
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 : ........................................................................................................
.......................................................................................................................................................

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 : ......................................................................................................................................
.......................................................................................................................................................

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 ): ................................................................................................
.......................................................................................................................................................

Pengkajian dan Riwayat Pengobatan
Pengguinaan obat-obatan yang diresepkan :

Nama                           Dosis                            Resep                           Hasil
........................                        ............................        ..............................      ................................
........................                        ...........................         ..............................      ................................
........................                        ...........................         ..............................      ................................

Penggunaan obat yang dijual bebas :

Nama                           Dosis                            Penggunaan Untuk        Hasil
........................                        ............................        ..............................      ...............................
........................                        ...........................         ..............................      ................................
........................                        ...........................         ..............................      ................................

Penggunaan Obat jalanan dan atau alkohol :
Jlh yg digunakan            Seberapa sering Kapan terakhir              Efek yang dihasilkan
                                    Digunakan                     Digunakan
.........................                       ..........................                      .......................................................................
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 : ..............................................
.......................................................................................................................................................

Perubahan nilai-nilai laboratorium dan kemungkinan bermakna :
..............................................................................................................................................................................................................................................................................................................

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         ; ..............................
                   ..................................................................................................................................

Pengkajian Fisik lainnya yang berkaitan : ................................................................................
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RINGKASAN PENGKAJIAN PSIKOSOSIAL/FISIK AWAL :




Kurang Pengetahuan Yang Teridentifikasi :





Diagnose Keperawatan yang Teridentifikasi :




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