CHAPTER III

FORMAT PENGKAJIAN MODEL DOENGES

General Information

Name: __________ Age: ____ DOB: ________ Gender: _______ Race: ___________

Admission Date: ___________________ Time: _________ From: ________________

Reason for this visit/admission (primary concern): _____________________________

Source of informatuion: _____________ Reliability (1-4, with 4 = very reliable): ____

Activity/Rest

Subjective (Reports)

Occupation: ___________ Able to participate in usual activities/hobbies: ___________

Leisure time/diversional activities: __________________________________________

Ambulatory: _______________ Gait (describe): _______________________________

Activity level (sedentary to veri active; use scale if available): ____________________

Daily exercise (type): ____________________________________________________

Change in muscle mass/tone/strength: _______________________________________

History of problems/limitations imposed by condition (e.g., immobility, transfer

difficulities, weakness, breathlessness): ______________________________________

Feelings (e.g, exhaustion, restlessness, boredom, dissatisfaction): __________________

Developmental factors (e.g., delayed/age appropriate): __________________________

Sleep: Hours: ______ Naps: ______ Aids: _____ Insomnia: _____ Related to: _______

Difficulty falling asleep: ___________ Difficulty staying asleep: ____________

Rested on awakening: ____ Excessive grogginess: _____ Bedtime rituals: _____

Relaxation techniques: _________ Sleeps on more than one pillow: __________

Use of oxygen (type): ______________________ When used: ____________________

Medications or herbals for/affecting sleep: ____________________________________

Objective (Exhibits)

Observed response to activity: Heart rate: __ Rhythm (reg/irreg): __ Blood pressure: __

Respiratory rate: _________________ Pulse oximetry: ____________________

Mental status (e.g., cognitive impairment, withdrawn/lethargic): ___________________

Neuromuscular assessment: Muscle mass/tone: ________________________________

Posture (e.g., normal, stooped, curved spine): _____ Tremors (location): ______

ROM: ____________ Strength: ______________ Deformity: _______________

Mobility aids (list): ______________________________________________________

Circulation

Subjective (Reports)

History of/treatment date: High blood pressure: _____ Brain injury: _____ Stroke: ____

Heart condition/surgery: ___ Rheumatic fever: ___ Palpitations: __ Syncope: __

Pain in legs: __ Ankle/leg edema: ___ Blood clots: ___ Bleeding tendencies: __

Spinal cord injury/dysreflexia episodes (describe): ________________________

Slow/delayed healing (describe): ____________________________________________

Extremities: Numbness (location): ___________ Tingling (location): _______________

Cough (describe)/hemoptysis: ______________________________________________

Change in frequency/amount of urine: _______________________________________

Medications herbals: _____________________________________________________

Objective (Exhibits)

Color (e.g., pale, cyanotic, jaundiced, mottled, ruddy): ___________ Skin: __________

Murcous membranes: ______ Lips: _____ Nailbeds: _____ Conjunctiva: _____

Skin moisture (e.g., dry, diaphoretic): ________________________________________

BP (R & L): Lying: __ Sitting: __ Standing: __ Pulse pressure: __ Auscoltatory gap: __

Pulses (palpated 1-4 strength): Carotid: ____ Temporal: ____ Jugular: ___ Radial: ____

Femoral: _______ Popliteal: ______ Posttibial: ______ Dorsalis pedis: _______

Cardiac (palpation): Thrill: ____________________ Heaves: _____________________

Heart sounds (auscultation): Rate: ____ Rhythm: ____ Quality: ____ Friction rub: ____

Murmur (describe location/sounds): ___________________________________

Vascular bruit (location): ______________Jugular vein distention: ________________

Breath sounds (describe location & sounds): __________________________________

Extremities: Temperature: _______ Color: _______ Capillary refill (1-3 sec): ________

Edema (+1 to +4): _________________________________________________

Varicosities (location): _________________ Nail abnormalities: __________________

Distribution/quality of hair: ___________ Trophic skin changes:_____________

Ego Integrity

Subjective (Reports)

Relationship status: ______________________________________________________

Expressed concerns (e.g., financial, relationship, recent or anticipated lifestyle/role

changes, recent tour(s) of combat duty: _______________________________________

Stress factors: _______________ Usual ways of handling stress: __________________

Expression of feelings of: Anger: ______ Anxiety: ______ Fear: ______ Grief: ______

Helplessness: ________ Hopelessness: _________ powerlessness: __________

Cultural factors ethnic ties: ________________________________________________

Religious affiliation: _____ Active/practicing: ____ Practices prayes/meditation: _____

Religious/spiritual concerns: ____________ Desires clergy visit: ____________

Medications/herbals: _____________________________________________________

Objective (Exhibits)
Emotional status (check those that apply):

Calm: _____ Anxious: _____ Withdrawn: _____ Fearful: _____ Irritable: _____

Restive: ___________________________ Euphoric: _____________________

Observed body language: _________________________________________________

Observed physiological responses (e.g., crying, change in voice quality/

volume): _________________________________________________________

Changes in energy field: Temperature: _______ Color: _______ Distribution: ________

Movement: _________________________ Sounds: ______________________

Elimination

Subjective (Reports)

Usual bowel elimination pattern: ____ Character of stool (e.g., hard, soft, liquid): _____

Stool color (e.g., brown, black, yellow, clay colored, tarry): ________________
Last BM/Character of stool: ________ Constipation (acute/chronic): _________
Diarrhea (acute/chronic): ___ Bowel incontinence: ___ History of bleeding: ___
Hemorrhoids/fistula: _______________________________________________

Laxative use: ____ How often: ____ Enema/suppository: ____ How often: ____

Usual voiding pattern and character of urine: __________________________________

Difficulty voiding: _____ Urgency: _____ Frequency: _____ Retention: ______

Bladder spasms: _____________________ Pain/burning: __________________

Urinary incontinence (type & time of dat usually occurs): ________________________

History of kidney/bladder disease or stones: ___________________________________

Diuretic use: _________________ Other medications/herbals: ____________________

Objective (Exhibits)

Abdomen (auscultation): Bowel sounds (location/type): _________________________

Abdomen (palpation): Soft/firm: ___ Tenderness/pain (quadrant location): ____

Palpable mass: ____________________ Size/grith: _______________________

Bladder palpable: _______ Residual (per scan): _______ Overflow voiding: ________

Rectal sphincer tone (describe): ___________ Hemorrhoids/fistulas: _______________

Stool in rectum: ________ Impaction: _______ Occult blood: (+ or -): ________

Presence/use of catheter or continence devices: ________________________________

Ostomy appliances (describe appliance and location): _____________________

Food/Fluid

Subjective (reports)

Usual diet (type): ___ Calorie/carbohydrate/protein/fat (g/day): __ # of meals daily: ___

Snacks (# daily, time consumed, type): _________________________________

Last meal consumed/content: ______________________________________________

Food preferences: ______________ Food allergies/intolerances: __________________

Cultural or religious food preparation concerns/prohibitions: _____________________

Usual appetite: ____________________ Change in appetite: _____________________

Usual weight: ___________ Unexpected/undesired weight loss or gain: ____________

Nausea/vomiting: ____ Related to? ____ Heartburn/indigestion: ____ Related to? ____

Relieved by? _____________________________________________________

Chewing/swallowing problems: __________ Gag/swallow reflex (present): _________

Facial injury/surgery: __________ stroke/other neurologic deficit: ___________

Teeth: Normal: _______ Dentures (full/partial): _______ Loose/absent teeth: ________

Sore mouth/gums: _________________________________________________

Dental hygiene practices: __________ Professional dental care/frequency: __________

Diabetes/type: ______________ Controlled with diet/pills/insulin: _________________

Vitamin/food supplement use: ______________ Medications/herbals: ______________

Objective (Exhibits)
Current weight: _______ Height: _______ Body build: _______ Body fat %: ________

Skin turgor (e.g., firm, supple, dehydrated): ____ Mucous membranes (moist/dry): ____

Edema (describe): Generalized: ____ Dependent: ___ Feet/ankles: ___Periorbital: ____

Abdominal/ascites: ________________________________________________

Jugular vein distention: ___________________________________________________

Breath sounds (auscultation)/location: Normal: ____ Diminshed: ____ Crackles: _____

Wheezes: ________________________________________________________

Condition of teeth/gums: Appearance of tongue: _______ Mucous membranes: ______

Bowel sounds (quadrant location/type): ____________ Hernia/masses: _____________

Urine S/A or Chemstix: ____________ Serum glucose (Glucometer): ______________

Hygiene

Subjective (Reports)

Ability to carry out activities of daily living: Independent/dependent (level 1-4, with 1 =
no assistance needed to 4 = completely dependent):

Mobility: ____ Needs assistance (describe): ____ Assistance provided by: ____
Equipment/prosthetic devices required: ________________________________

Feeding: _________ Needs assistance preparing/eating (describe): __________

Assistance devices: ________________________________________________

Bathing: Needs assistance setup/regulating water temperature/washing body

parts (describe): ________________ Assistance provided by: _______________

Preferred time of personal care/bath: ___________________________________

Dressing: Needs assistance selecting clothing/dressing self (describe): ________

Toileting: Needs assistance transferring/cleaning self (describe): ____________

Objective (Exhibits)

General appearance: Manner of dress: _________ Grooming/personal habits: ________

Condition of hair/scalp: _____________________________________________

Body odor: ______________ presence of vermin (e.g., lice, scabies): ______________

Neurosensory

Subjective (Reports)

History of brain injury, trauma, stroke (residual effects): _________________________

Fainting spells/dizziness: _________ Headaches (location/type/frequency): __________

Tingling/numbness/weakness (location): _____________________________________

Seizures: History/onset: ____ Type (e.g., generalized, partial): _____ Frequency: _____

Aura (describe): ________ Postical state: ________ How controlled: _________

Vision loss/changes: ____ Glasses/contacts: _____ Last exam: _____Glaucoma: _____

Cataract: _________________ Eye surgery (type/date): ___________________

Hearing loss: _____ Sudden/gradual: ______ Hearing aids: ______ Last exam: _______

Sense of smell (changes): _________________________________________________

Sense of taste (changes): __________________________________________________

Other: _________________________________________________________________

Objective (Exhibits)

Mental status (note duration of change):

Oriented: Time: _______ Place: _______ Person: _______ Situation: ________

Check all that apply: Alert: ____ Drowsy: ____ Lethargic: ___ Stuporous: ____
Comatose: _______________________________________________________

Cooperative: _______ Follows commands: _______ Agitated/restless: _______

Combative: _______________________________________________________

Delusions (describe): ____________ Hallucinations (describe): _____________

Affect (describe): _____________________ Speech: _____________________

Memory: Recent: _______________________ Remote: _________________________

Pupil shape: __________Size/reaction: R/L: __________ Accommodation: _________

Facial droop: ______________________ Swallowing: __________________________

Hand grasp/release, R: _________________________ L: ________________________

Coordination: ______ Balance: _____ Walking: ______ Sitting: _____ Standing: _____

Deep tendon reflexes (present/absent/location): _____ Tremors: _____ Posturing: ____

Paralysis (L/R): ___________________________________________________

Pain/Discomfort

Subjective (Reports)

Primary focus: Location: ___________ Intensity (use pain scale/pictures): __________

Quality (e.g., stabbing, aching, burning): __________ Radiation: ____________

Frequency: ______________________ Duration: ________________________

Precipitating/aggravating factors: ___________________________________________

How relieved: OTP/prescription: _________ Nonpharmaceuticals/therapies: _________

Associated symptoms (e.g., nausea, sleep, problems, photosensitivity): _____________

Effect on daily activities: _____ Relationships: ____ Job: ____ Enjoyment or life: ____

Additional pain focus/describe: _____________________________________________

Cultural expectations regarding pain perception and expression: ___________________

Objective (Exhibits)

Facial grimacing: ______ Guarding affected area: _____ Posturing Behaviours: ______

Narrowed focus: __________________________________________________

Emotional response (e.g., crying, withdrawal, anger): ___________________________

Vital sign changes (acute pain): BP: _______ Pulse: ________ Respirations: _________

Respiration

Subjective (Reports)
Dyspnea/related to: _______ Precipitating factors: _______ Relieving factors: _______

Airway clearance (e.g., spontaneous/device): __________________________________

Cough (e.g., hard, persistent, croupy): _________ sputum color/character: ___________

Requires suctioning:________________________________________________

History of/date: Bronchitis: ________ Emphysema: ________Tuberculosis: _________

Recurrent pneumonia: ______________________________________________

Exposure to noxious fumes/allergens, infectious agent/diseases, poisons: ______

Smoker: _____ pack/day: ____ # of pack years: ____Cigar use: ____ Smokeless: _____

Use of respiratory aids: __________ Oxygen (type, frequency, rate): _______________

Medications/herbals: _____________________________________________________

Objective (Exhibits)

Respirations (spontaneous/assisted): _________ Rate: __________ Depth: __________

Chest excursion (e.g., equal/symmetrical): ______________________________

Use of accessory muscles: _______ Nasal flaring: _______ Fermitus: ________

Breath sounds (describe): ___________________ Egophony: _____________________

Skin/mucous membrane color (e.g., pale, cyanotic): ____________________________

Clubbing of fingers: ________________________________________________

Sputum characteristics: ___________________________________________________

Mentation (e.g., calm, anxious, restless): _____________________________________

Pulse oximetry: _________________________________________________________

Safety

Subjective (Reports)

Allergies/sensitivity (medications, foods, environment, iodine, latex): ______________

Type of reaction: __________________________________________________

Blood transfusion/number: ______ Date: _________ Reaction (describe): ___________

Exposure to infectious diseases (e.g., measles, influenza, pink eye, whooping cough): __

Exposure to pollution, toxins, poisons/pesticides, radiation (describe reactions): ______

Geographic areas lived in/recent travel: ______________________________________

Immunization history/date: Tetanus: __ MMR: __ Polio: __ Hepatitis: __Pneumonia: __

Influenza: ___________________________ HPV: _______________________

Altered/suppressed immune system (list cause): ________________________________

History of sexually transmitted infection (date/type): ___________ Testing: _________

High-risk behaviors (specify): ______________________________________________

Uses seat belt regulary: ______ Uses bike helmet: ______ Other safety devices: ______

Workplace safety/health issues (describe): ____ Occupation: ___ Curently working: ___

Rate working conditions (e.g., safety, noise, heating, water, ventilation): ______

History of injuries (e.g., fall, vehicle crash, blast, gunshot, electrical, chemical): ______

Fractures/dislocations: ______________________________________________

Arthritis/unstable joints: _______ Joint replacement surgeries (type and date): _______

Back problems: ___________________________________________________

Skin problems (e.g., rashes, lesions, moles, breast lumps, enlarged nodes)/describe: ___

Delayed healing(describe): ________________________________________________

Cognitive limitations (e.g., disorientation, confusion): ___________________________

Sensory limitations (e.g., impaired vision/hearing, detecting heat/cold, taste, smell,

touch): ________________________________________________________________

Prosthesis (type and date received): ___________ Ambulatory devices: _____________

Violence (episodes or tendencies): __________________________________________

Objective (Exhibits)

Body temperature/method (e.g., oral, rectal, temporal, tympanic): __________________

Skin integrity (mark location on diagram): Scars: ____ Rashes: ____ Lacerations: ____
 Ulcerations: ______________________ Bruises: _________________________

Blisters: _________ Drainage: ________ Burns (degree/% of body surface): ________

Musculoskeletal: General strength: _____ Muscle tone: _____ Gait: _____ ROM: ____

Paresthesia/paralysis: _______________________________________________

Results of testing (e.g., cultures, immune function, TB, hepatitis): _________________

Sexuality (Component od Social Interaction)

Subjective (Reports)

Sexually active: ____ Monogamous/committed relationship: ___ Use of condoms: ___

Birth control method: _____________________________________________________

Sexual concerns/difficulties: ________ Recent change in frequency/interest: _________

Pain /discomfort: __________________________________________________

Objective (Exhibits)

Comfort level with subject matter: __________________________________________

Female: Subjective (Reports)

Menstruation: Age at menarche: _______ Length of cycle: _______ Duration: _______

Number of pads/tampons used a/day: _______ Last menstrual period: ________

Bleeding between periods: _______ Menopausal: _______ Last period: _______

 Hysterectomy (type/date): __________ Problems with: Hot flashes: __________

Night sweats: _______ Vaginal lubrication: _______ Veginal discharge: ______

Gynecological/breast surgery (type and date): _________________________________

Infertility concerns: ___________________ Type of therapy: _____________________

Pregnant now: __________ Para: _________Gravida: _________ Due date: _________

Practices breast self-examination: _____ Last mammogram: ____ Last Pap smear: ____

Hormonal theraphy: ____ Supplemental calcium: ____ Other medications/herbals: ____

Female: Objective (Exhibits)

Breast examination: ______________________________________________________

Genetalia: _________ Warts/lesions: _________ Vaginal bleeding/discharge: ________

Test result: _________ Pap: __________ Mammogram: __________ STI: __________

Male: Subjective (Reports)

Penis: Circumcised: _________ Lesions/discharge: _________ Vasectomy: _________

Prostate disorder/voiding difficulties: ________________________________________

Practice self-examination: Breast: _________________ Testicles: _________________

Last proctoscopic/prostate examination: ______________ Last PSA: _______________

Medications/herbals: _____________________________________________________

Male: Objective (Exhibits)

Genetalia: Penis: _________ Warts/lesions: _________ Bleeding/discharge: _________

Testicles (e.g., descended, lumps): ____________________________________

Prostate: _______________________________________________________________

Breast examination: ______________________________________________________

Test results: _________________ STI: ________________ PSA: _________________

Social Interactions
Subjective (Reports)

Relationship status: Single: __ Married: __ Living partner: __ Divorced: __ Widowed: _

Years in relationship: ___ perception of relationship: ___ Concerns/stresses: __

Role within family structure: _____________ Number/age of children: _____________

Individuals living in home: ________ Caregiver (to who, & how long): _______

Extended family/availability: ____________ Other support person(s): ______________

Perception of relationship with family members: _______________________________

Ethnic/cultural affilliation: ____________ Strength of ethnic identity: ______________

Lives in ethnic community: __________________________________________

Feelings of (describe): Mistrust: ________ Rejection: ________ Unhappiness: _______

Loneliness/isolation: _______________________________________________

Problems related to ilness/condition: _________________________________________

Difficulties with communication (e.g., speech, another language, brain injury): _______

Use of communication aids (list): __________ Requires interpreter: __________

Genogram: (complete on separate form)

Objective (Exhibits)

Communication/speech: Clear: _____ Slurred: ____ Unintelligible: ____ Aphasic: ____

Unsual speech pattern/impairment: ________ Laryngectomy present: ________

Use of speech/communication aids: ___________________________________

Verbal/nonverbal communication with family/significant other(s): _________________

Family interaction (behavioral) pattern: ________________________________

Teaching/Learning

Subjective (Reports)

Communication: Dominant language (specify): _________ Second language: ________

 Literate (reading/writing):___________________________________________

Education level: _____ Learning disabilities (specify): ____ Cognitive limitations: ____

Culture/ethnicity: ____ Where born: ____ If immigrant, how long in this country: ____

Health and illness beliefs/practices/customs: __________________________________

Which family member makes healthcare decisions/is spokesperson for client: __

Presence of Advance Directives: _________________ Code status: ________________

Durable Medical Power of Attorney: _____________ Designee: ____________

Health goals: ___________________________________________________________

Current health problem: ___________ Client understanding of problem: ____________

Special healthcare concerns (e.g., impact of religious/cultural practices, healthcare

decisions, family involvement): ____________________________________________

Familial risk factors (indicate relationship): Diabetes: ______ Thyroid (specify): _____

Tubeculosis: ___ Heart disease: __ Stroke: __ High BP: __ Epilepsy/seizures: __

Kidney disease: ____ Cancer: ____ Mental illness/depressions: ____ Other: ___

Prescirbed medications (list each separately):

Drug: ___________ Dose: ___________ Times (circle last dose): ___________

Take regularly: _________ Purpose: ________ Side effects/problems: ________

Nonprescription drugs/frequency:

OTC drugs: _______ Vitamins: _______ Herbals: _______ Street drugs: ______

Alcohol (amount/frequency): _______ Tabacco: _______ Smokeless tobacco: _______

Admitting diagnosis per provider: ___________________________________________

Reason for hospitalization/visit per client: ____________________________________

History of current problem/concern: ___________________________________

Client expectations of this hospitalization/visit: __________________________

Will admission cause any lifestyle changes (describe): __________________________

Previous illnesses and/or hospitalizations/surgeries: _____________________________

Evidence of failure to improve: _____________________________________________

Last complete physical examination: ________________________________________

Discharge Plan Considerations

Projected length of stay (hour/days): ________ Anticipated date of discharge: ________

Date information obtained: __________________ Source: _________________

Resources available: Persons: ___ Financial: ___ Community supports: ___ Groups: __

Areas that may require alteration/assistance: Food preparation: _____ Shooping: _____

Transportation: _____________________ Ambulation: ___________________

Self-care (specify): __________________ Socialization: __________________

Medication/IV therapy: ____ Treatments: ____ Wound care: ____ Supplies: ___

Homemaker/maintenance (specify): ____ Physical layout of home (specify): ___

Anticipated changes in living situation after discharge: __________________________

Living facility other than home (specify): _______________________________

Referrals (date/source/services): Social services: _________ Rehabilitation: _________

Dietary: ____ Home care: ____ Resp/O2: ___ Equipment: ___ Supplies: ___ Other: ___

DAFTAR PUSTAKA

Doenges, Marilynn E., Mary Frances Moorhouse & Alice C Murr. 2016. Nursing
Diagnosis Manual: Planning, Individualizing, and Documenting Client Care fifth
edition. F. A. Davis Company: United State of America.