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PENGKAJIAN KEPERAWATAN

ASUHAN KEPERAWATAN PSIKOSOSIAL


JURUSAN KEPERAWATAN POLTEKKES YOGYAKARTA

Nama mhs/klp : ........................................


Tgl/jam pengkajian : ........................................
Sumber data : .
Metode :
Alat/bahan :
Diagnosa medis : ........................................
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Tgl/jam MRS : ........................................
No. RM : ........................................
Ruangan/kelas : ........................................
No.kamar : ......................................

I. IDENTITAS

1. Nama : .....................................................................................................................
2. Umur : .....................................................................................................................
3. Jenis kelamin : .....................................................................................................................
4. Status : .....................................................................................................................
5. Agama : .....................................................................................................................
6. Suku/bangsa : .....................................................................................................................
7. Bahasa : .....................................................................................................................
8. Pendidikan : .....................................................................................................................
9. Pekerjaan : .....................................................................................................................
10. Alamat dan no. telp : .....................................................................................................................
11. Penanggung jawab : .....................................................................................................................
& hubgan dg klien

II. POLA PERSEPSI KESEHATAN ATAU PENANGANAN KESEHATAN


1. Keluhan utama :
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2. Riwayat penyakit sekarang :
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3. Lamanya keluhan
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4. Faktor yang Memperberat
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5. Upaya yang Dilakukan Untuk Mengatasi Keluhan
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6. Riwayat penyakit dahulu :
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7. Persepsi klien tentang status kesehatan dan kesejahteraan
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8. Riwayat kesehatan keluarga :
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9. Susunan keluarga (genogram) :

III. POLA KOGNITIF DAN PERSEPTUAL


Berbicara : ( ) normal ( ) gagap ( ) bicara tak jelas
Bahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya, ....................................
Kemampuan membaca : ( ) bisa ( ) tidak
Tingkat ansietas : ( ) Gelisah ( ) Inkoheren ( ) Menyampaikan kekhawatirannya
Sebab, ...................................................................................................
Kemampuan interaksi : ( ) sesuai ( ) tidak,....................................................................

Vertigo : ( ) tidak ( ) ya
Nyeri : ( ) tidak ( ) ya
Bila ya, P : .........................................................................................................................................
Q : .........................................................................................................................................
R : .........................................................................................................................................
S : .........................................................................................................................................
T : .........................................................................................................................................

IV. POLA PERSEPSI DIRI / KONSEP DIRI


1. Body image/gambaran diri
( ) cacat fisik ( ) keluhan karena kondisi tubuh
( ) perubahan ukuran fisik ( ) pernah operasi
( ) fungsi alat tubuh terganggu ( ) menolak berkaca
( ) prosedur pengobatan yang mengubah fungsi alat tubuh
Jelaskan : ........................................................................................................................................

.........................................................................................................................................
Masalah keperawatan : ...................................................................................................................
2. Role/peran
( ) overload peran ( ) perubahan peran ( ) transisi peran karena sakit
( ) konflik peran ( ) keraguan peran
Jelaskan : ........................................................................................................................................

........................................................................................................................................
Masalah keperawatan : ...................................................................................................................
3. Identity/identitas diri
( ) kurang percaya diri ( ) merasa kurang memiliki potensi
( ) merasa terkekang ( ) menolak menjadi tua
( ) tidak mampu menerima perubahan
Jelaskan : ........................................................................................................................................

........................................................................................................................................
Masalah keperawatan : ...................................................................................................................
4. Self esteem/harga diri
( ) mengkritik diri sendiri dan orang lain ( ) menyangkal kepuasan diri
( ) merasa jadi orang penting ( ) polarisasi pandangan hidup
( ) menunda tugas ( ) mencemooh diri
( ) merusak diri ( ) mengecilkan diri
( ) menyangkal kemampuan pribadi ( ) menyalahgunakan zat
( ) rasa bersalah
Jelaskan : .......................................................................................................................................

........................................................................................................................................
Masalah keperawatan : ...................................................................................................................
5. Self ideal/ideal diri
( ) terserah pada nasib ( ) tidak memiliki cita-cita
( ) merasa tidak memiliki kemampuan ( ) merasa tidak berdaya
( ) tidak memiliki harapan ( ) enggan membicarakan masa depan
( ) tidak ingin berusaha
Jelaskan : ........................................................................................................................................

...........................................................................................................................................
Masalah keperawatan : ......................................................................................................................

V. POLA PERAN DAN HUBUNGAN


Pekerjaan : ..........................................................................................................
Kualitas bekerja : ..........................................................................................................
Hubungan dengan orang lain :
Sistem pendukung : ( ) pasangan ( ) tetangga/teman ( ) tidak ada
( ) lainnya,......................................................................................
Masalah keluarga mengenai perawatan di RS : ....................................................................................

VI. POLA SEKSUALITAS / REPRODUKSI


Menstruasi terakhir : .....................................................................................................................
Masalah menstruasi : .....................................................................................................................
Pap smear terakhir : .....................................................................................................................
Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidak
Masalah seksual yang berhubungan dengan penyakit : ...............................................................
Lain-lain: ..................................................................

VII. POLA KOPING / TOLERANSI STRESS


1. Masalah utama selama MRS (penyakit, biaya, perawatan diri)
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2. Kehilangan perubahan yang terjadi sebelumnya
a. Tahap Denial/Penolakan
( ) penolakan terhadap situasi ( ) merasa tertekan
( ) tidak percaya pada orang lain ( ) wawasan sempit

Jelaskan : ..................................................................................................................................

..................................................................................................................................

Masalah keperawatan : .............................................................................................................

b. Tahap Anger/Marah
( ) marah pada diri sendiri
( ) marah pada orang lain
( ) meningkatnya kesadaran klien pada realita
Jelaskan :

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Masalah keperawatan :
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3. Kemampuan adaptasi
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VIII. POLA NILAI / KEPERCAYAAN


Agama : ................................................................................

Pelaksanaan ibadah :
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Pantangan agama : ( ) tidak ( )


ya, ................................................................

Meminta kunjungan rohaniawan : ( ) tidak ( ) ya