PENGKAJIAN KEPERAWATAN

ASUHAN KEPERAWATAN PSIKOSOSIAL

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

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

I. IDENTITAS
1. Nama : Ferli windi amelia........................................................................................
2. Umur : 15 tahun.......................................................................................................
3. Jenis kelamin : perempuan ..................................................................................................
4. Status : belum menikah ...........................................................................................
5. Agama : muslim.........................................................................................................
6. Suku/bangsa : jawa madura ...............................................................................................
7. Bahasa : indonesia, daerah.........................................................................................
8. Pendidikan : smp..............................................................................................................
9. Pekerjaan : siswa............................................................................................................
10. Alamat dan no. telp : mlokorejo-puger-jember..............................................................................
11. Penanggung jawab : sugiono (ayah pasien)..................................................................................
& hubgan dg klien

II. POLA PERSEPSI KESEHATAN ATAU PENANGANAN KESEHATAN

1. Keluhan utama :
Sesak nafas, nyeri kaki, darah rendah.............................................................................................
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2. Riwayat penyakit sekarang :
Sesak nafas, nyeri kaki, dan darah rendah......................................................................................
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3. Lamanya keluhan
Satu tahun terakhir..........................................................................................................................
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4. Faktor yang Memperberat
Darah rendah, ketika makan sayur kol. Sesak nafas jika stress atau banyak pikiran, kaki
kambuh kalua mandi malamsesak kambuh, ...................................................................................
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5. Upaya yang Dilakukan Untuk Mengatasi Keluhan
Sesak nafas cari udara segar, nyeri kaki minta diurut atau dipijit, mengonsumsi obat dan banyak
beristirahat.......................................................................................................................................
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6. Riwayat penyakit dahulu :
Tifus pada usia 6 tahun....................................................................................................................
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7. Persepsi klien tentang status kesehatan dan kesejahteraan
Kesehatan penting dan paling utama...............................................................................................
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8. Riwayat kesehatan keluarga :
Ibu- overdosis obat, kolestrol, komplikasi, covid-19......................................................................
Kakak- sesak nafas, radang.............................................................................................................
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9. Susunan keluarga (genogram) :
Sesak nafas, radang, dari kakak

10. Riwayat alergi :

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III. POLA NUTRISI DAN METABOLIK

1. Pola makan
Di rumah Makanan disukai : nasi goreng,
Frekuensi :3-4 kali sehari telur.........................
......................... Di rumah sakit
Jenis : nasi, lauk pauk, Frekuensi :satu kali sehari
sayuran, dan makanan ..................................
ringan......................... Jenis :nasi, lauk pauk dan
Porsi : satu piring sayur, bubur, sayuran berkuah
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Pantangan : makanan Porsi :
berminyak, asam dan pedas
......................... berkurang..................................
Diit khusus : ..................................
Nafsu makan di RS : ( ) normal ( ) bertambah ( ) berkurang
( ) mual ( ) muntah, .............. cc ( ) stomatitis
Kesulitan menelan : ( ) tidak ( ) ya
Gigi palsu : ( ) tidak ( ) ya
NG tube : ( ) tidak ( ) ya
(JIKA MAKAN-MINUM BIASA (TANPA NGT) SEJAUH MANA KEMAMPUANNYA
2. Pola minum
Di rumah Di rumah sakit
Frekuensi : 8 gelas Frekuensi :
sehari.........................
Jenis : air putih berkurang..................................
......................... Jenis : teh
Jumlah : kurleb 1 ..................................
setengah liter......................... Jumlah : dua gelas sehari,
Pantangan : -........................ sisanya tetap air
. putih..................................
Minuman disukai : milkshake,
boba.........................

IV. POLA ELIMINASI

1. Buang air besar
Di rumah
Frekuensi : 1-2 kali dalam sehari Di rumah sakit
.................................. Frekuensi : 2 hari seklai
Konsistensi : ..................................
Konsistensi : lebih cair atau
padat.................................. lembek..................................
Warna : kuning kecoklatan Warna : ( - ) kuning
.................................. ( ) bercampur darah
( ) lainnya, ..............
Masalah di RS : ( ) konstipasi ( ) diare ( ) inkontinen
Kolostomi : ( ) tidak ( ) ya
 2. Buang air kecil
Di rumah Di rumah sakit
Frekuensi : 4-5 kali Frekuensi :
sehari..................................
Jumlah : makin banyak jarang..................................
minum makin banyak Jumlah :
jumlahnya..................................
Warna : tetap..................................
Warna : agak
kuning.................................. mengeruh..................................
Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria
( ) retensi ( ) inkontinen
Kateter : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari

V. POLA AKTIVITAS DAN LATIHAN

1. Kemampuan perawatan diri
SMRS MRS
Aktivitas
0 1 2 3 4 0 1 2 3 4
Mandi - -
Berpakaian/berdandan - -
Eliminasi/toileting - -
Mobilitas di tempat tidur - -
Berpindah - -
Berjalan - -
Naik tangga - -
Berbelanja - -
Memasak - -
Pemeliharaan rumah - -

Skor 0 = mandiri 3 = dibantu orang lain & alat

1 = alat bantu 4 = tergantung/tidak mampu
2 = dibantu orang lain

Alat bantu : ( ) tidak ( ) kruk ( ) tongkat

( - ) pispot disamping tempat tidur ( ) kursi roda

2. Kebersihan diri
Di rumah Di rumah sakit
Mandi : 2-3........................ Mandi : 1........................ 
 /hr /hr
Gosok gigi : 2........................  Gosok gigi : 2........................ 
/hr /hr
Keramas : 4....................  Keramas : 2.................... 
/mgg /mgg
Potong kuku : 2....................  Potong kuku : 0.................... 
/mgg /mgg
3. Aktivitas sehari-hari
Waktu sakit fokus untuk istirahat, minum obat. Waktu sehat seklah, bermain, emmasak, bersih
rumah...............................................................................................................................................
4. Rekreasi
Waktu sakit tidak rekreasi, waktu sehat iya....................................................................................
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5. Olahraga : ( - ) tidak ( ) ya
Karena tidak kuat atau capek..........................................................................................................

VI. POLA ISTIRAHAT DAN TIDUR

 Di rumah Di rumah sakit
Waktu tidur : Siang ....12.00..........- Waktu tidur : Siang 12.00..............-
15.00.............. 16.00...............
Malam 11.00............- Malam 7.00............-
5.00............... 6.00...............
Jumlah jam tidur : ....................................... Jumlah jam tidur : .......................................
Masalah di RS : ( ) tidak ada ( - ) terbangun dini ( ) mimpi buruk
( ) insomnia ( ) Lainnya, ..............................................................................

VII. POLA KOGNITIF DAN PERSEPTUAL

Berbicara : ( - ) normal ( ) gagap ( ) bicara tak jelas
Bahasa sehari-hari : ( ) Indonesia ( - ) Jawa ( ) lainnya, ....................................
Kemampuan membaca : ( - ) bisa ( ) tidak
Tingkat ansietas : ( - ) ringan ( ) sedang ( ) berat ( ) panik
Sebab, ...................................................................................................
Kemampuan interaksi : ( - ) sesuai ( ) tidak,....................................................................

Vertigo : ( ) tidak ( - ) ya
Nyeri : ( - ) tidak ( ) ya

Bila ya, P : .........................................................................................................................................

Q : .........................................................................................................................................
R : .........................................................................................................................................
S : .........................................................................................................................................
T : .........................................................................................................................................

VIII. POLA PERSEPSI DIRI / KONSEP DIRI

1. Body image/gambaran diri
( ) cacat fisik ( ) pernah operasi
( ) perubahan ukuran fisik ( ) proses patologi penyakit
( ) fungsi alat tubuh terganggu ( ) kegagalan fungsi tubuh
( - ) keluhan karena kondisi tubuh ( ) gangguan struktur tubuh
( - ) transplantasi alat tubuh ( ) menolak berkaca
( - ) prosedur pengobatan yang mengubah fungsi alat tubuh
( - ) perubahan fisiologis tumbuh kembang
Jelaskan : keluhan kondisi tubuh karena berat badan ynag berlebih jadi mudah sesak nafas.........

Perubahan fisiologis menjadi lenih gemuk.....................................................................

Masalah keperawatan : ...................................................................................................................
2. Role/peran
( - ) overload peran ( ) perubahan peran ( - ) transisi peran karena sakit
( ) konflik peran ( ) keraguan peran
Jelaskan : menjadi pelajar, berlatih paskibra, membantu pekerjaan rumah, ketika sakit tidak
bisa menjalankan peran sebagia siswa ....................................................................................................

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Masalah keperawatan : ...................................................................................................................
3. Identity/identitas diri
( - ) kurang percaya diri ( - ) merasa kurang memiliki potensi
( ) merasa terkekang ( ) kurang mampu menentukan pilihan
( - ) tidak mampu menerima perubahan ( ) menolak menjadi tua
 Jelaskan : karena masalah fisik (berat badan), perubahan terasa berat bagi subjek, karena
kurang percaya diri (kurang memiliki potensi), ......................................................................................

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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 ( - ) keluhan fisik
( - ) rasa bersalah ( - ) menyalahgunakan zat
Jelaskan :karena ada kesibukan lain, kurang percaya diri, memiliki perasaan yang rendah diri,
gaenakan sama orang lain mencemooh diri karena sering merasa insecure, mengucilkan diri dg
alasan yg sama..........................................................................................................................................

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

IX. POLA PERAN DAN HUBUNGAN

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

X. POLA SEKSUALITAS / REPRODUKSI

Menstruasi terakhir : bulan lalu.....................................................................................................
Masalah menstruasi : terkadang, mens tidak lancar, bisa jadi karena stress..................................
Pap smear terakhir : tidak pernah.................................................................................................
Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( - ) tidak
Masalah seksual yang berhubungan dengan penyakit : tidak ada................................................

XI. POLA KOPING / TOLERANSI STRESS

1. Masalah utama selama MRS (penyakit, biaya, perawatan diri)
Perawatan diri , penyakit itu sendiri................................................................................................
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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 : karena semangat terbesar ada pada ibu.....................................................................

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Masalah keperawatan : .............................................................................................................
b. Tahap Anger/Marah
( - ) marah pada diri sendiri ( - ) meningkatnya kesadaran klien
( ) marah pada orang lain pada realita
Jelaskan : marah pada diri sendiri karena menyesal karena belum bisa berbakti.....................
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Masalah keperawatan : .............................................................................................................
3. Kemampuan adaptasi
Belum mampu sepenuhnya beradaptasi setelah ditinggal oleh ibu.................................................
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XII. POLA NILAI / KEPERCAYAAN

Agama :

islam................................................................................................
Pelaksanaan ibadah :

iya................................................................................................
Pantangan agama : ( ) tidak ( ) ya, rasa malas, tidak smpat, dan
berhalangan untuk beribadah................................................................
Meminta kunjungan rohaniawan : ( - ) tidak ( ) ya
XIII. PENGKAJIAN PERSISTEM (Review of System)
1. Tanda-Tanda Vital
a. Suhu : ................... °C lokasi : ......................
b. Nadi : ...................  /menit irama : ...................... pulsasi : ......................
c. Tekanan darah : ................... mmHg lokasi : ......................
d. Frekuensi nafas : ...................  /menit irama : ......................
e. Tinggi badan : ................... cm
f. Berat badan : SMRS ................... kg MRS .................... kg

2. Sistem Pernafasan (Breath)

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3. Sistem Kardiovaskuler (Blood)
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4. Sistem Persarafan (Brain)
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5. Sistem Perkemihan (Bladder)
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6. Sistem Pencernaan (Bowel)
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7. Sistem Muskuloskeletal (Bone)
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8. Sistem Integumen
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9. Sistem Penginderaan
Mata
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Hidung
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Telinga
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10. Sistem Reproduksi Dan Genetalia
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XIV. PEMERIKSAAN PENUNJANG
1. Laboratorium
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2. Photo
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3. Lain-lain
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XV. TERAPI
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Yogyakarta, .....................
Mahasiswa

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 ANALISA DATA

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. RM : ..............................................

No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)

 PRIORITAS MASALAH

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. RM : ..............................................

Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama perawat)
 RENCANA KEPERAWATAN

No. Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi Rasional

 TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

Waktu Waktu Catatan Perkembangan

No. Tindakan TT TT
Tgl/jam Tgl/jam (SOAP)