PENGKAJIAN KEPERAWATAN

ASUHAN KEPERAWATAN PSIKOSOSIAL

PRODI PROFESI NERS STIKes KARSA HUSADA GARUT

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

Tgl/jam pengkajian : ........................................
Sumber data : ………………………….
Metode : …………………………
Alat/bahan : …………………………

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. Hubungan dg mahasiswa ;
:

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) :

10. Riwayat alergi :

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III. POLA NUTRISI DAN METABOLIK
1. Pola makan

Frekuensi : .........................

Jenis : .........................

Porsi : .........................

Pantangan : .........................

Makanan disukai : .........................

Nafsu makan : ( ) normal ( ) bertambah ( ) berkurang

( ) mual ( ) muntah, .............. cc ( ) stomatitis

Kesulitan menelan : ( ) tidak ( ) ya

Gigi palsu : ( ) tidak ( ) ya

2. Pola minum
Frekuensi : ......................... Pantangan : .........................

Jenis : ......................... Minuman disukai : .........................

Jumlah : .........................

IV. POLA ELIMINASI

1. Buang air besar
Frekuensi : ..................................

Konsistensi : ..................................

Warna :

2. Buang air kecil

Frekuensi : ..................................

Jumlah : ..................................

Warna : ..................................
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
Mandi : ........................ ¿ /hr

Gosok gigi : ........................ ¿ /hr

Keramas : .................... ¿ /mgg

Potong kuku : .................... ¿ /mgg

3. Aktivitas sehari-hari
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4. Rekreasi
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5. Olahraga : ( ) tidak ( ) ya
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 VI. POLA ISTIRAHAT DAN TIDUR

Waktu tidur : Siang ..............-...............

Malam ............-...............

Jumlah jam tidur : .......................................

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

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

2. Role/peran
( ) overload peran ( ) perubahan peran ( ) transisi peran karena sakit

( ) konflik peran ( ) keraguan peran

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

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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 :

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

5. Self ideal/ideal diri

( ) masa depan suram

( ) terserah pada nasib

( ) merasa tidak memiliki kemampuan

 ( ) tidak memiliki harapan

( ) tidak ingin berusaha

( ) tidak memiliki cita-cita

( ) merasa tidak berdaya

( ) enggan membicarakan masa depan

IX. 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 : ...................................................................................

X. POLA SEKSUALITAS / REPRODUKSI

Menstruasi terakhir : .....................................................................................................................

Masalah menstruasi : .....................................................................................................................

Pap smear terakhir : .....................................................................................................................

Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidak

Masalah seksual yang berhubungan dengan penyakit : ...............................................................

XI. POLA KOPING / TOLERANSI STRESS

1. Masalah utama yang berhubungan dengan (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 : ..................................................................................................................................

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

3. Kemampuan adaptasi
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XII. POLA NILAI / KEPERCAYAAN

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

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

Pantangan agama : ( ) 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 : ................... 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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Garut, .....................

Mahasiswa

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