U N I V E R S I T A S B O N D O W O S O

PROGRAM STUDI DIII KEPERAWATAN

Jalan Chairil Anwar No.3B Tlp/Fax. (0332) 433015 Bondowoso

FORMAT PENGKAJIAN
KEBUTUHAN PSIKOSOSIAL DAN SPIRITUAL

Rumah sakit :…………………………………………………………………………………..

Ruangan :…………………………………………………………………………………..
Tgl/Jam MRS :…………………………………………………………………………………..
Dx. Medis :………………………………………………………………………………......
No. Register :………………………………………………………………………………......

Pengkajian Oleh :..................................................................................................................

Tgl/Jam pengkajian :..................................................................................................................

I. BIODATA PENANGGUNG JAWAB

Nama Klien Nama :……………………........
:..............................................................................................................
Umur Umur :………………………….
:..............................................................................................................
Jenis Kelamin Pendidikan :………………………….
:..............................................................................................................
Suku/Bangsa Pekerjaan :………………………….
:..............................................................................................................
Bahasa Alamat :………………………….
:..............................................................................................................
Pendidikan Hubungan dengan klien
:..............................................................................................................
Pekerjaan Suami/ Istri/Orangtua/…………………..
:..............................................................................................................
Agama :..............................................................................................................
Gol. Darah :...............................................
Alamat :..................................................................................................................

II. RIWAYAT KESEHATAN

1. Keluhan Utama :
a. Saat MRS
..........................................................................................................................................
.
..........................................................................................................................................
.
b. Saat Pengkajian
..........................................................................................................................................
.
..........................................................................................................................................
.
2. Riwayat Penyakit Sekarang :
................................................................................................................................................
................................................................................................................................................
 ................................................................................................................................................
3. Riwayat Penyakit Dahulu :
................................................................................................................................................
................................................................................................................................................
4. Riwayat Penyakit Keluarga :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
5. Genogram :
Ket :..........................................

III. POLA FUNGSI KESEHATAN

a. Pola Persepsi dan Tata Laksana Kesehatan
Pengetahuan tentang penyakit (secara umum) :
................................................................................................................................................
................................................................................................................................................
Perilaku pencegahan yang dilakukan :
................................................................................................................................................
................................................................................................................................................
Harapan terhadap penyakit/selama MRS :
................................................................................................................................................
................................................................................................................................................
Gambaran tingkat kesehatan klien saat ini (menurut klien) :
................................................................................................................................................
................................................................................................................................................
b. Pola Nutrisi
Keterangan Sebelum Sakit Saat sakit
Makan
 Frekuensi ............................... ................................
 Jenis ............................... ................................
 Porsi ............................... ................................
 Keluhan ............................... ................................

Minum
  Frekuensi ............................... ................................
 Jenis ............................... ................................
 Jumlah ............................... ................................
 Keluhan ............................... .................................

c. Pola Eliminasi
Kebiasaan BAB
Keterangan Sebelum Sakit Saat Sakit

 Frekuensi ..................................... .......................................

 Jumlah ....................................... .......................................
 Bau ....................................... .......................................
 Warna ....................................... .......................................
 Konsistensi ....................................... .......................................
 Keluhan ....................................... .......................................

Kebiasaan BAK
Keterangan Sebelum Sakit Saat Sakit
 Frekuensi ....................................... .......................................
 Jumlah ....................................... .......................................
 Bau ....................................... .......................................
 Warna ....................................... .......................................
 Keluhan ....................................... .......................................

d. Pola Aktivitas dan kebersihan diri

Keterangan Sebelum Sakit Saat Sakit
Mobilitas Rutin
Waktu Senggang
Mandi
Berpakaian
Berhias
Toileting
Makan-minum
Keterangan :
0 : mandiri
1 : dengan alat bantu
2 : dibantu oleh orang lain
3 : dibantu oleh orang lain dan alat
4 : tergantung secara total

e. Pola Istirahat-Tidur
Keterangan Sebelum Sakit Saat Sakit
Lama tidur siang
Lama tidur malam
Pengantar tidur
Gangguan tidur
f. Pola Kognitif dan Persepsi Sensori
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
g. Pola Konsep Diri
 Citra Tubuh
Bagaimana klien berespon terhadap perubahan struktur/fungsi tubuhnya :
Verbal :....................................................................................................................................
Non verbal:.............................................................................................................................
 Ideal Diri
Apa tujuan/keinginan yang ingin dicapai :
................................................................................................................................................
Apa upaya yang dilakukan untuk mencapai keinginan itu :
................................................................................................................................................
Apa kondisi sakitnnya mempengaruhi klien dalam mencapai tujuan itu :
................................................................................................................................................
 Harga Diri
Bagaimana klien menilai kemampuannya untuk mencapai ideal dirinya :
................................................................................................................................................
................................................................................................................................................
 Peran Diri
Bagaimana perilaku klien terhadap peran yang dimiliki saat ini (keluarga, kelompok,
masyarakat) :
................................................................................................................................................
................................................................................................................................................
Apakah sakit mempengaruhi peran diri klien :
................................................................................................................................................
 Identitas Diri
Apakah klien mengenali identitas dirinya :
................................................................................................................................................
................................................................................................................................................

h. Pola Hubungan dan Peran (Pola Komunikasi)

Adakah defisit pendengaran :
................................................................................................................................................
Bahasa yang paling disukai saat berkomunikasi :
................................................................................................................................................
Masalah dalam berkomunikasi dengan perawat, jelaskan :
................................................................................................................................................
Apakah klien tinggal sendiri ”ya/tidak”, dengan siapa :
................................................................................................................................................
Kepada siapa klien meminta bantuan bila memerlukan :
................................................................................................................................................
 Pengambilan keputusan dalam keluarga :
................................................................................................................................................

i. Pola Nilai dan Kepercayaan

Bagaimana praktek ibadah klien :
 Sebelum
sakit :..................................................................................................................
 Saat sakit
:.....................................................................................................................
...
Apakah yang klien inginkan terhadap praktek keagamaan selama dalam perawatan :
................................................................................................................................................
................................................................................................................................................

j. Pola Penanggulangan Stress/Koping-Toleransi Stress

Bagaimana klien membuat keputusan, sendiri/bantu :
...............................................................................................................................................
Adakah perubahan dalam kehidupan klien dalam 6 bulan terkhir (sekolah, status
perkawinan, pekerjaan, kehamilan, komposisi keluarga, kesehatan) :
................................................................................................................................................
Apa yang klien lakukan jika mengalami stress :
...............................................................................................................................................

IV. PEMERIKSAAN FISIK

1. Keadaan Umum :..................................................................................................................
Kesadaran :.....................................................................................................................
Suhu :...............................oC TB :................................cm
RR :...............................x/mnt BB saat ini :..........................Kg
TD :...............................mmHg BB Ideal :...........................Kg
Nadi :...............................x/mnt

2. Kepala
 Rambut : ……………………………………………………………………………….....
 Wajah : ……………………………………………………………………………….....
 Mata : ……………………………………………………………………………….....
 Hidung : ……………………………………………………………………………….....
 Mulut : ……………………………………………………………………………….....
 Gigi : ……………………………………………………………………………….....
 Telinga : ……………………………………………………………………………….....

3. Leher
I.............................................................................................................................................
 P...........................................................................................................................................

4. Payudara dan Ketiak

I.............................................................................................................................................
P...........................................................................................................................................

Dada
Paru-Paru
I……………………………………………………………………………………………………
P...........................................................................................................................................
P...........................................................................................................................................
A………………………………………………………………………………………………….
Jantung
I……………………………………………………………………………………………………
P...........................................................................................................................................
P...........................................................................................................................................
A………………………………………………………………………………………………….

5. Abdomen
I……………………………………………………………………………………………….......
A…………………………………………………………………………………………………..
P…………………………………………………………………………………………………..
P…………………………………………………………………………………………………..

6. Ekstremitas
Atas
I………………………………………………………………………………………………….....
P……………………………………………………………………………………………………
Gerakan Sendi……………………………………………………………………………………
……………………………………………………………………………………………………..
Kekuatan Otot……………………………………………………………………………………

Bawah
I…………………………………………………………………………………………………….
P…………………………………………………………………………………………………...
Gerakan Sendi…………………………………………………………………………………..
……………………………………………………………………………………………………..
Kekuatan Otot……………………………………………………………………………………

7. Tulang Belakang/ Punggung-pinggang

I ……………………………………………………………………………………………………
P……………………………………………………………………………………………………
 8. Anus – Genetalia
…………………………………………………………………………………………………….
……………………………………………………………………………………………………..

9. Pemeriksaan Neurologis
Kesadaran………………………………………………………………………………………
Meningeal Sign…………………………………………………………………………………
Refleks
 Fisiologis…………………………………………………………………………………
 Patologis…………………………………………………………………………………
Pemeriksaan Saraf Kranial (I-XII)
……………………………………………………………………………………………………
………………………………………………………………………………………………………………...
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V. Pemeriksaan diagnostik (cantumkan tanggal pemeriksaan)

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VI. Pemeriksaan Laboratorium (cantumkan tanggal dan nilai normal)

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VII. Terapi ( disertai dosis tiap pemberian )

Oral
.....................................................................................................................................................
.....................................................................................................................................................
Parenteral
.....................................................................................................................................................
.....................................................................................................................................................

………………,…………………..20…..
Mahasiswa

( )
NIM…………………………