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PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN PSIKOSOSIAL
JURUSAN KEPERAWATAN

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 : .....................................................................................................................
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) :

10. Riwayat alergi :

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III. POLA NUTRISI DAN METABOLIK

1. Pola makan
Di rumah Di rumah sakit
Frekuensi : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Porsi : ......................... Porsi : ..................................
Pantangan : ......................... Diit khusus : ..................................
Makanan disukai : .........................
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 : ......................... Frekuensi : ..................................
Jenis : ......................... Jenis : ..................................
Jumlah : ......................... Jumlah : ..................................
Pantangan : .........................
Minuman disukai : .........................

IV. POLA ELIMINASI

1. Buang air besar
Di rumah Warna : ..................................
Frekuensi : ..................................
Konsistensi : ..................................
Di rumah sakit Warna : ( ) kuning
Frekuensi : .................................. ( ) bercampur darah
Konsistensi : .................................. ( ) lainnya, ..............
Masalah di RS : ( ) konstipasi ( ) diare ( ) inkontinen
Kolostomi : ( ) tidak ( ) ya
 2. Buang air kecil
Di rumah Di rumah sakit
Frekuensi : .................................. Frekuensi : ..................................
Jumlah : .................................. Jumlah : ..................................
Warna : .................................. Warna : ..................................
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 : ........................ Mandi : ........................
/hr /hr
Gosok gigi : ........................ Gosok gigi : ........................
/hr /hr
Keramas : .................... Keramas : ....................
/mgg /mgg
Potong kuku : .................... Potong kuku : ....................
/mgg /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

Di rumah Di rumah sakit
Waktu tidur : Siang ..............-............... Waktu tidur : Siang ..............-...............
Malam ............-............... Malam ............-...............
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 : ........................................................................................................................................

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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/id entitas 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 ( ) 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 : ..........................................................................................................
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 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 : ..................................................................................................................................

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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, ................................................................
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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............., .....................
Mahasiswa

(...............................)
KUESIOENER HARS ( Hamilton Ranting Scale For Anxiety)

Skor : 0 = tidak ada

1 = ringan

2 = sedang

3 = berat

4 = berat sekali

N0. Pertanyaan 0 1 2 3 4
1 Perasaan Ansietas
- Cemas
- Firasat Buruk
- Takut Akan Pikiran Sendiri
- Mudah Tersinggung
2 Ketegangan
- Merasa Tegang
- Lesu
- Tak Bisa Istirahat Tenang
- Mudah Terkejut
- Mudah Menangis
- Gemetar
- Gelisah
3 Ketakutan
- Pada Gelap
- Pada Orang Asing
- Ditinggal Sendiri
- Pada Binatang Besar
- Pada Keramaian Lalu Lintas
- Pada Kerumunan Orang Banyak
4 Gangguan Tidur
- Sukar Masuk Tidur
- Terbangun Malam Hari
- Tidak Nyenyak
- Bangun dengan Lesu
- Banyak Mimpi-Mimpi
- Mimpi Buruk
- Mimpi Menakutkan
5 Gangguan Kecerdasan
- Sukar Konsentrasi
- Daya Ingat Buruk
6 Perasaan Depresi
- Hilangnya Minat
- Berkurangnya Kesenangan Pada Hobi
- Sedih
- Bangun Dini Hari
- Perasaan Berubah-Ubah Sepanjang Hari
7 Gejala Somatik (Otot)
- Sakit dan Nyeri di Otot-Otot
- Kaku
- Kedutan Otot
- Gigi Gemerutuk
 - Suara Tidak Stabil
8 Gejala Somatik (Sensorik)
- Tinitus
- Penglihatan Kabur
- Muka Merah atau Pucat
- Merasa Lemah
- Perasaan ditusuk-Tusuk
9 Gejala Kardiovaskuler
- Takhikardia
- Berdebar
- Nyeri di Dada
- Denyut Nadi Mengeras
- Perasaan Lesu/Lemas Seperti Mau Pingsan
- Detak Jantung Menghilang (Berhenti
Sekejap)
10 Gejala Respiratori
- Rasa Tertekan atau Sempit Di Dada
- Perasaan Tercekik
- Sering Menarik Napas
- Napas Pendek/Sesak
11 Gejala Gastrointestinal
- Sulit Menelan
- Perut Melilit
- Gangguan Pencernaan
- Nyeri Sebelum dan Sesudah Makan
- Perasaan Terbakar di Perut
- Rasa Penuh atau Kembung
- Mual
- Muntah
- Buang Air Besar Lembek
- Kehilangan Berat Badan
- Sukar Buang Air Besar (Konstipasi)
12 Gejala Urogenital
- Sering Buang Air Kecil
- Tidak Dapat Menahan Air Seni
- Amenorrhoe
- Menorrhagia
- Menjadi Dingin (Frigid)
- Ejakulasi Praecocks
- Ereksi Hilang
- Impotensi
13 Gejala Otonom
- Mulut Kering
- Muka Merah
- Mudah Berkeringat
- Pusing, Sakit Kepala
- Bulu-Bulu Berdiri
Jumlah
Interpretasi Skor : kurang dari 14 = tidak ada kecemasan

14 – 20 = kecemasan ringan

21 – 27 = kecemasan sedang

28 – 41 = kecemasan berat

42 – 56 = kecemasan berat sekali

 ANALISA DATA

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

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

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

 RENCANA KEPERAWATAN

No. Diagnosa Keperawatan Tujuan Dan Kriteria Hasil Intervensi

 TINDAKAN KEPERAWATAN DAN CATATAN PERKEMBANGAN

Waktu Waktu Catatan Perkembangan

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