PENGKAJIAN KEPERAWATAN

ASUHAN KEPERAWATAN PSIKOSOSIAL

PROGRAM STUDI ILMU KEPERAWATAN
STIKES TENGKU MAHARATU

Nama mhs/klp : ........................................ Tanggal Masuk : ........................................

Tgl/jam pengkajian : ........................................ No. RM : ........................................
Sumber data : …………………………. Ruangan/kelas : ........................................
Diagnosa medis : ........................................ No.kamar : ........................................
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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 Di rumah sakit
Frekuensi : .................................. Frekuensi : ..................................
Konsistensi : .................................. Konsistensi : ..................................
Warna : .................................. Warna : ( ) kuning
( ) bercampur darah
( ) 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/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 ( ) 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 ( ) meningkatnya kesadaran klien pada
( ) marah pada orang lain 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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Pekanbaru, .....................
Mahasiswa

(...............................)
 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)