FORMAT PENGKAJIAN KLIEN DENGAN PSIKOSOSIAL

Nama perawat : .....................

Tanggal pengkajian : .....................
Tempat pengkajian : .....................
Sumber data : .....................

I. IDENTITAS KLIEN
Nama klien lengkap : ..........................................
Nama panggilan klien : ..........................................
Umur/TTL : ..........................................
Jenis kelamin : ..........................................
Agama : ..........................................
Pendidikan : ..........................................
Pekerjaan : ..........................................
Suku bangsa : ..........................................
Status marital : ..........................................
Alamat lengkap : ..........................................

II. PENGKAJIAN FISIK

1. Tanda vital : TD : N: S: P:
2. Ukur : TB : BB :
3. Keluhan fisik : Ya Tidak
Jelaskan :

Masalah keperawatan :

III. PSIKOSOSIAL
1. Genogram
Jelaskan :
Masalah Keperawatan :

2. Konsep diri
a Gambaran diri :

b. Identitas :

c. Peran :

d. Ideal diri :
e. Harga diri :

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Masalah Keperawatan :

3. Hubungan Sosial
a. Orang yang berarti :

b. Peran serta dalam kegiatan kelompok / masyarakat :

c. Hambatan dalam berbuhungan dengan orang Lain :

Masalah keperawatan:

4. Spiritual
a. Nilai dan keyakinan :

b. Kegiatan ibadah :

Masalah Keperawatan

IV. Mekanisme Koping

Adaptif Maladaptif
Bicara dengan orang lain Minum alkohol
Mampu menyelesaikan masalah reaksi lambat/berlebih
Teknik relaksasi bekerja berlebihan
Aktivitas konstruktif menghindar
Olahraga mencederai diri
Lainnya lainnya :
Masalah Keperawatan :

V. Masalah Psikososial dan Lingkungan:

Masalah dengan dukungan kelompok, spesifik

Masalah berhubungan dengan lingkungan, spesifik

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Masalah dengan pendidikan, spesifik

Masalah dengan pekerjaan, spesifik

Masalah dengan perumahan, spesifik

Masalah ekonomi, spesifik

Masalah dengan pelayanan kesehatan, spesifik

Masalah lainnya, spesifik

Masalah Keperawatan :

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 ANALISA DATA

No Data Etiologi Masalah

Keperawatan

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 INTERVENSI KEPERAWATAN
PSIKOSOSIAL DI KOMUNITAS

Diagnosa Intervensi Keperawatan

No Tujuan
Keperawatan

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 CATATAN KEPERAWATAN KLIEN DENGAN PSIKOSOSIAL

Nama Puskesmas :
Nama Perawat :

Hari/tanggal :
Pertemuan ke :

Data ( Subyektif dan Obyektif ) :

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Diagnosis Keperawatan :
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Tindakan Keperawatan :
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Evaluasi (SOAP) :
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…………, 2023
Pembimbing Klinik Mahasiswa

(…………..............………) (…………....................…..)
NIP……………… NIM……….

Profesi Ners 2023

 CATATAN KEPERAWATAN KLIEN DENGAN PSIKOSOSIAL

Nama Puskesmas :
Nama Perawat :

Hari/tanggal :
Pertemuan ke :

Data ( Subyektif dan Obyektif ) :

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Diagnosis Keperawatan :
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Tindakan Keperawatan :
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Evaluasi (SOAP) :
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…………, 2023
Pembimbing Klinik Mahasiswa

(…………..............………) (…………....................…..)
NIP……………… NIM……….

Profesi Ners 2023

 CATATAN KEPERAWATAN KLIEN DENGAN PSIKOSOSIAL

Nama Puskesmas :
Nama Perawat :

Hari/tanggal :
Pertemuan ke :

Data ( Subyektif dan Obyektif ) :

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Diagnosis Keperawatan :
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Tindakan Keperawatan :
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Evaluasi (SOAP) :
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…………, 2023
Pembimbing Klinik Mahasiswa

(…………..............………) (…………....................…..)
NIP……………… NIM……….

Profesi Ners 2023

 CATATAN KEPERAWATAN KLIEN DENGAN PSIKOSOSIAL

Nama Puskesmas :
Nama Perawat :

Hari/tanggal :
Pertemuan ke :

Data ( Subyektif dan Obyektif ) :

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Diagnosis Keperawatan :
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Tindakan Keperawatan :
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Evaluasi (SOAP) :
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…………, 2023
Pembimbing Klinik Mahasiswa

(…………..............………) (…………....................…..)
NIP……………… NIM……….

Profesi Ners 2023

 CATATAN KEPERAWATAN KLIEN DENGAN PSIKOSOSIAL

Nama Puskesmas :
Nama Perawat :

Hari/tanggal :
Pertemuan ke :

Data ( Subyektif dan Obyektif ) :

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Diagnosis Keperawatan :
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Tindakan Keperawatan :
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Evaluasi (SOAP) :
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…………, 2023
Pembimbing Klinik Mahasiswa

(…………..............………) (…………....................…..)
NIP……………… NIM……….

Profesi Ners 2023

 CATATAN KEPERAWATAN KLIEN DENGAN PSIKOSOSIAL

Nama Puskesmas :
Nama Perawat :

Hari/tanggal :
Pertemuan ke :

Data ( Subyektif dan Obyektif ) :

......................................................................................................................................................
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Diagnosis Keperawatan :
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Tindakan Keperawatan :
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Evaluasi (SOAP) :
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…………, 2023
Pembimbing Klinik Mahasiswa

(…………..............………) (…………....................…..)
NIP……………… NIM……….

Profesi Ners 2023

 CATATAN KEPERAWATAN KLIEN DENGAN PSIKOSOSIAL

Nama Puskesmas :
Nama Perawat :

Hari/tanggal :
Pertemuan ke :

Data ( Subyektif dan Obyektif ) :

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
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Diagnosis Keperawatan :
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Tindakan Keperawatan :
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Evaluasi (SOAP) :
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…………, 2023
Pembimbing Klinik Mahasiswa

(…………..............………) (…………....................…..)
NIP……………… NIM……….

Profesi Ners 2023

 CATATAN KEPERAWATAN KLIEN DENGAN PSIKOSOSIAL

Nama Puskesmas :
Nama Perawat :

Hari/tanggal :
Pertemuan ke :

Data ( Subyektif dan Obyektif ) :

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
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......................................................................................................................
Diagnosis Keperawatan :
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Tindakan Keperawatan :
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Evaluasi (SOAP) :
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…………, 2023
Pembimbing Klinik Mahasiswa

(…………..............………) (…………....................…..)
NIP……………… NIM……….

Profesi Ners 2023

 CATATAN KEPERAWATAN KLIEN DENGAN PSIKOSOSIAL

Nama Puskesmas :
Nama Perawat :

Hari/tanggal :
Pertemuan ke :

Data ( Subyektif dan Obyektif ) :

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................
Diagnosis Keperawatan :
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Tindakan Keperawatan :
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Evaluasi (SOAP) :
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…………, 2023
Pembimbing Klinik Mahasiswa

(…………..............………) (…………....................…..)
NIP……………… NIM……….

Profesi Ners 2023

Profesi Ners 2023
 STANDAR PENGKAJIAN GANGGUAN CITRA TUBUH
KOGNITIF AFEKTIF FISIOLOGIS PERILAKU SOSIAL
Kerusakan/gangguan Mudah Kardiovaskular : Gelisah Kadang-kadang
perhatian terganggu Palpitasi Ketegangan fisik menghindar
Kurang konsentrasi Tidak sabar Rasa mau pingsan/pingsan Tremor Kontak /aktifitas
Kesalahan dalam Gelisah TD menurun Gugup sosial Kadang-
menilai Tegang Hipotermia Bicara cepat kadang mudah
Kreativitas berkurang Gugup Extremitas dingin Kurang tersinggung/marah
Produktivitas menurun Takut Nyeri dada koordinasi
Bingung Frustasi Pusing Cenderung
Sangat waspada Teror Vasokontriksi perifer mendapat cedera
Berkurangnya Merasa Denyut nadi Menarik diri
objektivitas bersalah menurun, irreguler, dari hubungan
Takut kehilangan Pemalu aritmia Pernafasan : interpersonal
kontrol Pemarah Nafas cepat Melarikan diri
Takut tidak sempurna Nafas pendek dari masalah
Takut akan terluka atau Tekanan pada dada Menghindar
kematian Nafas dangkal Hiperventilasi
Kesadaran menurun Pembengkakan pada Sering muntah
Mimpi buruk tenggorokan Menggunakan
Sensasi tercekik laksatif/diuretik
Terengah-engah Aktifitas
berlebihan

STANDAR PENGKAJIAN BERDUKA ANTISIPASI

KOGNITIF AFEKTIF FISIOLOGIS PERILAKU SOSIAL
Tidak dapat Reaksi kecemasan Ketidak Mondar mandir Ketidak mampuan
berfikir logis secara umum seimbangan : Perilaku aneh berkomunikasi
Gangguan konsentrasi Kegembiraan yang GH Daya tilik diri kurang Acuh dengan
rendah berlebihan, Prolaktin Tidak bisa mengontrol lingkungan
Tidak mampu kesedihan yang ACTH diri Kemampuan sosial
mengambil keputusan berlarut, takut LH Penampilan tidak menurun
Gangguan bicara berlebihan, marah, FSH sesuai Paranoid
Flight of Idea curiga berlebihan, TSH Perilaku yang diulang- Personal
Ambivalen defensif, sensitif, Insulin ulang Hygien kurang
Pesimis kesepian, bersedih, Katekolamin Agresi Sulit berinteraksi
Menyalahkan diri harga diri rendah, Epinefrin Gelisah Tidak tertarik
sendiri putus asa, berasa Norepinefrin Negativism dengan kegiatan
Kehilangan rasa bersalah, Dopamin Melakukan suatu yang bersifat
tertarik terhadap menyangkal Oksitosin pekerjaan tidak tuntas menghibur
sesuatu dan kehilangan perasaan Gerakan: katatonia, Penyimpangan
motivasi Bingung kaku, gerakan mata seksual
Emosional diri (tidak banormal, grimasem, Menarik diri
mampu mengendalikan gaya berjalan tidak
emosi normal
Agitasi

Profesi Ners 2023

 STANDAR PENGKAJIAN ANSIETAS
KOGNITIF AFEKTIF FISIOLOGIS PERILAKU SOSIAL
Kerusakan perhartan Mudah Kardiovaskular : Gelisah Kadang-
Kurang konsentrasi terganggu Palpitasi Ketegangan fisik kadang
Pelupa Tidak sabar Jantung berdebar Tremor menghin
Kesalahan dalam menilai Gelisah TD meningkat/ menurun Gugup dar
Blocking Tegang Rasa mau pingsan/pingsan Bicara cepat Kontak
Penurunan lapang Gugup Denyut nadi menurun Kurang sosial/ak
pandang Takut Pernafasan : koordinasi tifitas
Berkurangnya kreativitas Waspada Nafas cepat, Nafas pendek Cenderung menurun
Produktivitas menurun Frustasi Tekanan pada dada mendapat cedera Kadang-
Bingung Merasa Nafas dangkal Menarik diri dari kadang
Sangat waspada bersalah Pembengkakan pada hubungan menunju
Berkurangnya Merasa tenggorokan interpersonal kkan
objektivitas khawatir Sensasi tercekik, Terengah- Melarikan diri sikap
Takut kehilangan kontrol engah dari masalah bermusu
Takut akan terluka atau Neuromuskuler : Menghindar han
kematian Reflex meningkat, Mata Hiperventilasi
Kesadaran diri berkedip-kedip Suara meninggi
meningkat Insomnia, Tremor, Rigiditas Meremas tangan
Mimpi buruk Gelisah, Wajah tegang Banyak bicara
Sulit membuat keputusan Muka kerut, Kedutan otot Tidak mampu
muka rileks
Integumen : Susah tidur
Wajah kemerahan Koordinasi
Berkeringat pada telapak motoric kurang
tangan, Gatal Aktifitas tidak
Rasa panas dan dingin bertujuan
pada kulit
Wajah pucat
Berkeringat seluruh tubuh
Bibir bergetar

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