PENGKAJIANKEPERAWATAN

ASUHANKEPERAWATANPSIKOSOSIA

Namamhs/klp : FAKHRI MULYADI

Tgl/jampengkajian : 08-07-2023 Tgl/jamMRS : ........................................
Sumberdata : Pasien No.RM : ........................................
Metode : Wawancara Ruangan/kelas : ........................................
Alat/bahan : Tensi,termometer, No.kamar : ........................................
Diagnosa medis : Diabetes Melitus

I. IDENTITAS
1. Nama : Tn.R ................................................................................................................................
2. Umur : 35 Tahun ........................................................................................................................
3. Jeniskelamin : LAKI-LAKI ............................................................................................................................
4. Status : Menikah...................................................................................................
5. Agama : Islam ...............................................................................................................................
6. Suku/bangsa : Jawa/Indonesia ...........................................................................................................
7. Bahasa : Indonesia .......................................................................................................................
8. Pendidikan : SMA .................................................................................................................................
9. Pekerjaan : Karyawan Swasta ........................................................................................................
10. Alamat dan no.telp : Tanah Tinggi,0895123452372 ..........................................................................................
11. Penanggung jawab : Tn.A, Kakak Kandung .................................................................................................
& hubungan dg klien

I . POLAPERSEPSIKESEHATANATAUPENANGANANKESEHATAN
1. Keluhan utama:
Tidur tidak nyenyak, kaki kanan pegal, badan tremor, lemas, pucat keringat dingin, dan tidak
berdaya akan sakit yang ia derita .........................................................................................................................................

2. Riwayat penyakitsekarang :
Klien terkonfirmasi Diabetes Melitus Sejak 2 tahun yang lalu .......................................................................

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3. Lamanyakeluhan
Sejak 2 tahun lalu .....................................................................................................................................................

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4. Faktor yang Memperberat
Aktivitas terbatas ....................................................................................................................................................

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 5. Upaya yang Dilakukan Untuk Mengatasi Keluhan
Berobat ke rumah sakit ..........................................................................................................................................

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6. Riwayat penyakitdahulu:
Pasien mengatakan suka makan yang bersantan, suka makan yang manis- manis, makan tidak
teratur, dan pasien suka ngemil. Tn.R mengatakan pasien sangat suka minum teh manis, kopi, dan
minuman instan.Pasien mengatakan mengalami Diabetes Melitus Tipe I sejak tahun 2021. .............

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7. Persepsi klien tentang status kesehatan dan kesejahteraan
Klien mengatakan bahwa kesehatan itu penting, kesehatan itu nomor satu, jadi saya harus sehat,
saya harus bisa mengontrol aktivitas saya dan konsumsi saya ...................................................................

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8. Riwayat kesehatan keluarga:
Pasien mengatakan ayah pasien juga mengalami penyakit yang sama dengan ia mempunyai
riwayat diabetes. Tidak ada riwayat penyakit keturunan lainnya seperti hipertensi, Penyakit jantung
koroner, strokedan lain-lainya. ............................................................................................................................

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9. Susunankeluarga(genogram):
Ibu
AyahTn.R Tn.R
Riwayat DM (alm)

Kakak Kakak laki- Kakak Kakak laki- Tn.R

Tn.R laki Tn.R ipar laki Ny.N
Ny.N

Keponaka
n Ny.N

10. Riwayat alergi :

Tidakada ...................................................................................................................................................................

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II . POLANUTRISIDANMETABOLIK
1. Polamakan
Dirumah Dirumahsakit

Frekuensi : 2-3 kali sehari Frekuensi : 2 kali sehari

Jenis : nasi, laukpauk Jenis : nasi, sayuran, lauk

pauk, daging tanpa
Porsi : 1 porsi lemak
Pantangan : tidak ada Porsi : 1 porsi
Makanan disukai : ayam Diitkhusus : ada

2. Polaminum
Dirumah
Dirumahsakit
Frekuensi : 7 gelas sehari
Frekuensi : 8 gelas sehari
Jenis : air putih
Jenis : air putih
Jumlah : 1 liter
Jumlah : 2 liter
Pantangan : tidak ada

Minuman disukai : kopi dan

susu

IV. POLAELIMINASI
1. Buangairbesar
Dirumah Dirumahsakit

Frekuensi : 5 kalisehari Frekuensi : 1 kalisehari

Konsistensi : cair Konsistensi : normal

Warna : hitam Warna : ( ) kuning

( )

bercampurdarah ()

lainnya,..............

Masalahdi RS : ( ) konstipasi ( ) diare ( ) inkontinen

Kolostomi : ( V) tidak ( ) ya
 2. Buangairkecil
Dirumah Dirumahsakit
Frekuensi : 10 kalisehari Frekuensi : 3-4 kalisehari
Jumlah : 3 liter sehari Jumlah : 1 liter
Warna : keruh Warna : kuning

Masalahdi RS : ( ) disuria ( ) nokturia ( ) hematuria

( ) retensi ( ) inkontinen

Kateter : ( ) tidak ( v ) ya,kateter foley produksi: 1000 cc/hari

V. POLAAKTIVITASDANLATIHAN
1. Kemampuan perawatandiri
SMRS MRS
Aktivitas
0 1 2 3 4 0 1 2 3 4

Mandi v v

Berpakaian/berdandan v V

Eliminasi/toileting v v

Mobilitasditempat tidur V v

Berpindah V v

Berjalan V V

Naik tangga v v

Berbelanja v V

Memasak v v

Pemeliharaan rumah v v

Skor 0 =mandiri 3 =dibantuoranglain&alat

1 =alatbantu 4 =tergantung/tidak mampu
2 =dibantuorang lain

Alatbantu : ( ) tidak ( ) kruk ( v) tongkat

( ) pispotdisamping tempat tidur ( ) kursiroda

2. Kebersihan diri
Dirumah Mandi : 2 /hr
 Gosokgigi : 2 /hr Mandi : 2 /hr

Keramas : 1 /mgg Gosokgigi : 2 /hr

Potongkuku : 1 /mgg Keramas : 1 /mgg

Dirumahsakit Potongkuku : 1 /mgg

3. Aktivitassehari-hari
Menonton Tv ............................................................................................................................................................

4. Rekreasi
Tidakada ...................................................................................................................................................................

5. Olahraga: ( v) tidak ( ) ya
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VI. POLAISTIRAHATDANTIDU
R Dirumah Dirumahsakit

Waktutidur : Siang 13.00-14.000 Waktu tidur : Siang 13.00-14.00

Malam20.00-05.00 Malam20.00-05.00
Jumlah jamtidur: 10 Jumlahjamtidur : 10 jam
jam

Masalahdi RS : ( ) tidakada ( v) terbangundini ( ) mimpi buruk

( ) insomnia ( ) Lainnya, . ...............................................................................................

VI . POLAKOGNITIFDANPERSEPTUAL
Berbicara : ( v) normal ( ) gagap ( ) bicaratakjelas

Bahasasehari-hari : ( v ) Indonesia ( ) Jawa ( ) lainnya, ............................................

Kemampuan membaca : ( v) bisa ( ) tidak

Tingkatansietas : ( ) ringan ( v) sedang ( ) berat ( ) panik

Sebab, tidak percaya dengan diri sendiri dan merasa tidak ada
perubahan padapenyakityang iaderita

Kemampuan interaksi : ( v) sesuai ( ) tidak, .................................................................................

Vertigo : ( v) tidak ( ) ya

Nyeri : ( v) tidak ( ) ya

Bilaya, P : .................................................................................................................................................................

Q : .................................................................................................................................................................

R : .................................................................................................................................................................

S : .................................................................................................................................................................

T : .................................................................................................................................................................
 VII . POLAPERSEPSIDIRI/KONSEPDIRI
1. Bodyimage/gambarandiri
( ) cacat fisik ( ) pernahoperasi

( ) perubahan ukuranfisik ( ) proses patologipenyakit

( ) fungsialattubuhterganggu ( ) kegagalan fungsitubuh (

( v) keluhan karenakondisi ) gangguan strukturtubuh

tubuh ( ) transplantasialattubuh ( ) menolakberkaca

( ) prosedur pengobatan yang mengubah fungsialattubuh

( ) perubahan fisiologistumbuh kembang

Jelaskan: Klienmasih tidakterimadengan penyakit yangiaalami ...........................................................

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Masalahkeperawatan: Gangguan Citra Tubuh

2. Role/peran
( ) overloadperan ( ) perubahanperan ( v) transisiperan karenasakit
( ) konflikperan () keraguanperan
Jelaskan : klien tidak bisa melakukan kegiatan/aktivitas sehari-hari seperti sebelumnya
karenapenyakityangiaderita .............................................................................................................

Masalahkeperawatan:Ketidakberdayaan .......................................................................................................

3. Identity/identitasdiri
( v) ( v ) merasa kurang memiliki potensi
kurangpercayadiri ( ) ( v ) kurang mampumenentukan
merasa terkekang pilihan ( ) menolakmenjadi tua
( v ) tidak mampumenerima perubahan

Jelaskan: Pasien mengatakan merasa kurang dalamdirinya .....................................................................

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Masalahkeperawatan: Harga Diri RendahKronis ...........................................................................................

4. Selfesteem/hargadiri
( v) mengkritik ( ) menyangkal kepuasandiri
dirisendiridanoranglain ( ) merasa jadi ( ) polarisasipandanganhidup
orangpenting ( ) mencemoohdiri
( ) menunda tugas ( v) mengecilkandiri

( ) merusak diri ( v) keluhan fisik

( v ) menyangkal kemampuan ( ) menyalahgunakan zat

pribadi ( ) rasabersalah
Jelaskan : pasientidakpercayadiri denganpenyakit yangiaderita ...........................................................

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 Masalahkeperawatan: Harga Diri RendahSitusaional ..................................................................................

5. Selfideal/idealdiri
( v ) masadepan suram ( ( v ) tidak inginberusaha
v ) terserahpadanasib ( v ) tidak memiliki cita-cita
( v) merasa tidak memiliki kemampuan ( v ) merasa tidakberdaya

( v ) tidak memiliki harapan ( ) engganmembicarakan masadepan

Jelaskan : klien mengatakan tidak ada perubahan dalam keadaannya dan merasa takut sesuatu
terjadi .......................................................................................................................................................................................

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Masalahkeperawatan: Ansietas ............................................................................................................................

IX. POLAPERANDANHUBUNGAN
Pekerjaan : pegawai swasta ..............................................................................................

Kualitasbekerja : karena sakittidak bisabekerja .....................................................................

Hubungandengan oranglain : baik

Sistempendukung : ( ) pasangan ( ) tetangga/teman () tidakada

( v) lainnya, keluarga .....................................................................................

Masalahkeluargamengenai perawatandi RS: tidak memiliki biaya .................................................................

X. POLASEKSUALITAS/REPRODUKSI
Menstruasi terakhir : 30-06-2023 ....................................................................................................................

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

Papsmear terakhir : ..........................................................................................................................................

Pemeriksaanpayudara/testis sendiri tiapbulan : ( ) ya ( v) tidak

Masalahseksual yangberhubungandenganpenyakit : tidak ada ........................................................

XI. POLAKOPING/TOLERANSISTRESS
1. MasalahutamaselamaMRS(penyakit,biaya, perawatandiri)
Klien merasa gelisah dan khawatir dan merasa sebagai suatu ancaman takut terjadi sesuatu atau
faktorpenyakitnyayang diderita tidaksembuh ...............................................................................................

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2. Kehilanganperubahanyangterjadisebelumnya
a. Tahap Denial/Penolakan
( ) penolakanterhadap situasi ( v ) merasa tertekan
( ) tidakpercayapadaoranglain
( ) wawasansempit
 Jelaskan: Pasien merasa tertekandengan hidupnya yangseperti ini .................................................

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Masalahkeperawatan: ketidakberdayaan ................................................................................................

b. Tahap Anger/Marah
( v) marahpadadiri ( ) meningkatnyakesadaranklien pada
sendiri ( ) realita
marahpadaorang lain
Jelaskan: menyalahkan dirisendiriataspenyakityang diaderita dan merasatidak berguna
untukhidup ...................................................................................................................................
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Masalahkeperawatan: berduka ..................................................................................................................

3. Kemampuanadaptasi
Tidaklangsung beradaptasi dengan hidupyangiaalami ..............................................................................

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XI . POLANILAI/KEPERCAYAAN
Agama : Islam..............................................................................................
..

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

Pantanganagama : ( ) tidak ( v) ya, makanan

haram Memintakunjunganrohaniawan : ( v) tidak ( ) ya

XII . PENGKAJIANPERSISTEM( )
1. Tanda-TandaVital
a. Suhu : 36,5............° C lokasi:......................
b. Nadi : 89............... /menit irama: ...................... pulsasi:......................
c. Tekanan darah : 140/90........ mmHg lokasi:......................
d. Frekuensi nafas : 20............... /menit irama: ......................
e. Tinggibadan : 160...............cm
f. Berat badan : SMRS ...55...kg MRS........50............kg

2. SistemPernafasan( )
Normal .......................................................................................................................................................................

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3. SistemKardiovaskuler( )
Tekanan Darah Meningkat140/90 mmHg ......................................................................................................

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4. SistemPersarafan( )
 Normal .......................................................................................................................................................................

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5. SistemPerkemihan( )
Seringbuangairkecil dengan frekuensi 10 kalisehari ...................................................................................

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6. SistemPencernaan( )
Normal .......................................................................................................................................................................

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7. SistemMuskuloskeletal( )
Rasa lemasataukehilangan dayakoordinasitangandan kekakuanpada tulang atausendi ...............

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8. SistemIntegumen
Kelainankulitseperti neuropati perifer ..............................................................................................................

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9. SistemPenginderaan
Mata

Normal .......................................................................................................................................................................

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Hidung

Normal .......................................................................................................................................................................

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Telinga

Normal .......................................................................................................................................................................

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10. SistemReproduksiDanGenetalia
Normal .......................................................................................................................................................................
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XIV. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

Masalahdengan dukungankelompok, spesifik

Masalahberhubungan denganlingkungan,spesifik

Masalahdengan pendidikan, spesifik

v Masalahdengan pekerjaan, spesifik

Masalahdengan perumahan, spesifik

v Masalahekonomi, spesifik

Masalahdengan pelayanan kesehatan, spesifik

Masalahlainnya, spesifik

MasalahKeperawatan :

Penurunankapasitasadaptifintrakranial.................................................................................
XV. PEMERIKSAANPENUNJANG
1. Laboratorium
Testoleransi glukosaoral(TTGO) .......................................................................................................................

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2. Photo
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3. Lain-lain
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XVI. TERAPI
Terapi Insulinpadadiabetes melitustipe1 ..............................................................................................................

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2. PEMERIKSAANPENUNJANG
4. Laboratorium
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5. Photo
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6. Lain-lain
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3. TERAPI
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Mahasiswa

(FAKHRI MULYADI)