PROSES KEPERAWATAN

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 BAHASAN
1. Konsep pengertian pengkajian
2. Tujuan pengkajian
3. Konsep pengumpulan data
4. Tipe data
5. Sumber data;
6. Metode pengumpulan data
7. Hal – hal yang harus diperhatikan dalam pengkajian
8. Validasi data
9. Identifikasi masalah
10.Pengdokumendasian data
PENGKAJIAN
PENGERTIAN Your Picture Here Your Picture Here

PENGKAJIAN
Pengkajian adalah tahap awal dari proses Your Picture Here And Send To Back

keperawatan dan merupakan proses yang sistematis

dalam pengumpulan data dari berbagai sumber data
untuk mengevaluasi dan mengidentifikasi status
kesehatan pasien menurut Lyer et al (1996, dalam
Setiadi, 2012). P

Your Picture Here

 01 Untuk memperoleh 02 Untuk menentukan
informasi tentang masalah keperawatan
keadaan kesehatan dan kesehatan pasien
pasien.

TUJUAN
PENGKAJIAN
03 Untuk menilai keadaan 04 Untuk membuat
kesehatan pasien. keputusan yang tepat
dalam menentukan
langkah-langkah
berikutnya.
PENGUMPULAN DATA
• Pengumpulan data adalah pengumpulan informasi tentang klien yang dilakukan secara sistematis untuk
menentukan masalah-masalah, serta kebutuhan-kebutuhan keperawatan dan kesehatan klien.
• Pengumpulan informasi merupakan tahap awal dalam proses keperawatan.
• Dari informasi yang terkumpul, didapatkan data dasar tentang masalah-masalah yang dihadapi klien.
• Selanjutnya data dasar tersebut digunakan untuk menentukan diagnosis keperawatan, merencanakan
asuhan keperawatan, serta tindakan keperawatan untuk mengatasi masalah-masalah klien.
• Pengumpulan data dimulai sejak klien masuk ke rumah sakit (initial assessment), selama klien dirawat
secara terus-menerus (ongoing assessment), serta pengkajian ulang untuk menambah / melengkapi
data (re-assessment).
• Tujuan Pengumpulan Data
a) Memperoleh informasi tentang keadaan kesehatan klien.
b) Untuk menentukan masalah keperawatan dan kesehatan klien.
c) Untuk menilai keadaan kesehatan klien.
d) Untuk membuat keputusan yang tepat dalam menentukan langah-langkah berikutnya
Tipe Data
Tipe Data :
1. Data Subjektif
adalah data yang didapatkan dari klien sebagai suatu pendapat terhadap suatu situasi dan kejadian.
Informasi tersebut tidak bisa ditentukan oleh perawat, mencakup persepsi, perasaan, ide klien tentang status
kesehatannya. Misalnya tentang nyeri, perasaan lemah, ketakutan, kecemasan, frustrasi, mual, perasaan
malu.
2. Data Objektif
adalah data yang dapat diobservasi dan diukur, dapat diperoleh menggunakan panca indera (lihat, dengar,
cium, raba) selama pemeriksaan fisik.
Misalnya frekuensi nadi, pernafasan, tekanan darah, edema, berat badan, tingkat kesadaran.
Tipe Datalanjutan
Karakteristik Data
1. Lengkap
Data yang terkumpul harus lengkap guna membantu mengatasi masalah klien yang adekuat.
Misalnya klien tidak mau makan selama 3 harPerawat harus mengkaji lebih dalam mengenai masalah
klien tersebut dengan menanyakan hal-hal sebagai berikut: apakan tidak mau makan karena tidak ada nafsu
makan atau disengaja? Apakah karena adanya perubahan pola makan atau hal-hal yang patologis?
Bagaimana respon klien mengapa tidak mau makan.
2. Akurat dan nyata
Untuk menghindari kesalahan, maka perawat harus berfikir secara akurat dan nyata untuk membuktikan
benar tidaknya apa yang didengar, dilihat, diamati dan diukur melalui pemeriksaan ada tidaknya validasi
terhadap semua data yang mungkin meragukan. Apabila perawat merasa kurang jelas atau kurang mengerti
terhadap data yang telah dikumpulkan, maka perawat harus berkonsultasi dengan perawat yang lebih
mengerti.
Misalnya, pada observasi : “klien selalu diam dan sering menutup mukanya dengan kedua tangannya.
Perawat berusaha mengajak klien berkomunikasi, tetapi klien selalu diam dan tidak menjawab pertanyaan
perawat. Selama sehari klien tidak mau makan makanan yang diberikan”, jika keadaan klien tersebut ditulis
oleh perawat bahwa klien depresi berat, maka hal itu merupakan perkiraan dari perilaku klien dan bukan data
yang aktual. Diperlukan penyelidikan lebih lanjut untuk menetapkan kondisi klien. Dokumentasikan apa
adanya sesuai yang ditemukan pada saat pengkajian.
Tipe Datalanjutan
3. Relevan
Pencatatan data yang komprehensif biasanya menyebabkan banyak sekali data yang harus dikumpulkan,
sehingga menyita waktu dalam mengidentifikasi. Kondisi seperti ini bisa diantisipasi dengan membuat data
komprehensif tapi singkat dan jelas. Dengan mencatat data yang relevan sesuai dengan masalah klien, yang
merupakan data fokus terhadap masalah klien dan sesuai dengan situasi khusus
 Sumber Data
 Sumber data primer
Klien adalah sumber utama data (primer) dan perawat dapat menggali informasi yang
sebenarnya mengenai masalah kesehatan klien.
 Sumber data sekunder
Orang terdekat, informasi dapat diperoleh melalui orang tua, suami atau istri, anak,
teman klien, jika klien mengalami gangguan keterbatasan dalam berkomunikasi atau
kesadaran yang menurun, misalnya klien bayi atau anak-anak, atau klien dalam kondisi
tidak sadar.
 Sumber Data lainnya
Rekam
Pasien
Medik

Konsultasi Secara
Verbal Atau
Keluarga
Tulisan
Dan Masyarakat
Pemeriksaan
Diagnostik
Catatan
Keperawatan Literatur Yang
Berkaitan
 Metode Pengumpulan Data
Wawancara
Tanya jawab /komunikasi secara langsung dengan klien (auto anamnesis). Tanya jawab /komunikasi
secara tak langsung dengan klien (allo-anamnesis), komunikasi dilakukan pada keluarga untuk
menggali status kesehatan klien.
Tujuan melakukan anamnese adalah:
a) Mendapatkan informasi yang diperlukan untuk mengidentifikasi masalah klien
b) Meningkatkan hubungan perawat-klien
c) Membantu klien untuk berpartisipasi dalam mengenali masalah kesehatannya
d) Membantu perawat menentukan investigasi selanjutnya dalam pengkajian
e) Membantu perawat menganalisis dan menegakkan diagnosis serta penyusunan intervensi

Hal-hal yang harus diperhatikan pada saat melakukan anmnese

f) Ketrampilan membangun kepercayaan dengan klien
g) Perhatikan aspek verbal dan nonverbal
h) Kembangkan kemampuan berbahasa yang tepat
i) Tingkatkan pengetahuan
j) Kenali bahasa verbal/perilaku nonverbal
k) Hindari mealkukan interupsi ke pasien
l) Memberi kesempatan pasien untuk istirahat
 Metode Pengumpulan Data
Observasi
• Metode pengumpulan data dimana data dikumpulkan melalui observasi visual
• Teknik observasi dilakukan dengan 2S HFT ( Sight, smell, hearing, Feeling, Taste)
Adapun keterangan kegiatan dalam observasi adalah:
 S = Sight /melihat
• Gunakan indera penglihatan untuk menghasilkan data
• Lihat dan perhatikan Semua bentuk performance klien
• Lihat segala bentuk kelainan bentuk tubuh, raut muka, kondisi umum klien
 S = Smell
• Gunakan indera penciuman untuk menghasilkan data
• Bau/cium yang tidak wajar pada pasien atau lingkungan disekitar pasie
• bau pernafasan, kulit, urine, faeces , discharge luka dll
• Misalkan bau alcohol, foetor aceton, foetor uremic
 H = Hearing
• Menggunakan indera pendengaran untuk menghasilkan data
• Pemeriksaan dengan auskultasi
• Alat yang digunakan stetoskop, phonenduskup,alat audiovisual lainnya
• Mendengarkan suara nafas, bunyi jantung, denyut jantung janin dll
 Metode Pengumpulan Data
Observasilanjutan
 F = Feeling
• Menggunakan daya rasa
• Meningkatkan empati ke pasien
• Meningkatkan responsitas dan sensitivitas perawat terhadap kondisi dan kebutuhan klien
• Misalkan ikut bahagia jika pasien bisa sembuh, melahirkan dengan selamat
• Ikut berempati pada saat pasien mengalami fase kehilangan/kematian
 T = Taste
Pada teknik terakhir ini perawat tidak saja melakukan perabaan namun juga harus biasa bisa
merasakan apa yang diraba.
Contoh dari teknikini yaitu:
• Saat kita meraba kulit pasien , kita harus merasakan bagaimana suhu tubuh pasien panas atau
tidak
• Saat kita meraba denyut nadi, kita harus merasakan kekuatan denyutan, volume pengisian
nadinya cukup atau tidak, reguleritas nadi
• Saat kita meraba tulang- tulang pasien, apakah tulangnya teraba simetris, ada tidaknya
deformitas, krepitasi, keutuhan dan kekuatan tulang dan otot Misalnya meraba kulit pasien untuk
merasakan perubahan suhu, kondisi akral, denyut nadi.
Metode Pengumpulan Data

Konsultasi
Seorang spesialis diminta untuk
mengidentifikasi cara-cara pengobatan dan
memangani masalah-masalah klien
Metode Pengumpulan Data
Pemeriksaan Fisik
Pemeriksaan fisik adalah salah satu bagian dari proses keperawatan.
Proses inspeksi tubuh (head to toe) dan sistem tubuh untuk
menentukan ada atau tidaknya penyakit penyakit yang didasarkan pada
temuan berikut ini:

Pemeriksaan fisik
Empat prosedur yang digunakan
• Inspeksi
• Palpasi
• Perkusi
• auskultasi.
 Metode Pengumpulan Data
Pemeriksaan Fisik
• Inspeksi
Tahapan yang bertujuan melihat bagian tubuh dan menentukan apakah seseorang mengalami kondisi
tubuh normal atau abnormal. Inspeksi dilakukan secara langsung (seperti penglihatan, pendengaran,
dan penciuman) dan tidak langsung (dengan alat bantu).
Contohnya:
kondisi umum pasien, melihat irama nafas pasien, melihat kondisi konjungtiva dan sklera, ada
tidaknya oedema, ada tidaknya perlukaan, karakteristik urine/faeces

• Palpasi
Pemeriksaan fisik lanjutan dengan menyentuh tubuh dan dilakukan bersamaan dengan inspeksi.
Palpasi dilakukan menggunakan telapak tangan, jari, dan ujung jari. Tujuannya untuk mengecek
kelembutan, kekakuan, massa, suhu, posisi, ukuran, kecepatan, dan kualitas nadi perifer pada tubuh.
Contohnya;perawat ingin mengidentifikasi ada tidaknya nyeri, vokal fremitus, ictus cordis, ada
tidaknya massa/benjolan, petanda appendiksitis, dsb
 Metode Pengumpulan Data
Pemeriksaan Fisik
• Perkusi
Perkusi adalah pemeriksaan dengan melakukan ketukan pada tubuh pasien dengan memakai jari
tengah perawat atau refleks hammer. Ketukan dengan menggunakan jari tengah perawat
dilakukan saat kita melakukan pemeriksaan paru-paru, batas jantung, perkusi abdomen.
Sedangkan ketukan dengan menggunakan reflex hammer digunakan saat perawat melakukan
pemeriksaan pada reflek patella, reflex bisep & trisep, reflex brachiobranchiali
Adapun suara-suara yang dijumpai pada perkusi adalah:
• Sonor: suara perkusi jaringan yang normal.
• Redup : suara perkusi jaringan yang lebih padat, misalnya di daerah paru-paru pada
pneumonia.
• Pekak : suara perkusi jaringan yang padat seperti pada perkusi daerah jantung, perkusi daerah
hepar.
• Hipersonor/timpani : suara perkusi pada daerah yang lebih berongga kosong, misalnya daerah
caverna paru, pada klien asthma kronik.
 Metode Pengumpulan Data
Pemeriksaan Fisik
• Auskultasi
Auskultasi merupakan pemeriksaan fisik dengan menggunakan alat seperti stetoskop, phonenduskup, garpu
talla, opthalmuskop dsb.
Contoh:
1) Stetoskop digunakan oleh perawat saat mengidentifikasi suara nafas, suara jantung, peristaltik usus
2) honenduskup digunakan oleh perawat/bidan untuk mendengarkan denyut jantung janin
3) Garpu talla digunakan perawat saat melakukan pemeriksaan fungsi teling ( weber, rine, swabach)
4) Opthalmuskup digunakan untuk pemeriksaan fungus oculi pada mata
Suara tidak normal yang dapat diauskultasi pada nafas adalah :
• Rales : suara yang dihasilkan dari eksudat lengket saat saluran-saluran halus pernafasan mengembang
pada inspirasi (rales halus, sedang, kasar). Misalnya pada klien pneumonia, TBC.
• Ronchi : nada rendah dan sangat kasar terdengar baik saat inspirasi maupun saat ekspirasi. Ciri khas
ronchi adalah akan hilang bila klien batuk. Misalnya pada edema paru.
• Wheezing : bunyi yang terdengar “ngiii….k”. bisa dijumpai pada fase inspirasi maupun ekspirasi. Misalnya
pada bronchitis akut, asma.
• Pleura Friction Rub ; bunyi yang terdengar “kering” seperti suara gosokan amplas pada kayu. Misalnya
pada klien dengan peradangan pleura
 Metode Pengumpulan Data
Pemeriksaan Fisik
Pendekatan pengkajian fisik dapat menggunakan:
 Head to toe (kepala ke kaki)
Pendekatan ini dilakukan mulai dari kepala dan secara berurutan sampai ke kaki. Mulai dari : keadaan
umum, tanda-tanda vital, kepala, wajah, mata, telinga, hidung, mulut dan tenggorokan, leher, dada, paru,
jantung, abdomen, ginjal, punggung, genetalia, rectum, ektremita
 ROS (Review of System / sistem tubuh) 
Pengkajian yang dilakukan mencakup seluruh sistem tubuh, yaitu : keadaan umum, tanda vital, sistem
pernafasan, sistem kardiovaskuler, sistem persyarafan, sistem perkemihan, sistem pencernaan, sistem
muskuloskeletal dan integumen, sistem reproduksi. Informasi yang didapat membantu perawat untuk
menentukan sistem tubuh mana yang perlu mendapat perhatian khusus
 Pola fungsi kesehatan Gordon, 1982
Perawat mengumpulkan data secara sistematis dengan mengevaluasi pola fungsi kesehatan dan
memfokuskan pengkajian fisik pada masalah khusus meliputi : persepsi kesehatan-penatalaksanaan
kesehatan, nutrisi-pola metabolisme, pola eliminasi, pola tidur-istirahat, kognitif-pola perseptual, peran-pola
berhubungan, aktifitas-pola latihan, seksualitas-pola reproduksi, koping-pola toleransi stress, nilai-pola
keyakinan.
 DOENGOES (1993)
Mencakup : aktivitas / istirahat, sirkulasi, integritas ego, eliminasi, makanan dan cairan, hygiene,
neurosensori, nyeri / ketidaknyamanan, pernafasan, keamanan, seksualitas, interaksi sosial, penyuluhan /
pembelajaran.
Hal yang harus diperhatikan selama pengkajian

Menggunakan berbagai sumber Dilakukan secara

Data yang
dikumpulkan harus yang ada relevansinya dengan sistematis dan terus
menyeluruh meliputi masalah pasien dan menerus
aspek bio-psiko-sosial menggunakan cara-cara
dan spiritual
pengumpulan data yang sesuai
dengan kebutuhan pasien

Dicatat dalam catatan Dikelompokkan menurut

keperawatan secara Dianalisis dengan
kebutuhan bio-psiko-sosial
sistematis dan terus dukungan
dan spiritual
menerus pengetahuan yang
relevan
Validasi Data Your Picture Here Your Picture Here

Validasi data merupakan upaya untuk memberikan Your Picture Here And Send To Back

justifikasi data yang telah dikumpulkan dengan

melakukan perbandingan data subyektif dan obyektif
yang didapatkan dari berbagai sumber dengan
berdasar standar nilai normal untuk diketahui
kemungkinan tambahan atau pengkajian ulang
tentang data yang ada.
Your Picture Here
 Identifikasi Masalah Your Picture Here Your Picture Here

• Identifikasi masalah adalah suatu proses yang

paling penting dalam melakukan sebuah Your Picture Here And Send To Back
penelitian selain dari latar belakang dan juga
perumusan masalah yang ada
• Identifikasi masalah (problem identification)
adalah proses dan hasil pengenalan masalah atau
inventarisasi masalah

Your Picture Here

 Langkah Identifikasi Masalah

Content Here

Content Here

Menciptakan kalimat
Content Here
isu/kalimat
Mengidentifikasi permasalahan (Problem
Content Here Statement) yang
sumber
menjelaskan
permasalahan (Root
Menemukan dan permasalahan yang
cause sudah diidentifikasi
masalah yang ada
(Problem)
 Pendokumentasian Data
• Dokumentasi merupakan bukti pencatatan dan pelaporan yang dimiliki perawat dalam catatan
yang berguna untuk kepentingan klien, perawat dan tim kesehatan dalam memberikan pelayanan
kesehatan dengan dasar data yang akurat dan lengkap secara tertulis sebagai tanggung jawab
perawat (Wahid & Suprapto,2012)
• Pendokumentasian asuhan keperawatan juga dapat digunakan sebagai tanggung jawab dan
tanggung gugat dari berbagai kemungkinan masalah yang akan dialami oleh pasien atau klien
baik masalah kepuasan maupun ketidak puasan terhadap pelayanan kesehatan yang diberikan
(Nursalam,2001)
 Pendokumentasian Data
Tujuan dari Pendokumentasian itu tersebut ialah
• untuk Mengkomunikasikan data klien ke semua anggota tim kesehatan sehingga tidak terjadi
data yang salah dalam memberikan asuhan keperawatan
• untuk jadi bukti guna tujuan evaluasi hasil dari implementasi asuhan keperawatan
• Untuk jaminan kepada masyarakat tentang lingkup dan mutu pelayanan keperawatan dan
membuktikan pekerjaan perawatan serta meningkatkan tanggung gugat perawat, serta dapat
menjadi sumber data untuk melakukan penelitian
 Pendokumentasian Data
Dalam melaksanakan dokumentasi pada tahap pengkajian perlu diketahui bahwa jenis
dokumentasi keperawatan meliputi:
• Dokumentasi pada saat pengkajian awal (InitialAssessment) Dokumentasi yang dibuat ketika
pasien pertama kali masuk rumah sakit. Data yang dikaji pada pasien berupa data awal yang
digunakan sebagai dasar dalam pemberian asuhan keperawatan.
• Dokumentasi pengkajian lanjutan (Ongoing Assessment) Data pada dokumentasi ini
merupaka pengembangan dasar yang dilakukan untuk melengkapi pengkajian awal dengan
tujuan semua data menjadi lengkapsehingga mendukung infromasi tentang permasalahan
kesehatan pasien. Hasil pengkajian ini dimasukkan dalam catatan perkembangan terintegrasi
pasien atau pada lembar data penunjang
• Dokumentasi pengkajian ulang (Reassessment) Dokumentasi ini merupakan pencatatan
terhadap hasil pengkajian yang didapat dari informasi selama evluasi. Perawat mengevauasi
kemajuan dta terhadap pasien yang sudah ditentukan
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