Dokumentasi Pengkajian Keperawatan

Oleh: Ns. Anisah Ardiana, M.Kep.

Standar kompetensi
Mahasiswa dapat mengaplikasikan
pendokumentasian pengkajian
keperawatan dalam pemberian asuhan
keperawatan.

Kompetensi Dasar:
Mahasiswa dapat menjabarkan pengertian pengkajian
keperawatan
Mahasiswa dapat mengidentifikasi macam-macam data
Mahasiswa mampu menganalisis beberapa kesalahan
dalam pengkajian
Mahasiswa dapat mengaplikasikan beberapa metoda
pengkajian
Mahasiswa mampu melakukan analisis data
Mahasiswa mampu mendokumentasikan pengkajian
dengan tepat

Pengkajian
The first step in the nursing process.
it is systematic and continuous collection, validation and
communication of client data as compared to what is
standard/norm.
Includes systematic collection, verification, organization,
interpretation, and documentation of data.
Mengumpulkan data apa adanya, dilakukan sebelum
analisa

Tujuan
Untuk memperoleh data dasar tentang informasi yang sesuai
keadaan pasien termasuk kemampuan koping pasien.
To organize a database regarding a clients physical,
psychosocial, and emotional health.
To identify health-promoting behaviors and actual and/or
potential health problems.
To establish a data base (all the information about the client):
nursing health history, physical assessment, the physicians
history & physical examination, results of laboratory &
diagnostic tests, material from other health personnel

Pengkajian meliputi:
Derajat kesehatan pasien: sehat-sakit
Gangguan terhadap kesehatan dan respon
terhadap gangguan tersebut
Koping yang dimiliki
Faktor risiko
Sumber daya yang ada, misal lembaga
kesehatan

Tipe pengkajian
Comprehensiveprovides baseline client data.
comprehensive information you gather on initial
contact with the person to assess all aspects of health
status.
Focusedlimited to a particular need or health care
concern. the data you gather to determine the status of
a specific condition.
Ongoingincludes systematic monitoring of specific
problems.

Activities:

Collection of data
Validation of data
Organization of data
Analyzing of data
Recording/documentation of data

Collection of data:
gathering of information about the client
includes physical, psychological, emotion, socio-cultural,
spiritual factors that may affect clients health status
includes past health history of client (allergies, past
surgeries, chronic diseases, use of folk healing methods)
includes current/present problems of client (pain, nausea,
sleep pattern, religious practices, meds or treatment the
client is taking now)

Macam-macam data
1. Objective data / sign/ over data (data terlihat)
: observable and measurable, obtained through both physical
examination and the results of lab and diagnostic testing.
Deteksi dan observasi memakai standar. Misal: pallor,
diaphoresis, BP=150/100, yellow discoloration of skin
2. Subjective data/ symptom/ covert data (data tertutup)
: data from clients point of view, and include perceptions,
feelings, and concerns. Collected by interview. Orang lain
tidak bisa mengetahui data orang yang lainnya, misal: pusing,
mual

3. Data variabel
: bervariasi dari waktu ke waktu mengacu
pada standar. Misal: TD, frekuensi nadi,
frekuensi pernapasan
4. Data konstan/ tetap
: TTL, nama, suku
No 1 dan 2 yang biasa dipakai

Sumber data
Primary source
: client or the major provider of information
about a client.
Secondary source
: sources of data other than client and
include family members, other health care
providers, and medical records.

Metode pengkajian
(pengumpulan data):
1. Interview
a planned, purposeful conversation/communication with the
client to get information, identify problems, evaluate change,
to teach, or to provide support or counseling.
it is used while taking the nursing history of a client
2. Observation use to gather data by using the 5 senses and
instruments.

3. . Examination
systematic data collection to detect health problems using
unit of measurements, physical examination techniques
(IPPA), interpretation of laboratory results.
should be conducted systematically:
Cephalocaudal approach head-to-toe assessment
Body System approach examine all the body system
Review of System approach examine only particular area
affected

a Nursing Health History a structured interview designed to collectspecific data and

to obtain a detailed health record of a client.

Biographic data name, address, age, sex, marital status,

occupation, religion.
Reason for visit/Chief complaint primary reason why client seek
consultation or hospitalization.
History of present Illness includes: usual health status,
chronological story, family history, disability assessment.
Past Health History includes all previous immunizations,
experiences with illness
Family History reveals risk factors for certain disease diseases
(Diabetes, hypertension, cancer, mental illness).

 Review of systems review of all health problems by body

systems
Lifestyle include personal habits, diets, sleep or rest patterns,
activities of daily living, recreation or hobbies.
Social data include family relationships, ethnic and
educational background, economic status, home and
neighborhood conditions.
Psychological data information about the clients emotional
state.
Pattern of health care includes all health care resources:
hospitals, clinics, health centers, family doctors.

Validating of data:
: the act of double-checking or verifying data to confirm that it is
accurate and complete.
Tujuan:
ensure that data collection is complete
ensure that objective and subjective data agree
obtain additional data that may have been overlooked
avoid jumping to conclusion
differentiate cues and inferences (dry skin = dehidrasi)
Prevents misunderstandings, omissions, and incorrect inferences and
conclusions.

Organization of data
Data must be organized.
Data clustering is the process of putting the data
together in order to identify areas of the clients
problems and strengths.
uses a written or computerized format that organizes
assessment data systematically.
Hirarki kebutuhan Maslow, model system, ataupun
menurut Gordon

Analyzing of data
compare data against standard and identify significant cues.
Standard/norm are generally accepted measurements, model, pattern:
Ex: Normal vital signs, standard Weight and Height, normal
laboratory/diagnostic values, normal growth and development pattern
Organizing data in clusters helps to recognize patterns of response or
behavior:
Distinguish between relevant, irrelevant.
Determine whether and where there are gaps in the data.
Identify patterns of cause and effect.

Documenting of data
nurse records all data collected about the clients health status
data are recorded in a factual manner not as interpreted by the nurse
record subjective data in clients word; restating in other words
what client says might change its original meaning.
The nurse must decide which data should be immediately reported
and which data can just be recorded.
It is essential for accurate and complete recording of assessment
data to communicate information to other health care team
members.

Kesalahan dalam pengkajian

Memberi pendapat pribadi
Generalisasi
Diinterpretasikan sebagai data, padahal
bukan suatu data

Selamat mencoba....