HESTI, KURNIAWATI (2024) PELAKSANAAN DOKUMENTASI ASUHAN KEPERAWATAN PSIKOSOSIAL PADA PASIEN PNEUMONIA DI RSUD Dr. H. MOCH. ANSARI SALEH BANJARMASIN : SECONDARY DATA ANALYSIS TAHUN 2024. Other thesis, STIKES SUAKA INSAN.
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Abstract
PELAKSANAAN DOKUMENTASI ASUHAN KEPERAWATAN PSIKOSOSIAL PADA PASIEN PNEUMONIA DI RSUD Dr. H. MOCH. ANSARI SALEH BANJARMASIN : SECONDARY DATA ANALYSIS TAHUN 2024 Hesti Kurniawati¹, Maria Silvana Dhawo², Maria Frani Ayu Andari Dias² INTISARI Latar belakang : Pneumonia adalah salah satu penyakit pernapasan yang sering memerlukan perawatan intensif dan holistik di rumah sakit. Aspek psikososial dalam perawatan yang holistik memiliki peran penting dalam pemulihan dan kesejahteraan pasien dengan pneumonia. Selama ini, perawatan psikososial pada pasien pneumonia masih belum mendapatkan perhatian terutama dalam pelaksanaan dokumentasi keperawatan. Tujuan : Mendeskripsikan pelaksanaan dokumentasi asuhan keperawatan psikososial di RSUD Dr. H. Moch Ansari Saleh Banjarmasin dengan menggunakan pendekatan secondary data analysis. Metode : Penelitian ini merupakan penelitian deskriptif retrospektif dengan sampel berjumlah 179 medical record, dipilih dengan tekhnik purposive sampling. Instrumen yang digunakan yaitu lembar checklist Pelaksanaan Dokumentasi Asuhan Keperawatan Psikososial Pada Pasien Pneumonia. Analisa data yang digunakan yaitu analisa univariat disajikan dalam bentuk tabel distribusi frekuensi. Hasil : Dokumentasi asuhan keperawatan psikososial adalah tidak lengkap (97,20%). Dokumentasi untuk pengkajian identitas pasien lengkap (100%), pengkajian fisik head to toe tidak lengkap (94,95%), pengkajian umum tidak diisi (96,08%), pengkajian psikososial tidak diisi (83,80%), diagnosa psikososial tidak diisi (83,80%), luaran psikososial tidak diisi (77,09%), intervensi psikososial tidak diisi (77,09%), implementasi psikososial tidak diisi (77,09%), evaluasi asuhan keperawatan tidak diisi (77,09%), dan evaluasi terhadap luaran psikososial berdasarkan SOAP tidak diisi (83,80%). Kesimpulan: Pelaksanaan dokumentasi asuhan keperawatan psikososial pada pasien pneumonia belum dilakukan secara lengkap. Meskipun demikian, pengkajian dan pencatatan identitas pasien oleh perawat telah lengkap dilakukan. Upaya untuk meningkatkan pelaksanaan asuhan keperawatan psikososial dan dokumentasi perlu dilakukan untuk meningkatkan pelayanan holistik bagi pasien, terutama mereka dengan masalah pneumonia. Kata kunci : Asuhan Keperawatan, Dokumentasi Asuhan Keperawatan, Dokumentasi Asuhan Keperawatan Psikososial, Pneumonia, Perawat ────────────────────────────── ¹ Mahasiswa Sekolah Tinggi Ilmu Kesehatan Suaka Insan Banjarmasin ² Dosen Sekolah Tinggi Ilmu Kesehatan Suaka Insan Banjarmasin 13 IMPLEMENTATION OF PSYCHOSOCIAL NURSING CARE DOCUMENTATION FOR PATIENTS WITH PNEUMONIA AT DR. H. MOCH. ANSARI SALEH BANJARMASIN HOSPITAL : SECONDARY DATA ANALYSIS IN 2024 Hesti Kurniawati¹, Maria Silvana Dhawo², Maria Frani Ayu Andari Dias² ABSTRACT Introduction : Pneumonia is one of the respiratory diseases that often requires intensive and holistic care in hospitals. The psychosocial aspect in holistic care has an important role in the recovery and well-being of patients with pneumonia. So far, psychosocial care for pneumonia patients has not received attention, especially in the implementation of nursing documentation. Purpose : Describe the implementation of psychosocial nursing care documentation at Dr. H. Moch Ansari Saleh Banjarmasin Regional Hospital using a secondary data analysis approach. Method: This study is a cohort analytical study with a sample of 179 medical records, selected by purposive sampling technique. The instrument used was a checklist sheet for the Implementation of Documentation of Psychosocial Nursing Care in Pneumonia Patients. The data analysis used, namely univariate analysis, is presented in the form of a frequency distribution table. Results : The completeness of nursing care documentation was 97.20% incomplete and 2.80% complete. In detail, the percentage of assessment scores is as follows, patient identity assessment 100% complete, head to toe physical assessment 94.98% incomplete, general assessment 96.08% incomplete, psychosocial assessment 83.80% not filled in, psychosocial diagnosis 83.80% not filled in, psychosocial outcomes 77.09% not filled in, psychosocial interventions 77.09% not filled in, psychosocial implementation 77.09% not filled in, psychosocial care evaluation 77.09% not filled in and SOAP output evaluation 83.80% not filled in. Conclusion : The implementation of psychosocial nursing care documentation for pneumonia patients has not been carried out completely. However, the assessment and recording of patient identity by nurses has been completely carried out. Efforts to improve the implementation of psychosocial nursing care and documentation need to be made to improve holistic services for patients, especially those with pneumonia problems. Keywords : Nursing care, Nuerse, Nursing Care Documentation, Pneumonia, Psychosocial Nursing Care ────────────────────────────── ¹ The Student of nursing program STIKES Suaka Insan ² The Lecturer of nursing program STIKES Suaka Insan
| Item Type: | Thesis (Other) |
|---|---|
| Subjects: | R Medicine > RT Nursing |
| Divisions: | S1 Ilmu Keperawatan |
| Depositing User: | Abdul Kadir S.Kom |
| Date Deposited: | 12 Sep 2024 06:33 |
| Last Modified: | 12 Sep 2024 06:33 |
| URI: | https://repository.stikessuakainsan.ac.id/id/eprint/368 |
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