TEORI & MODEL

KEPERAWATAN DAN
PENERAPAN DALAM
Oleh: Nursalam

FILSAFAT
ILMU KEPERAWATAN
KEPERAWATAN
ILMU

NURSING PHILOSOPHY
.. The study of the thruths and principles of being, knowledge,
or conduct (Flexner, 1994 cited in Chitty, 1997: 179)

. Statements of beliefs about nursing and

expressions of values in nursing that are used as
bases for thinking an acting: Holism, Humanism, Care
(Chitty, 1997: 182)
.. Membantu memenuhi kebutuuhan pasien
akibat ketidakmampuannya secara biologis dan
psikologis untuk mencapai suatu respons
adaptasi (CHS,1999)

Lanjutan ..

NURSING SCIENCES?
SCIENCES?
NURSING
nursing
nursing as
as an
an art
art and
and discipline
discipline

separate from
from medicine
medicine ..
.. the
the
separate
unique function
function of
of the
the nurse
nurse
is
is
unique
to assist
assist the
the individual,
individual, sick
sick or
or well
well
to
in the
the performance
performance of
of those
those activities
activities
in
contributing to
to health
health or
or its
its
contributing
recovery.
recovery.
(Henderson,1966:
1966:15
15cited
citedin
inChitty,
Chitty,1997:
1997:219)
219)
(Henderson,

STRUKTUR ILMU KEPERAWATAN

FILOSOFI KEPERAWATAN
FILOSOFI KEPERAWATAN

HUMANISM
HUMANISM

HOLISM
HOLISM

CARE
CARE

PERSON
PERSON
CENTER
OF CENTER
NURSING
OF NURSING

CARING
CARING
AS
BASIC
BASIC
OFAS
NURSING
OF NURSING

PARADIGMA KEPERAWATAN
PARADIGMA KEPERAWATAN

MAN

HEALTH

ENV

NURSING
NURSING

Patobiologi:
Perub Biologis (imbalance)
Lanjutan :

Fisiobiologis:
Perub Biologis (balance)
NURSING
NURSING

ART
ART

I. PSIKOLOGI

SCIENCE
SCIENCE
I. KEDOKTERAN

PROFESSION
PROFESSION

THE HEALTH SCIENCE

THE HEALTH SCIENCE
OF CARING
OF CARING

HEALTH SCIENCE
HEALTH SCIENCE

BEHAVIORAL SCIENCES
BEHAVIORAL SCIENCES
SOCIAL SCIENCES
SOCIAL SCIENCES

BIOMEDICAL SCIENCES
BIOMEDICAL SCIENCES
PUBLIC HEALTH SCIENCES
PUBLIC HEALTH SCIENCES

NURSING SCIENCE /
NURSING
SCIENCE /
CARING
SCIENCE
CARING SCIENCE
BASIC NURSING SCIENCES
BASIC NURSING SCIENCES
CLINICAL NURSING SCIENCES
CLINICAL NURSING SCIENCES
COMMUNITY NURSING
COMMUNITY
NURSING
SCIENCES
SCIENCES

2
PARADIGMA
ILMU KEPERAWATAN
KEPERAWATAN
ILMU

NURSING PARADIGM

Manusia

Kesehatan

Lingkungan

Keperawatan
(NURSING)

Chitty (1997)

NURSE
N
U

= Nurture - Asuhan
= Understand

R
S
E

= Review
= Serve
= Educate

CURING - CARING
WHAT DISTINGUISHED NURSING &
MEDICINE

Physicin focus on biological

systems and persons disesease,
whereas nursing focuses on the
person as a total being who
responds to internal & external
environment stimuli (Roy, 1970; Roy &
Roberts, 1981)

ROLE HISTORY OF THE NURSE

HISTORICAL ROLE
C Compassion
A Amateur
R Reward
E Entrustment

Driven
Driven
Driven
Driven

RELIGIUS
Spiritual

YESTERDAY ROLE
C
A
R
E

Community
Attention
Regulatory
Example

Expectation
Expectation
Expectation
Expectation

Doctors order
(dependencey)

NEEDS

TODAY ROLE
C
A
R
E

Communicative
Activity
Responsibility
Expectation

Awareness
Awareness
Awareness
Awareness

Skill /technical

FUTURE ROLE
Cooperative
Advisory
Revisionary
Evaluatary

Focus
Focus
Focus
Focus

Humanistic,
Holistic

IDENTITY

PROFESSIONAL

C A R E
C

= Communication

= Activity

C = Cooperative

= Review

C = Considered

A = Accurate
R = Rapid
E = English

A = Applicable
R = Responsive
E = Empathy

A = Appropriate
R = Reasoned
E = Evaluated

= Education

A = Academic
R = Research
E = Extended

C = Complete

C = Committed

HUMAN NEEDS (MASLOW)

F = FISIOLOGIS
A = AMAN
K = KASIH SAYANG
H = HARGA DIRI
A = AKTUALISASI DIRI

ENVIRONMENT SBG. STRESSOR

PERILAKU TIDAK TERAPEUTIK
Get
up !

Oh
my
God

Stop
It, HELP
ME!

Interaksi
perawat dan klien,
keluarga,
budaya, masyaraka
(Chitty, 1997)

HEALTH
LINGKUNGAN

HOST
SEHAT

Hubungan
TERAPI GAGAL

timbal-balik
STATUS
KESEHATAN

MENINGGAL

SAKIT

KONSEP / TEORI
KEPERAWATAN
1.C.ROY
2. F. NIGHTINGALE
3. OREM
4. KING
5. ORLANDO

S.C ROY
ADAPTATION MODEL

KONSEP TEORI
ADAPTASI
PROCESS
(COPING MECH.)
-Emotional
-- problem solving

INPUT

OUTPUT

COGNATOR

INTERNAL

ADAPTIVE
PHYSIC
SELF-CONCEPT

PSYCHIC

PERCEPTION

INTERDEPENDEN
CE

STIGMA
ROLE

EXTERNAL

SOCIAL
REGULATOR

PAKAR

IN-EFFEC
TIVE

STRESSOR
(Enviromental
stimuli External)

RESP. PERCEPTION (COGNATOR)

Role
Function

RESP. BIOLOGICAL

Interdependence

Sell-Concept

Physiological
Mode

PAKAR
Behavior

Research

-Predisposing

variabels

--Enabling

hipothesized

--Reinforcing

INDIVIDU

(Demographics)

relatioships
Severity of
Deseast

functional

psychological

status

state

Psychosocial
Interpersonal
Relations

Treatment
Regimen

MODEL - ADAPTASI DARI ROY

(Nursalam 2008)

IMMUNE
STATUS

COGNATOR
Internal
stimuli

Intact pathways
and apparatus for
Perceptual/ information
processing

Processes for
Selective attention, coding,
and memory

Perception
Learning

Judgement

Imitation,
reinforcement, insight

Problem Solving &

Decision Making

Psychomotor choice
of response

Effectors

Response

ADAPTIF
Emotion

G
External
stimuli

PAKAR

Defenses to seek
relief , affective
appraisal &
attachement

IMMUNE RESPONSE
IMMUNE SYSTEM RESPONSE TO
IMMUNOGEN

NOTE
IMMUNOGEN VS ANTIGEN
(EPITOPE)

IMMUNE RESPONSE

RECOGNATION
RESPONSE

Immune recognation
Immune response is able to
remarkable for its specificity.
discriminate between foreign
The immune system is able
molecules and the bodys own
to recognized subtle chemical
cell and protein.
ifferences that distinguish one
oreign pathogen from another.

IMMUNOLOGICAL MEMORY

Immunogen

T helper cell
central to
adaptive
Immune
response

T helper

RECOGNATION
T & B LYMPHOCYTE RECOGNIZE DISCRETE
SITES (EPITOPE OR ANTIGENIC
DETERMINANTS) ON ANTIGEN

REGULATOR
Internal

Neural

Spinal
cord;brainstem and
autonomic reflexes

stimuli

Automatic
reflex
response

Effectors

Chemical

Intac

Intact

Circulation

Pathways
to & from

Responsiveness
of endocrine
glands

Hormonal
output

Responsiveness
of target organs or
tissues

Body
response

CNS

Chemical
External
stimuli

Neural

Perception

Short term
memory

Long term
memory

Psychomotor
choice of
response

Effectors

Immunogen

T helper cell
central to
adaptive
Immune
response

T helper

Stres
Cortical

Limbic
+

Ser
+

SNS

NE

Ach
+

CRF

AVP

+
-

hypotalamus

SOM

DOP
+

Brain stem

LC

+
+
-

NE
+

POMC

BEND

ACTH

Pituitary

AM

Adrenal

AC
+

NE

CS

Periphery

PN

E
+
+

NE

ENK
-

Black (1994)

(+)

Immune System

+
+

IL-1,2,3,6,8
TNF-
IFN-
IFN-

GH

PRL

HOLISTIC NURSING MODEL

APPROACH
Coping Strategy

INPUT

Social Support

HIV

COGNITIVE /
COGNATOR
RESPONSE
Perception (+)

LEARNING PROCESS

PROCESS
Cerebral Cortex
(Cognition:
Astrocyte)

LIMBIG SYSTEM
(Emotion: .Amigdala)

Learning (+)

Judgment(+)

Emotion (+)

Emotion (+)

Anxiety(-)

COPING STYLE (+)

-Rationalizations
-Utilizing Social Support
-Looking for Silver Lining
Nursalam_Holistic_Unair_09

Social Interaction
(+)

Susunya
habis
dik !!

Ahh ..
Ayo,
belaja
r
COPIN
G mas
!!!

Stresor

Tidak ada rotan,

akarpun jadi.
Tak ada susu,
jari tanganpun
jadi.

persepsi

Coping

Aksis
hipotalamus-pituitari-adrenal
(HPA)

taat

Modulasi
Respons
imun
Nursalam_Holistic_Unair_09

HPA-AXIS
Hypothalamus
(CRF )

BIOLOGICAL /
COGNATOR

PROCESS
Pituitary
(ACTH)

RESPONSE

Cortex Adrenal:
Fasciculate Zone
(Cortical)

IMMUNE RESPONSE MODULATION

Th
Th-1 (CD4 )
NKcell &
CTL

IL-2, IL-10,
IFN-

Anti-HIV
Nursalam_Holistic_Unair_09

AIDS (-) QUALITY

Th-2 (CD8 )

OUTPUT

APLIKASI MODEL ROY

ASUHAN KEPERAWATAN

A. ASSESSMENT &
PROBLEMS

Nursalam_Holistic_Unair_09

B. DIAGNOSIS

NURSING PROBLEMS PATIENT WITH

HIV/AIDS (HOLISTIC)

BIOLOGY:

Psychosocial-Spiritual
1. The decrease of
immunity (Seluler
& Humoral: CD4,
cytokine, Anti-HIV) PSYCHOLOGICAL
SOCIAL
and RNA
1. Self
1. Isolated
SPIRITUAL
Concept
(-)
2. Respiration : cough;
2. Discriminati 1. Separation
TBC; Chronic
Pneumonia

3.

Digestive: diarrhea

4.

Integument: Allergy
(Ig E); Herpes;
Steven Johnson;
Kaposi Sarcoma.

5.

Neurology:
Encephalopathy;
Joint pain, etc)

2.
3.

Rejection
Frustration

on
3. Social
interaction
(-)

2. Stress Spiritual

BIOLOGICAL

Nursalam_Holistic_Unair_09

Common symptom (PSYCHOLOGICAL)

symptom

PREVALENCIES

Pain
Pale

52%
50%

Anxiety 40%

Sleep disturbance
Stomatitis
33%
Sad 32%
Weight lost
31%
Anorexia
28%
Fever 27%
Cough
27%
Diarrhea
24%
Skin problems 24%

Depression 24%

37%

Source : Larue F, et al (1994) Pain & symptoms during HIV disease. A French national
study. Journal Palliative
Care: 10(2):95 referred from Agung (2005)
Nursalam_Holistic_Unair_09

SOCIAL
STIGMA

KETAKUTAN

DISKRIMINASI

DENIAL

BLAME &
COUNTER-BLAME

PERSECUTION

Nursalam_Holistic_Unair_09

DISINTEGRASI
Nyeri spiritual

SPIRITUAL

: merasa dihukum Tuhan

Pengkucilan spritual : merasa dikucilkan
Kecemasan spiritual : takut berhadapan Tuhan
Bersalah spiritual : sadar gaya hidup salah
Marah spiritual : tidak terima takdir
Kehilangan spiritual : ditinggalkan Tuhan
Kesedihan spiritual : kehilangan cinta Tuhan

C.
INTERVENSI

HOLISTIC NURSING CARE

MODEL

INPUT

Enviromental
stimuli
-External

Role
Function

Interdependence

Sell-Concept

Physiological
Mode

OUTPUT

KOPING
Behavior

MODEL
ASKEP
PENGEMBANGAN
MODEL ROY

INDIVIDU

-Predisposing
(Demographics)

--Enabling
--Reinforcing

Severity of
Deseast

functional

psychological

status

state

Psychosocial
Spiritual

Interpersonal
Relations

IMMUNE
STATUS

Treatment
Regimen

STRATEGI KOPING HIV/AIDS

(Roy Adaptation Model
Developed by Nursalam, 2007)
Nursalam_Holistic_Unair_09

HOLISTIC NURSING MODEL

APPROACH Coping Strategy

PNI
INPUT

Social Support

HIV

COGNITIVE /
COGNATOR
RESPONSE
Perception (+)

LEARNING PROCESS

PROCESS
Cerebral Cortex
(Cognition:
Astrocyte)

LIMBIG SYSTEM
(Emotion: .Amigdala)

Learning (+)

Judgment(+)

Emotion (+)

Emotion (+)

Anxiety(-)

COPING STYLE (+)

-Rationalizations
-Utilizing Social Support
-Looking for Silver Lining

Social Interaction
(+)

HPA-AXIS

PROCESS
Hypothalamus
(CRF )

BIOLOGICAL
REGULATOR

Pituitary
(ACTH)

RESPONSE

Cortex Adrenal:
Fasciculate Zone
(Cortical)

IMMUNE RESPONSE MODULATION

Th
Th-1 (CD4 )
NKcell &
CTL

IL-2, IL-10,
IFN-

Anti-HIV
Nursalam_Holistic_Unair_09

AIDS (-) QUALITY

Th-2 (CD8 )

OUTPUT

HOLISTIC INTERVENTION
FOR hiv - aids
1. BIOLOGIS
2. PSIKOLOGIS
3. SOSIAL
4. SPIRITUAL

1. BIOLOGICAL SUPPORT
ARV & I-O
2. NUTRITION: Carbohydrate;
PROTEIN, MULTIVITAMIN,
ANTIOXYDANT
3. REST AND ACTIVITY
4. UNIVERSAL PRECAUTIONS
1.

Nursalam_Holistic_Unair_09

Nursalam_Holistic_Unair_09

I-O
INFEKSI
OPORTUNISTIK
& NYERI

TB- Infiltrat interstitial

HERPES SIMPLEK

HERPES SIMPLEK

PPE

CANDIDIASIS

SARKOMA KAPOSI

NUTRISI

ANTIOKSIDANTKW & TKTP

MULTIVITAMIN

AKTIVITAS

Nursalam_Holistic_Unair_09

UNIVERSAL PRECAUTIONS
CUCI

TANGAN
APD (ALAT PELINDUNG
DIRI)
DEKONTAMINASI
LIMBAH
Nursalam_Holistic_Unair_09

Nursalam_Holistic_Unair_09

BIOLOGICAL
RESPONSE

Indicator of Biological Response

Progress
Psychological response (IMMUN
response)
1. Cortisol (-)

2.

CD4

3.

Cytokine (IFN gamma, IL-2)

mRNA
Antigen Antibody - HIV

4.
5.

2. PSIKOLOGIS

Nursalam_Holistic_Unair_09

Kenyataan Hidup
Penyakit

adalah kejadian besar dalam

hidup yang menyebabkan timbulnya
pertanyaan besar bagi diri, tujuan dan
arti hidup.
Penyakit dapat mengganggu karir,
kehidupan keluarga dan kemampuan
untuk menikmati hidup

Nursalam_Holistic_Unair_09

PENANGANAN STRES

Nursalam_Holistic_Unair_09

PSYCHOLOGICAL INTERVENTION

SELF POTENTION

EMPOWERMENT

COGNITION TECHNIQUE

PROCESS)

BEHAVIOR

(LEARNING

(ACT HEALTH CONDITION)

Indicator adaptive psychological

response (psychology)

psychology
- Kubler Ross
(Sign. Anger &
Bargaining)

Psychological response progress

(Acceptance response)
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Nursalam_Holistic_Unair_09

3. SOCIAL (16-19)
EMOSIONAL
MATERIAL / FASILITAS
INFORMASI
PENGHARGAAN

Nursalam_Holistic_Unair_09

ASPEK SOSIAL
PENDERITA HIV & AIDS

Nursalam_Holistic_Unair_09

Indicator adaptive social

response
Social adaptation progress
1. Emotional need
2. Self definition(-)
Social (Emotional)
3. Interpersonal
relationship (+)

4. SPIRITUAL
Pray
Self

control

Nursalam_Holistic_Unair_09

SPIRITUAL
INTERVENTION
Spiritual : values & religiosity
Hope
Reality

Life value : Meaningful Life

Religiosity : Improve

Daya Tahan & Dukungan

Emosional Beribadah
Mengenali

kekuatan diri hasil beribadah,

mengklarifikasikan dan menyempurnakannya
contoh : berdoa kala sedih tenang
Menimbulkan tilikan diri yang positif.
contoh : keraguan akan Tuhan pada saat
krisis adalah manusiawi atasi
Manejemen stres agar sampai ketahap
BERSERAH DIRI
Nursalam_Holistic_Unair_09

Indicator of Adaptive spiritual

response

Spiritual

Response
1. Realistic expectation
2. Patience
3. Looking for silver lining
(-)

SPIRITUAL
Principle

ITS
IKHTIAR - IKHLAS,
TAWAKKAL, SABAR

C. EVALUATION

Kesimpulan
MODEL
of PAKAR
Coping strategy
Soc. support

COPING
(+)

LEARNING
PROCESS
Stress
PERCEPTION

-Utilizing sos. Support

-Looking for silver Lining
-Acceptance-Rasionalisation

(-)

RESP. BIOLOGICAL
HPA-AXIS (cortisol -)
ADAPTATION

Induce
Immune response

Immune response
Modulation
(CD4, IFN- , A-HIV)