form pengkajian jiwa edit fixs

PROGRAM STUDI S1 KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN BALI

PENGKAJIAN KEPERAWATAN

KESEHATAN JIWA

RUANG RAWAT:

TANGGAL DIRAWAT:

I. IDENTITAS KLIEN

Inisial:___________________________(L/P)Tanggal Pengkajian :_____________________

Umur:___________________________RM No.

:_____________________

Alamat:___________________________

Pekerjaan:___________________________

Informan:___________________________

II. ALASAN MASUK

______________________________________________________________________________________________________________________________________________________________________

III. FAKTOR PRESIPITASI/ RIWAYAT PENYAKIT SEKARANG

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IV. FAKTOR PREDISPOSISI

RIWAYAT PENYAKIT LALU

1. Pernah mengalami gangguan jiwa di masa lalu? FORMCHECKBOX ya FORMCHECKBOX tidak

Bila ya jelaskan___________________________________________________________________

2. Pengobatan sebelumnya FORMCHECKBOX Berhasil FORMCHECKBOX Kurang Berhasil FORMCHECKBOX Tidak Berhasil

3. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang) FORMCHECKBOX ya

FORMCHECKBOX tidak

Bila ya jelaskan___________________________________________________________________

RIWAYAT PSIKOSOSIAL

Pelaku/ usiaKorban/ usiaSaksi/ usia

1. Aniaya fisik

2. Aniaya seksual

3. Penolakan

4. Kekerasan dalam keluarga

5. Tindakan kriminal

Jelaskan:___________________________________________________________________

___________________________________________________________________

6. Pengalaman masa lalu lain yang tidak menyenangkan (bio, psiko, sosio, kultural, spiritual):

______________________________________________________________________________________________________________________________________________________________

Masalah keperawatan:____________________________________________________________

7. Kesan Kepribadian klien: FORMCHECKBOX extrovert FORMCHECKBOX introvert FORMCHECKBOX lain-lain :__________________

RIWAYAT PENYAKIT KELUARGA

1. Adakah anggota keluarga yang mengalami gangguan jiwa?

FORMCHECKBOX ya

FORMCHECKBOX tidak

Hubungan keluarga Gejala Riwayat Pengobatan/ perawatan

______________ ______________ _________________________

______________ ______________ _________________________

Masalah keperawatan:____________________________________________________________

V. STATUS MENTAL

1. Penampilan

FORMCHECKBOX tidak rapi

FORMCHECKBOX penggunaan pakaian FORMCHECKBOX Cara berpakaian

tidak sesuai

tidak seperti biasanya

Jelaskan: ______________________________________________________Masalah keperawatan : ____________________________________________________________

2. Kesadaran

Kwantitatif/ penurunan kesadaran]

FORMCHECKBOX compos mentis

FORMCHECKBOX apatis/ sedasi

FORMCHECKBOX somnolensia

FORMCHECKBOX sopor

FORMCHECKBOX subkoma

FORMCHECKBOX koma

Kwalitatif

FORMCHECKBOX tidak berubah

FORMCHECKBOX berubah

FORMCHECKBOX meninggi

FORMCHECKBOX gangguan tidur: sebutkan______________________________

FORMCHECKBOX hipnosa

FORMCHECKBOX disosiasi: sebutkan____________________________________

3. Disorientasi

FORMCHECKBOX waktu

FORMCHECKBOX tempat

FORMCHECKBOX orang

Jelaskan:___________________________________________________________________

Masalah keperawatan : ____________________________________________________________

4. Aktivitas Motorik/ Psikomotor

Kelambatan:

FORMCHECKBOX hipokinesia, hipoaktivitas

FORMCHECKBOX sub stupor katatonik

FORMCHECKBOX katalepsi

FORMCHECKBOX flexibilitas serea

Peningkatan:

FORMCHECKBOX hiperkinesia, hiperaktivitas

FORMCHECKBOX gaduh gelisah katatonik

FORMCHECKBOX TIK

FORMCHECKBOX grimase

FORMCHECKBOX tremor

FORMCHECKBOX gagap

FORMCHECKBOX stereotipi

FORMCHECKBOX mannarism

FORMCHECKBOX katalepsi

FORMCHECKBOX akhopraxia

FORMCHECKBOX command automatism

FORMCHECKBOX atomatisma

FORMCHECKBOX nagativisme

FORMCHECKBOX reaksi konversi

FORMCHECKBOX verbigerasi

FORMCHECKBOX berjalan kaku/ rigit

FORMCHECKBOX kompulsif

FORMCHECKBOX lain-2 sebutkan

5. Afek/ Emosi

FORMCHECKBOX adequat

FORMCHECKBOX tumpul

FORMCHECKBOX dangkal/ datar

FORMCHECKBOX labil

FORMCHECKBOX inadequat

FORMCHECKBOX anhedonia

FORMCHECKBOX marasa kesepian

FORMCHECKBOX eforia

FORMCHECKBOX ambivalen

FORMCHECKBOX apati

FORMCHECKBOX marah

FORMCHECKBOX depresif/ sedih

FORMCHECKBOX cemas:

FORMCHECKBOX ringan

FORMCHECKBOX sedang

FORMCHECKBOX berat

FORMCHECKBOX panik

Jelaskan:__________________________________________________________________

Masalah keperawatan : __________________________________________________________________

6. Persepsi

FORMCHECKBOX halusinasi

FORMCHECKBOX ilusi

FORMCHECKBOX depersonalisasi

FORMCHECKBOX derealisasi

Macam Halusinasi

FORMCHECKBOX pendengaran

FORMCHECKBOX penglihatan

FORMCHECKBOX perabaan

FORMCHECKBOX pengecapan

FORMCHECKBOX penghidu/ pembauan FORMCHECKBOX lain-lain, sebutkan...................

Jelaskan:_________________________________________________________________

Masalah keperawatan : _________________________________________________________________7. Proses Pikir

Arus Pikir

FORMCHECKBOX koheren

FORMCHECKBOX inkoheren

FORMCHECKBOX asosiasi longgar

FORMCHECKBOX fligt of ideas

FORMCHECKBOX blocking

FORMCHECKBOX pengulangan pembicaraan/ persevarasi

FORMCHECKBOX tangansial

FORMCHECKBOX sirkumstansiality FORMCHECKBOX logorea

FORMCHECKBOX neologisme FORMCHECKBOX bicara lambat FORMCHECKBOX bicara cepat

FORMCHECKBOX irelevansi FORMCHECKBOX main kata-kata FORMCHECKBOX afasi

FORMCHECKBOX assosiasi bunyi FORMCHECKBOX lain2 sebutkan..

Jelaskan:_________________________________________________________________

Masalah keperawatan : _________________________________________________________________ Isi Pikir

FORMCHECKBOX obsesif

FORMCHECKBOX ekstasi

FORMCHECKBOX fantasi

FORMCHECKBOX bunuh diri

FORMCHECKBOX ideas of reference

FORMCHECKBOX pikiran magis

FORMCHECKBOX alienasi

FORMCHECKBOX isolaso sosial

FORMCHECKBOX rendah diri

FORMCHECKBOX preokupasi

FORMCHECKBOX pesimisme

FORMCHECKBOX fobia sebutkan.........................

FORMCHECKBOX waham: sebutkan jenisnya

FORMCHECKBOX agama FORMCHECKBOX somatik, hipokondrik FORMCHECKBOX kebesaran

FORMCHECKBOX curiga FORMCHECKBOX nihilistik FORMCHECKBOX sisip pikir

FORMCHECKBOX siar pikir FORMCHECKBOX kontrol pikir FORMCHECKBOX kejaran

FORMCHECKBOX dosa

Jelaskan:__________________________________________________________________

Masalah keperawatan : __________________________________________________________________ Bentuk Pikir

FORMCHECKBOX realistik

FORMCHECKBOX nonrealistik

FORMCHECKBOX autistik

FORMCHECKBOX dereistik

8. Memori

FORMCHECKBOX gangguan daya ingat jangka panjang FORMCHECKBOX gangguan daya ingat jangka pendek

FORMCHECKBOX gangguan daya ingat saat ini

FORMCHECKBOX amnesia, sebutkan.........................

FORMCHECKBOX paramnesia, sebutkan jenisnya........................................................

FORMCHECKBOX hipermnesia, sebutkan ...................................................................

Jelaskan:_________________________________________________________________

Masalah keperawatan : _________________________________________________________________9. Tingkat Konsentrasi dan Berhitung

FORMCHECKBOX mudah beralih FORMCHECKBOX tidak mampu berkonsentrasi FORMCHECKBOX tidak mampu berhitung

sederhana

Jelaskan:_________________________________________________________________

Masalah keperawatan : _________________________________________________________________10. Kemampuan Penilaian

FORMCHECKBOX gangguan ringan

FORMCHECKBOX gangguan bermakna

Jelaskan:__________________________________________________________________

Masalah keperawatan : __________________________________________________________________11. Daya Tilik Diri/ Insight

FORMCHECKBOX mengingkari penyakit yang diderita FORMCHECKBOX menyalahkan hal-hal diluar dirinya

Jelaskan:__________________________________________________________________

Masalah keperawatan : __________________________________________________________________12. Interaksi selama Wawancara

FORMCHECKBOX bermusuhan

FORMCHECKBOX tidak kooperatif FORMCHECKBOX mudah tersinggung

FORMCHECKBOX kontak mata kurang FORMCHECKBOX defensif

FORMCHECKBOX curiga

Jelaskan:_________________________________________________________________

Masalah keperawatan : __________________________________________________________________VI. FISIK

1. Keadaan umum ____________________________________________________________________

_________________________________________________________________________________

2. Tanda vital: TD:___________N:___________

S:_____________P:_______

3. UKur:

TB:___________BB:__________

FORMCHECKBOX turun

FORMCHECKBOX naik4. Keluhan fisik:

FORMCHECKBOX tidak

FORMCHECKBOX ya jelaskan...............................

_________________________________________________________________________________

5. Pemeriksaan fisik:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Jelaskan

:_____________________________________________________________________Masalah keperawatan : _____________________________________________________________________VII. PENGKAJIAN PSIKOSOSIAL (sebelum dan sesudah sakit)

1. Konsep Diri

a. Citra tubuh :___________________________________________________________________

___________________________________________________________________

b. Identitas:___________________________________________________________________

___________________________________________________________________

c. Peran

:___________________________________________________________________

___________________________________________________________________

d. Ideal diri:___________________________________________________________________

___________________________________________________________________

e. Harga diri:___________________________________________________________________

___________________________________________________________________

Masalah keperawatan : _______________________________________________________________2. Genogram

3. Hubungan Sosial

a. Hubungan terdekat:

____________________________________________________________________________________________________________________________________________________________

b. Peran serta dalam kelompok/ masyarakat

____________________________________________________________________________________________________________________________________________________________

c. Hambatan dalam berhubungan dengan orang lain

____________________________________________________________________________________________________________________________________________________________

Masalah keperawatan : __________________________________________________________________________

4. Spiritual dan kultural

a. Nilai dan keyakinan

____________________________________________________________________________________________________________________________________________________________

b. Konflik nilai/ keyakinan/ budaya

____________________________________________________________________________________________________________________________________________________________

c. Kegiatan ibadah

____________________________________________________________________________________________________________________________________________________________

Masalah keperawatan: _________________________________________________________________VIII. AKTIVITAS SEHARI-HARI (ADL)

1.Makan

FORMCHECKBOX Bantuan minimal

FORMCHECKBOX Sebagian

FORMCHECKBOX Bantuan total

2.BAB/BAK




3.Mandi




4.Berpakaian/berhias




5.Istirahat dan tidur

FORMCHECKBOX Tidur siang lama: ______________________ s/d

_________________________

FORMCHECKBOX Tidur malam lama: ______________________ s/d

_________________________

FORMCHECKBOX Aktivitas sebelum / sedudah tidur : _____________________ s/d

________________________6.Penggunaan obat




7.Pemeliharaan kesehatan

Perawatan Lanjutan

FORMCHECKBOX Ya

FORMCHECKBOX Tidak

Sistem pendukung

FORMCHECKBOX Ya

FORMCHECKBOX Tidak

8. Aktivitas di dalam rumah

Mempersiapkan makanan FORMCHECKBOX Ya

FORMCHECKBOX Tidak

Menjaga kerapihan rumah FORMCHECKBOX Ya

FORMCHECKBOX Tidak

Mencuci pakaian

FORMCHECKBOX Ya

FORMCHECKBOX Tidak

Pengaturan keuangan

FORMCHECKBOX Ya

FORMCHECKBOX Tidak

9. Aktivitas di luar rumah

Belanja

FORMCHECKBOX Ya

FORMCHECKBOX Tidak

Transportasi

FORMCHECKBOX Ya

FORMCHECKBOX Tidak

Lain-lain

FORMCHECKBOX Ya

FORMCHECKBOX Tidak

Jelaskan:__________________________________________________________________

Masalah keperawatan : ____________________________________________________________IX. MEKANISME KOPING

Adatif

Maladaptif

FORMCHECKBOX Bicara dengan orang lain

FORMCHECKBOX Minum Alkohol

FORMCHECKBOX Mampu menyelesaikan masalah

FORMCHECKBOX Reaksi lambat / berlebih

FORMCHECKBOX Teknik relokasi

FORMCHECKBOX Bekerja berlebihan

FORMCHECKBOX Aktivitas konstruktif

FORMCHECKBOX Menghindar

FORMCHECKBOX Olah raga

FORMCHECKBOX Mencederai diri

FORMCHECKBOX Lainnya ......................

FORMCHECKBOX Lainnya ......................

Masalah keperawatan : ______________________________________________________________

X. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

FORMCHECKBOX Masalah dengan dukungan kelompok, uraikan __________________________________________________________________________ FORMCHECKBOX Masalah berhubungan dengan lingkungan, uraikan __________________________________________________________________________ FORMCHECKBOX Masalah dengan pendidikan, uraikan __________________________________________________________________________ FORMCHECKBOX Masalah dengan pekerjaan, uraikan __________________________________________________________________________ FORMCHECKBOX Masalah dengan perumahan, uraikan __________________________________________________________________________ FORMCHECKBOX Masalah dengan ekonomi, uraikan __________________________________________________________________________ FORMCHECKBOX Masalah dengan pelayanan kesehatan, uraikan __________________________________________________________________________ FORMCHECKBOX Masalah lainnya, uraikan __________________________________________________________________________Masalah keperawatan : ______________________________________________________________

XI. KURANG PENGETAHUAN TENTANG

FORMCHECKBOX Penyakit jiwa

FORMCHECKBOX Sistem pendukung

FORMCHECKBOX Faktor presiptasi

FORMCHECKBOX Penyakit fisik

FORMCHECKBOX Koping

FORMCHECKBOX Obat-obatan

FORMCHECKBOX Lainnya _______________________________________________________________________

Masalah keperawatan : ______________________________________________________________

XII. ASPEK MEDIK

Diagnosa medik: _________________________________________________________________

Terapi medik: _________________________________________________________________

_________________________________________________________________

_________________________________________________________________

XIII. DAFTAR MASALAH KEPERAWATAN

____________________________

_____________________________

____________________________

_____________________________

____________________________

_____________________________

____________________________

_____________________________

____________________________

_____________________________

XIV. ANALISA DATA

NoDATAMASALAH

XV. POHON MASALAH

XVI. DIAGNOSA KEPERAWATAN

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________

Mahasiswa

______________________________



DAFTAR DIAGNOSA KEPERAWATAN

(Berdasarkan prioritas)

Ruang

:

Nama Pasien:

No. Register:

No. DxTANGGAL MUNCULDIAGNOSA KEPERAWATANTANGGAL TERATASITANDA TANGAN



LAPORAN PENDAHULUAN

STRATEGI PELAKSANAAN

TINDAKAN KEPERAWATAN HARI KE..................

A. PROSES KEPERAWATAN

1. Kondisi klien:

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2. Diagnosa keperawatan:

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3. Tujuan khusus:

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4. Tindakan keperawatan:

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B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN KEPERAWATAN

ORIENTASI

1. Salam Terapeutik:

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2. Evaluasi/ Validasi:

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3. Kontrak: Topik, waktu, dan tempat

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KERJA: Langkah-Langkah Tindakan keperawatan

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TERMINASI:

1. Evaluasi respon klien terhadap tindakan keperawatan:

Subyektif:

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Obyektif:

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2. Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan yang telah dilakukan):

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3. Kontrak yang akan datang (Topik, waktu, dan tempat):

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form pengkajian jiwa edit fixs

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