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PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

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PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

I. IDENTITAS KLIEN

Nama: .. (L/P)Tanggal Dirawat: .

Umur: .. Tanggal Pengkajian: .............Pendidikan: ................................... Ruang Rawat: .Agama: ................................... Sumber Informasi: .................................Status: ...................................

Alamat:

Pekerjaan:

Jenis Kel.:

No RM:

II. ALASAN MASUKData Primer:

Data Sekunder:

III. FAKTOR PRESIPITASI

IV. FAKTOR PREDISPOSISI

RIWAYAT PENYAKIT LALU

1. Pernah mengalami gangguan jiwa di masa lalu ?

Jika Ya,Jelaskan:

2. Pengobatan sebelumnya

Jelaskan:

Masalah Keperawatan :

3. Pernah mengalami Penyakit Fisik (termasuk gangguan tumbuh kembang)

Jelaskan :

Masalah Keperawatan :

RIWAYAT TRAUMA

TraumaUsiaPelakuKorbanSaksi

1. Aniaya fisik

2. Aniaya seksual

3. Penolakan

4. Kekerasan dalam keluarga

5. Tindakan kriminal

Jelaskan:

4. Pengalaman masa lalu yang tidak menyenangkan (Bio, Psiko, Sosio, Kultural dan Spiritual)

Masalah Keperawatan :............................................................................................................... RIWAYAT PENYAKIT KELUARGA1. Anggota keluarga yang gangguan jiwa ?

Kalau ada :

Hubungan keluarga : ........................................................................................

............................................

Gejala : ..........................................

............................................

............................................

Riwayat pengobatan : .......................................................................................

............................................

...........................................

............................................

............................................

Masalah Keperawatan :..............................................................................................................V. PEMERIKSAAAN FISIK

1. Keadaan umum :

2. Tanda vital:

Tekanan Darah: .mm/Hg

Nadi:..x/mnt

Suhu: . CPernafasan:..x/mnt

3. Ukur:

Berat Badan ......kg

Tinggi Badan:....cm

4. Keluhan fisik:

Jelaskan 5. Pemeriksaan Fisik : (head to toe)

Jelaskan :

Masalah Keperawatan :..................................................................................................................VI. PENGKAJIAN PSIKOSOSIAL (Sebelum dan sesudah sakit)

1. Genogram:

Jelaskan:

2. Konsep Diri

a. Citra tubuh: ..............................................

.

b. Identitas: ........................

.......................

.

c. Peran: .......................

.......................

.......................

d. Ideal diri: .......................

.......................

.......................

e. Harga diri: .......................

.......................

.......................

Masalah Keperawatan :.............................................................................................................3. Hubungan sosial

a. Orang yang berarti/terdekat:

b. Peran serta dalam kegiatan kelompok/masyarakat:

c. Hambatan dalam berhubungan dengan orang lain:

Masalah Keperawatan :...........................................................................................................4. Spiritual

a. Nilai dan keyakinan

b. Kegiatan ibadah

Masalah Keperawatan:..........................................................................................................VII. STATUS MENTAL

1. Penampilan

1. Tidak rapi

Penggunaan pakaian tidak seperti biasannya

2. Lainnya.......................................................

Jelaskan:

Masaalah Keperawatan:...............................................................................................................2. Interaksi selama wawancara

Bermusuhan

Curiga

Tidak kooperatif

Defensif Mudah tersinggung

Lainnya.................................................. Kontak mata kurang

Jelaskan:

3. Pembicaraan

Cepat

Keras

Gagap

Tidak mampu memulai pembicaraan Lainnya..................................................Jelaskan:...

...

Masaalah Keperawatan:................................................................................................................4. Aktifitas Motorik Lesu

Fleksibilitas serea Tegang

Katatonik Gelisah

Agitasi

Kompulsif

Lainnya..................................................Jelaskan:

...

...

Masaalah Keperawatan:................................................................................................................5. Kesadaran

a. Kuantitatif Compos mentis

Apatis

Somnolensia

Sopor

Koma

Jelaskan:...

b. Kualitatif1. Relasi : A. diri sendiri B. lingkungan

2. Limitasi (Pembatasan)Jelaskan:

...

...

Masaalah Keperawatan:................................................................................................................7. Orientasi Waktu

Tempat

Orang

Jelaskan:

Masaalah Keperawatan:................................................................................................................8.Perasaan

A. Emosi

Sedih

Gembira

Takut

Cemas

Lainnya..................................................B. Afek

Adequat

Inadequat Tumpul

Labil Datar


Masaalah Keperawatan:................................................................................................................9.Persepsi Sensorik

Halusinasi

Pendengaran

Penglihatan

Perabaan

Pengecapan

Penciuman


Masaalah Keperawatan:................................................................................................................10. Proses Pikir

a. Arus Pikir

Koheren

Inkoheren

Sirkumstansial

Neologisme Tangensial

Logorea Flight of idea

Blocking

Lainnya..................................................Masaalah Keperawatan:.................................................................................................................b. Isi Pikir

Obsesif

Fobia Ekstasi

Fantasi Pikiran Bunuh Diri

Pikiran curiga Pikiran Isolasi sosial

Pikiran magis Pikiran Rendah diri

Lainnya.................................................. Waham

Agama

Sisip pikir Somatik

Siar pikir Kebesaran

Kontrol pikir Kejar atau curiga

Dosa Nihilistik

Lainnya..................................................Masaalah Keperawatan:................................................................................................................c. Bentuk Pikir

Realistik

Non Realistik

Relevan

Irrelevan

Logik

Non Logik

Rasional

Irrasional

Dereistik

Otistik

Lainnya..................................................

Jelaskan:

Masalah keperawatan: ...............................................................................................................11. Memori

Gangguan daya ingat jangka panjang ( > 1 bulan) Gangguan daya ingat jangka pendek ( 1 hari 1 bulan) Gangguan daya ingat saat ini ( < 24 jam) Amnesia


Masalah keperawatan:................................................................................................................12. Tingkat konsentrasi dan berhitung

Mudah beralih

Tidak mampu berkonsentrasi

Tidak mampu berhitung sederhanaJelaskan:

13. Kemampuan penilaian

Gangguan ringan

Gangguan bermakna

Jelaskan:

Masalah keperawatan:...............................................................................................................14. Daya tilik diri

Mengingkari penyakit yang diderita

Menyalahkan hal-hal diluar dirinya

Jelaskan:

Masalah keperawatan:................................................................................................................VIII. KEBUTUHAN PERSIAPAN PULANG

1. Makan

Bantuan Minimal

Bantuan total

Jelaskan:................................2. BAB/BAK

Bantuan minimal

Bantuan total

Jelaskan:................3. Mandi

Bantuan minimal

Bantuan total

Jelaskan:.................4. Berpakaian/berhias

Bantuan Minimal

Bantuan total

Jelaskan:.......................................................................................................................................................................................................................................................5. Istirahat dan tidur Tidur Siang, Lama : ____________ s/d _____________

Tidur Malam, Lama : _____________ s/d _____________

Aktifitas sebelum/sesudah tidur : __________ , _________

Jelaskan:................6. Penggunaan obat

Bantuan Minimal

Bantuan total

Jelaskan:........................................................................................................7. Pemeliharaan kesehatan

Ya

Tidak

Perawatan Lanjutan

Sistem pendukung

8. Aktifitas dalam rumah

Ya

Tidak

Mempersiapkan makanan

Menjaga kerapihan rumah

Mencuci Pakaian

Pengaturan keuangan

9. Aktifitas di luar rumah

Ya

Tidak

Belanja

Transportasi

Lain-lain

Jelaskan :

Masalah keperawatan:................................................................................................................IX. MEKANISME KOPING

AdaptifMaladaptif

Bicara dengan orang lain

Mampu menyelesaikan masalah

Teknik relaksasi

Aktifitas konstruktif

Olah raga

Lain-lain. Minum alkhohol

Reaksi lambat/berlebihan

Bekerja berlebihan

Menghindar

Menciderai diri

Lain-lain..

Masalah keperawatan:................................................................................................................X. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

Masalah dengan dukungan kelompok, spesifiknya ...

Masalah berhubungan dengan lingkungan, spesifiknya .... ........................................................................................................................................................ Masalah dengan pendidikan, spesifiknya .. ......................................................................................................................................................... Masalah dengan pekerjaan, spesifiknya . ......................................................................................................................................................... Masalah dengan perumahan, spesifiknya .. ......................................................................................................................................................... Masalah dengan ekonomi, spesifiknya .. ......................................................................................................................................................... Masalah dengan pelayanan kesehatan, spesifiknya ... ......................................................................................................................................................... Masalah lainnya, spesifiknya . .........................................................................................................................................................Masalah keperawatan:................................................................................................................XI. PENGETAHUAN KURANG TENTANG

Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang kurang tentang suatu hal?

Penyakit/gangguan jiwa

Sistem pendukung

Faktor presipitasi

Mekanisme koping

Penyakit fisik

Obat-obatan

Lain-lain, jelaskan

Jelaskan:

......................................................................................................................................................................................................................................Masalah keperawatan:................................................................................................................XII. ASPEK MEDIS

Diagnosis medik:

Terapi medik:1) . ...... ....2) . ...... ....

3) . ...... ....

4) . ...... ....

XIII. ANALISA DATA

NODATADIAGNOSA KEPERAWATAN

1.DS:

DO:

2.DS:

DO:

3.DS:

DO:

XIV. POHON MASALAH

XV. DAFTAR MASALAH KEPERAWATAN1. ..

2. ..

3. ..

4. ..

5. ..

6. ..

7. ..

8. ..

9. ...

10. .......XVI. PRIORITAS DIAGNOSA KEPERAWATAN1. ..

2. ..

3. ..

Malang, .

Perawat yang mengkaji

______________________________

NIM: .................RENCANA TINDAKAN KEPERAWATAN

Nama : ......................................

Ruang :................................. RM No:................................No DxRencana Tindakan KeperawatanRasional

Tujuan dan kriteria EvaluasiTindakan Keperawatan

TUM:

TUK:

Kriteria Evaluasi:

STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Hari : Senin, tgl :.......................................................

Interaksi IA. PROSES KEPERAWATAN.

1. Kondisi Klien:

......................................................................................................................................................................................................................................................................................................................

...........................................................................................................................................................

2. Diagnosa Keperawatan.

..........................................................................................................................................................

3. Tujuan Khusus (TUK)

...........................................................................................................................................................

4. Tindakan Keperawatan

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B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN KEPERAWATAN

a. FASE ORIENTASI

1. Salam Terapeutik.....................................................................................................................................................................................................................................................................................................................

...........................................................................................................................................................

2. Evaluasi / validasi.....................................................................................................................................................................................................................................................................................................................

...........................................................................................................................................................

3. Kontrak

Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................

b. FASE KERJA

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c. FASE TERMINASI

1. Evaluasi respon klien terhadap tindakan keperawatan

Evaluasi Subyektif (Klien)..................................................................................................................................................................................................................................................................................................................................................................................................................................................................Evaluasi Obyekti (Perawat)

..................................................................................................................................................................................................................................................................................................................................................................................................................................................................2. Rencana Tindak Lanjut

..................................................................................................................................................................................................................................................................................................................................................................................................................................................................3. Kontrak yang akan datang

Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................

IMPLEMENTASI DAN EVALUASI

Nama : ......................................

Ruang :................................. RM No:................................NO

DxTanggal & JamIMPLEMENTASI KEPERAWATANEVALUASI


Hari: Senin, tgl :.......................................................

Interaksi IIA. PROSES KEPERAWATAN.

1. Kondisi Klien:

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a. FASE ORIENTASI


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3. Kontrak

Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................

b. FASE KERJA

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c. FASE TERMINASI





Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................


Nama : ......................................

Ruang :................................. RM No:................................NO



Hari: Selasa, tgl :.......................................................


1. Kondisi Klien:

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a. FASE ORIENTASI


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...........................................................................................................................................................

3. Kontrak

Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................

b. FASE KERJA

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c. FASE TERMINASI





Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................


Nama : ......................................

Ruang :................................. RM No:................................NO



Hari: Selasa, tgl :.......................................................


1. Kondisi Klien:

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a. FASE ORIENTASI


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3. Kontrak

Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................

b. FASE KERJA

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c. FASE TERMINASI





Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................


Nama : ......................................

Ruang :................................. RM No:................................NO



Hari: Rabu, tgl :.......................................................


1. Kondisi Klien:

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a. FASE ORIENTASI


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3. Kontrak

Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................

b. FASE KERJA

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c. FASE TERMINASI





Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................


Nama : ......................................

Ruang :................................. RM No:................................NO



Hari: Rabu, tgl :.......................................................


1. Kondisi Klien:

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a. FASE ORIENTASI


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3. Kontrak

Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................

b. FASE KERJA

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c. FASE TERMINASI





Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................


Nama : ......................................

Ruang :................................. RM No:................................NO



Hari: Kamis, tgl :.......................................................


1. Kondisi Klien:

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a. FASE ORIENTASI


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3. Kontrak

Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................

b. FASE KERJA

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c. FASE TERMINASI





Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................


Nama : ......................................

Ruang :................................. RM No:................................NO



Hari: Kamis, tgl :.......................................................


1. Kondisi Klien:

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a. FASE ORIENTASI


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3. Kontrak

Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................

b. FASE KERJA

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c. FASE TERMINASI





Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................


Nama : ......................................

Ruang :................................. RM No:................................NO



Hari: Jum'at, tgl :.......................................................


1. Kondisi Klien:

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a. FASE ORIENTASI


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3. Kontrak

Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................

b. FASE KERJA

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c. FASE TERMINASI





Topik: ............................................................................................................

Waktu: ...........................................................................................................

Tempat: ...........................................................................................................


Nama : ......................................

Ruang :................................. RM No:................................NO



Hari: Jum'at, tgl :.......................................................


1. Kondisi Klien:

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a. FASE ORIENTASI


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