PENGKAJIAN KEPERAWATAN
KESEHATAN JIWA
I.
IDENTITAS KLIEN
Nama
: .. (L/P)
Umur
: ..
Pendidikan: ...................................
Agama
: ...................................
Status
: ...................................
Alamat
:
Pekerjaan :
Jenis Kel. :
No RM :
Tanggal Dirawat
: .
Tanggal Pengkajian
Ruang Rawat
Sumber Informasi
: .............
: .
: ..................................
ALASAN MASUK
II.
..
III.
FAKTOR PREDISPOSISI
RIWAYAT PENYAKIT LALU
1. Pernah mengalami gangguan jiwa di masa lalu ?
Ya
Tidak
Jika Ya,Jelaskan:
RIWAYAT TRAUMA
Korban
Trauma Usia
Saksi
Pelaku
2
1.
2.
3.
4.
5.
Aniaya fisik
Aniaya seksual
Penolakan
Kekerasan dalam keluarga
Tindakan kriminal
Jelaskan:
..............................................................................................................................
.....
...................................................................................................................................
Diagnosa Keperawatan :
_____________________________________________________
Diagnosa
Keperawatan:________________________________________________________
IV.
PEMERIKSAAAN FISIK
Tanggal : .
1. Keadaan umum :
2. Tanda vital:
TD: .mm/Hg
N:..x/m
S.
P..x/m
3. Ukur: BB .kg
TB.cm
Turun
Naik
4. Keluhan fisik:
Tidak
Ya,
Jelaskan
Jelaskan :
V.
Keterangan Gambar
Jelaskan:
2. Konsep Diri
a. Citra tubuh :
.
b. Identitas
:
.
c. Peran
:
d. Ideal diri
:
e. Harga diri :
3. Hubungan sosial
a. Orang yang berarti/terdekat:
Diagnosa Keperawatan
:_____________________________________________________
4. Spiritual
a. Nilai dan keyakinan
b. Kegiatan ibadah
Diagnosa Keperawatan:_____________________________________________________
VI.
STATUS MENTAL
1. Penampilan
Tidak rapi
Penggunaan pakaian tidak sesuai
Cara berpakaian tidak seperti biasanya
Jelaskan:
Diagnosa
Keperawatan:________________________________________________________
2. Kesadaran
Menurun:
Compos mentis
Sopor
Apatis/sedasi
Subkoma
Somnolensia
Koma
Meninggi
Hipnosa
Gangguan Tidur:
Disosiasi: .
Berubah
Gangguan perhatian
Jelaskan :
Diagnosa
Keperawatan:________________________________________________________
3. Orientasi
Waktu
Tempat
Orang
Jelaskan:
Diagnosa
Keperawatan:________________________________________________________
4. Pembicaraan
Cepat
Keras
Gagap
Apatis
Lambat
Membisu
Tidak mampu memulai pembicaraan
Lain-lain..
Jelaskan:
Diagnosa
Keperawatan:________________________________________________________
5. Aktifitas motorik/Psikomotor
Kelambatan :
Hipokinesia,hipoaktifitas
Katalepsi
Sub stupor katatonik
Fleksibilitas serea
Jelaskan:
Peningkatan :
Hiperkinesia,hiperaktifitas
Gagap
Stereotipi
Gaduh Gelisah Katatonik
Mannarism
Katapleksi
Tik
Ekhopraxia
Command automatism
Grimace
Otomatisma
Negativisme
Reaksi konversi
Tremor
Verbigerasi
Berjalan kaku/rigid
6
Kompulsif : sebutkan .
Jelaskan :
Diagnosa
Keperawatan :_____________________________________________________
Jelaskan:
...
Diagnosa Keperawatan
_____________________________________________
7. Persepsi Sensorik
Halusinasi
Pendengaran
Penglihatan
Perabaan
Pengecapan
Penciuman
..
Ilusi
Ada
Tidak ada
Depersonalisasi
Ada
Tidak ada
Derealisasi
Ada
Tidak ada
Jelaskan:
Diagnosa Keperawatan :
______________________________________________
8. Proses Pikir
a. Arus Pikir
Koheren
Inkoheren
Sirkumstansial
Neologisme
Tangensial
Logorea
Kehilangan asosiasi
Bicara lambat
Flight of idea
Bicara cepat
Irrelevansi
Main kata-kata
Blocking
Pengulangan Pembicaraan/perseverasi
Afasia
Asosiasi bunyi
Lain-lain
Jelaskan:
Diagnosa
Keperawatan:________________________________________________________
b. Isi Pikir
Obsesif
Ekstasi
Fantasi
Alienasi
Pikiran Bunuh Diri
Preokupasi
Pikiran Isolasi sosial
Ide yang terkait
Pikiran Rendah diri
Pesimisme
Pikiran magis
Pikiran curiga
Fobia,sebutkan..
Waham:
Agama
Somatik/hipokondria
Kebesaran
Kejar / curiga
Nihilistik
Dosa
Sisip pikir
Siar piker
Kontrol pikir
Lain lain.
c. Bentuk Pikir
Realistik
Non Realistik
Dereistik
Otistik
Jelaskan:
Jelaskan:
Diagnosa Keperawatan :
______________________________________________
10. 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
Paramnesia:
Konfabulasi
Dejavu
Jamaisvu
Fause reconnaissance
hiperamnesia
Jelaskan:
Diagnosa Keperawatan :
______________________________________________________
Jelaskan:
Diagnosa Keperawatan :
_________________________________________________________
Jelaskan:
Diagnosa Keperawatan :
________________________________________________________
Jelaskan:
Diagnosa Keperawatan :
_________________________________________________________
VII.
2. BAB/BAK
Bantuan minimal
Bantuan total
Jelaskan:
3. Mandi
Bantuan minimal
Bantuan total
Jelaskan
:
4. Berpakaian/berhias
Bantuan Minimal
Bantuan total
Jelaskan
:
10
6. Penggunaan obat
Bantuan Minimal
Bantuan total
Jelaskan
:
..
7. Pemeliharaan kesehatan
Perawatan Lanjutan
Sistem pendukung
Mempersiapkan makanan
Mencuci Pakaian
Pengaturan keuangan
Ya
Tidak
Ya
Tidak
Ya
Tidak
Belanja
Transportasi
Lain-lain
Jelaskan :
Diagnosa Keperawatan :
__________________________________________________
MEKANISME KOPING
Adaptif
Bicara dengan orang lain
Mampu menyelesaikan masalah
Teknik relaksasi
Aktifitas konstruktif
Olah raga
Lain-lain.
Maladaptif
Minum alkhohol
Reaksi lambat/berlebihan
Bekerja berlebihan
Menghindar
Menciderai diri
Lain-lain..
11
Masalah dengan pelayanan kesehatan, spesifiknya ...
VIII.
Jelaskan:
IX.
ASPEK MEDIS
Diagnosis medik:
Terapi medik: . .....
.
.
ANALISA DATA
NO
1.
DATA
DS:
DO:
DIAGNOSA KEPERAWATAN
X.
XI.
Malang, .
Perawat yang mengkaji
_____________________________
NIM/NIRM: .
JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
LAPORAN PENDAHULUAN
JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
STRATEGI PELAKSANAAN
TINDAKAN KEPERAWATAN HARI KE..................
A. PROSES KEPERAWATAN
1. Kondisi klien:
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
2. Diagnosa keperawatan:
..................................................................................................................................
................
..................................................................................................................................
................
3. Tujuan khusus:
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
4. Tindakan keperawatan:
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
2. Evaluasi/ Validasi:
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
TERMINASI:
1. Evaluasi respon klien terhadap tindakan keperawatan:
Subyektif:
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
Obyektif:
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
2. Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan yang telah
dilakukan):
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................
................
..................................................................................................................................................
JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
Nama Klien
No. Reg. :
Tan
gga No
l
:
Diagnosa
Keperawatan
Tujuan Kriteria
Standart
Intervensi
Rasional
T
T
JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
Nama : _________________
_________________
Ruangan : _____________________
RM
No.
N Tan
O
gga
D
l&
Jam
x
IMPLEMENTASI KEPERAWATAN
EVALUASI
JURUSAN KEPERAWATAN
FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
Inisial klien
: ...................................................................
: ...................................................................
Status interaksi perawat-klien : ...................................................................
: ...................................................................
Lingkungan
: ...................................................................
: ...................................................................
Deskripsi klien
: ...................................................................
: ...................................................................
Tujuan (berorientasi pada klien : ...................................................................
Nama Mahasiswa
Tanggal
Jam
Bangsal
KOMUNIKASI
VERBAL
P : ..............................
.......
K : ..............................
.......
P : ..............................
.......
K : ..............................
.......
P : ..............................
.......
KOMUNIKASI NON
VERBAL
P : ..............................
.......
K : ..............................
.......
ANALISA BERPUSAT
PADA PERAWAT
...................................
..
K : ..............................
.......
P : ..............................
.......
...................................
..
P : ..............................
.......
K : ..............................
.......
...................................
..
K : ..............................
.......
P : ..............................
.......
...................................
..
P : ..............................
.......
...................................
..
ANALISA BERPUSAT
PADA KLIEN
...................................
..
...................................
..
...................................
..
...................................
..
...................................
RASIONAL
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
K : ..............................
.......
P : ..............................
.......
K : ..............................
.......
K : ..............................
.......
K : ..............................
.......
P : ..............................
.......
...................................
..
P : ..............................
.......
K : ..............................
.......
...................................
..
K : ..............................
.......
P : ..............................
.......
...................................
..
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
...................................
..
Rekomendasi :...............................................................................................................................................................................................
..............