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PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA

LAPORAN PENDAHULUAN
STRATEGI PELAKSANAAN
TINDAKAN KEPERAWATAN HARI KE
A. PROSES KEPERAWATAN
1. Kondisi klien:
Ramah, menjabat tangan perawat,
2. Diagnosa keperawatan:
Halusinasi
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:
Perawat mengucapakan salam kepada pasien
2. Evaluasi/ Validasi:
Perawat menanyakan kabar pasien
3. Kontrak: Topik, waktu, dan tempat
Topik :

Waktu :
Tempat :
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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PROGRAM STUDI ILMU KEPERAWATAN


FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA

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?

ya

tidak

Bila ya jelaskan___________________________________________________________________
2. Pengobatan sebelumnya
Berhasil
Kurang Berhasil
Tidak Berhasil
3. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang)
ya
tidak
Bila ya jelaskan___________________________________________________________________

RIWAYAT PSIKOSOSIAL

1.
2.
3.
4.
5.

Aniaya fisik
Aniaya seksual
Penolakan
Kekerasan dalam keluarga
Tindakan kriminal

Pelaku/ usia

Jelaskan

Korban/ usia

Saksi/ usia

:___________________________________________________________________
___________________________________________________________________

6. Pengalaman masa lalu lain yang tidak menyenangkan (bio, psiko, sosio, kultural,
spiritual):
_______________________________________________________________________________________
_______________________________________________________________________
Masalah keperawatan
:____________________________________________________________
7. Kesan Kepribadian klien:

extrovert

RIWAYAT PENYAKIT KELUARGA

introvert

lain-lain:__________________

1. Adakah anggota keluarga yang mengalami gangguan jiwa?


ya
tidak
Hubungan keluarga
Gejala
Riwayat Pengobatan/
perawatan
_______________________
__________________________ ___________________________
_______________________ __________________________ ___________________________
Masalah keperawatan
:____________________________________________________________
V.

STATUS MENTAL
1. Penampilan
tidak rapi
tidak seperti

penggunaan pakaian

Cara berpakaian

tidak sesuai
biasanya
Jelaskan
: __________________________________________________________________
Masalah keperawatan : ____________________________________________________________
2. Kesadaran
Kwantitatif/ penurunan kesadaran]
compos mentis
apatis/ sedasi
sopor
subkoma

Kwalitatif
tidak berubah
meninggi
hipnosa

3. Disorientasi
waktu

somnolensia
koma

berubah
gangguan tidur: sebutkan______________________________
disosiasi: sebutkan____________________________________
tempat

orang

Jelaskan
:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
4. Aktivitas Motorik/ Psikomotor
Kelambatan:
hipokinesia, hipoaktivitas
katalepsi

sub stupor katatonik


flexibilitas serea

Peningkatan:
hiperkinesia, hiperaktivitas
gaduh gelisah katatonik
TIK
grimase
tremor
gagap
stereotipi
mannarism
katalepsi
akhopraxia
command automatism
atomatisma
nagativisme
reaksi konversi
verbigerasi
berjalan kaku/ rigit
kompulsif
lain-2 sebutkan
5. Afek/ Emosi
adequat
tumpul
dangkal/ datar
labil
inadequat
anhedonia
marasa kesepian
eforia
ambivalen
apati
marah
depresif/
sedih
cemas:
ringan
sedang
berat
panik
Jelaskan
:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________

6. Persepsi

halusinasi
derealisasi
Macam Halusinasi
pendengaran
pengecapan
sebutkan...................

ilusi

depersonalisasi

penglihatan
penghidu/ pembauan

perabaan
lain-lain,

Jelaskan
:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
7. Proses Pikir
Arus Pikir
koheren
fligt of ideas
persevarasi
tangansial
neologisme
main kata-kata
sebutkan..

inkoheren
blocking

asosiasi longgar
pengulangan pembicaraan/

sirkumstansiality
logorea
bicara lambat
bicara cepat
afasi
assosiasi bunyi

irelevansi
lain2

Jelaskan
:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
Isi Pikir
obsesif
ekstasi
fantasi
bunuh diri
ideas of reference
pikiran magis
alienasi
isolaso sosial
rendah diri
preokupasi
pesimisme
fobia
sebutkan.........................
waham: sebutkan jenisnya
agama
somatik, hipokondrik
kebesaran
curiga
nihilistik
sisip pikir
siar pikir
kontrol pikir
kejaran
dosa
Jelaskan
:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
Bentuk Pikir
realistik
autistik

nonrealistik
dereistik

8. Memori
gangguan daya ingat jangka panjang
gangguan daya ingat jangka pendek
gangguan daya ingat saat ini
amnesia, sebutkan.........................
paramnesia, sebutkan jenisnya........................................................
hipermnesia, sebutkan ...................................................................
Jelaskan
:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
9. Tingkat Konsentrasi dan Berhitung
mudah beralih
tidak mampu berkonsentrasi
sederhana

tidak mampu berhitung

Jelaskan
:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________

10.Kemampuan Penilaian
gangguan ringan

gangguan bermakna

Jelaskan
:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
11.Daya Tilik Diri/ Insight
mengingkari penyakit yang diderita

menyalahkan hal-hal diluar dirinya

Jelaskan
:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
12.Interaksi selama Wawancara
bermusuhan
tidak kooperatif
kontak mata kurang
defensif

mudah tersinggung
curiga

Jelaskan
:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
VI.

FISIK
1. Keadaan umum ____________________________________________________________________
_________________________________________________________________________________
2. Tanda vital: TD:___________
N:___________
S:_____________
P:_______
3. UKur:
TB:___________BB:__________
turun
naik
4. Keluhan fisik:
tidak
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
Bantuan minimal

Sebagian

Bantuan total

2. BAB/BAK
Bantuan minimal

Sebagian

Bantuan total

3. Mandi
Bantuan minimal

Sebagian

Bantuan total

4. Berpakaian/berhias
Bantuan minimal

Sebagian

Bantuan total

5. Istirahat dan tidur


Tidur siang lama: ______________________ s/d _________________________
Tidur malam lama
: ______________________ s/d _________________________
Aktivitas sebelum / sedudah tidur : _____________________ s/d _____________________
6. Pengginaan obat
Bantuan minimal

Sebagian

Bantuan total

7. Pemeliharaan kesehatan
Perawatan Lanjutan
Sistem pendukung

Ya

Tidak

8. Aktivitas di dalam rumah


Mempersiapkan makanan
Menjaga kerapihan rumah
Mencuci pakaian

Ya
Ya
Ya

Tidak
Tidak
Tidak

Ya

Tidak

Pengaturan keuangan
9. Aktivitas di luar rumah
Belanja
Transportasi
Lain-lain

Ya

Ya
Ya
Ya

Tidak

Tidak
Tidak
Tidak

Jelaskan
:___________________________________________________________________
Masalah keperawatan : ____________________________________________________________
IX.

MEKANISME KOPING
Adatif
Maladaptif
Bicara dengan orang lain
Minum Alkohol
Mampu menyelesaikan masalah
Reaksi lambat / berlebih
Teknik relokasi
Bekerja berlebihan
Aktivitas konstruktif
Menghindar
Olah raga
Mencederai diri
Lainnya ......................
Lainnya ......................
Masalah keperawatan : ______________________________________________________________

X.

MASALAH PSIKOSOSIAL DAN LINGKUNGAN


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

XI.

KURANG PENGETAHUAN TENTANG


Penyakit jiwa
Sistem pendukung
Faktor presiptasi
Penyakit fisik
Koping
Obat-obatan
Lainnya _______________________________________________________________________
Masalah keperawatan : ______________________________________________________________

XII. ASPEK MEDIK


Diagnosa medik: _________________________________________________________________
Terapi medik

: _________________________________________________________________
_________________________________________________________________
_________________________________________________________________

XIII. DAFTAR MASALAH KEPERAWATAN


____________________________
____________________________
____________________________
____________________________

_____________________________
_____________________________
_____________________________
_____________________________

____________________________
XIV. ANALISA DATA
No

_____________________________

DATA

MASALAH

10

XV. POHON MASALAH

XVI. DIAGNOSA KEPERAWATAN


__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________
______________________________
Mahasiswa

______________________________

PROGRAM STUDI ILMU KEPERAWATAN


FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA

11

DAFTAR DIAGNOSA KEPERAWATAN


(Berdasarkan prioritas)
Ruang
:
Nama Pasien :
No. Register :
No.
TANGGAL
Dx
MUNCUL

DIAGNOSA KEPERAWATAN

TANGGAL
TERATASI

PROGRAM STUDI ILMU KEPERAWATAN


FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA

IMPLEMENTASI DAN EVALUASI


KEPERAWATAN KESEHATAN JIWA

12

TANDA
TANGAN

Nama : _________________
NO
Dx

Tangga
l & Jam

Ruangan : _____________________

IMPLEMENTASI KEPERAWATAN

13

RM No. : _________________
EVALUASI