LAPORAN PENDAHULUAN

I.

DIAGNOSA KEPERAWATAN

II.

TINJAUAN TEORI
A. PENGERTIAN.
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B. FAKTOR PREDISPOSISI DAN PRESIPITASI
Faktor Predisposisi .
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Faktor Presipitasi
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C. RENTANG RESPON ( didalamnya ada pohon masalah )
D. PENENTUAN DIAGNOSA
( Dipakai salah satu dari Nanda International / Linda Jual/ Carpenito ) bisa DS &
DO tapi berdasarkan teori diatas.

B. MASALAH KEPERAWATAN dan DATA YANG PERLU DIKAJI

III.

DIAGNOSA KEPERAWATAN

IV.

RENCANA TINDAKAN KEPERAWATAN

pasien degan hipogonadisme atau tersier

Resi growth homone

PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

rawat :.
Tanggal dirawat/ MRS :..
I.
IDENTITAS KLIEN.
Nama :( L/P ) umur :.Tahun. Nomor CM :
II.
ALASAN MASUK

III.
RIWAYAT PENYAKIT SEKARANG.
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Ruang

IV.

FAKTOR PREDISPOSISI
RIWAYAT PENYAKIT LALU
1. Pernah mengalami gangguan jiwa dimasa lalu?
Ya
Tidak
Jika ya ,
jelakan : ......................................................................................................................
....................................................................................................................................
..............
2. Pengobatan sebelumnya :
berhasil
kurang berhasil
tidak berhasil
jelaskan : ....................................................................................................................
....................................................................................................................................
................
diagnosa keperawatan : .............................................................................................
3. Pernah mengalami penyakit fisik ( termasuk gangguan tumbuh kembang )
Riwayat Trauma :
Jenis trauma
usia
pelaku
korban
saksi
Aniaya fisik
Tah
un
Aniaya seksual
Tahun
Penolakan
Tahun
Kekerasan dalam keluarga
Tahun
Tindakan criminal
Tahun
Lain lain
Tahun

pasien degan hipogonadisme atau tersier

Jelaskan :

4. Pengalaman masa lalu yang tidak menyenangkan ( Bio, Psiko, Kultural dan
Spiritual )
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....................................................................................................................................
Diagnosa keperawatan :
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RIWAYAT PENYAKIT KELUARGA

Anggota keluarga yang gangguan jiwa?
Ada
Tidak ada
Kalau ada :
Hubungan keluarga : .
Gejala : ..
Riwayat pengobatan : ...
Diagnosa keperawatan : ............................................................................................

V.

PEMERIKSAAN FISIK
Tanggal : ..................................
1. Keadaan umum :
......................................................................................................................................
......................................................................................................................................
2. Tanda vital :
TD: /.. mm/Hg
N : ..X/ menit
S: C
P: ..X/menit
3. Ukuran : Berat badan ( BB ) : ..Kg Tinggi badan (TB ) : ..Cm
Turun
Naik
4. Keluhan fisik :
Tidak ada
Ya
Jelaskan : .
.
5. Pemeriksaan fisik : ( head to toe )
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......................................................................................................................................
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Diagnosa keperawatan : ............................................................................................

VI.

PSIKOSOSIAL
1. Genogram :
Keterangan gambar

pasien degan hipogonadisme atau tersier

Jelaskan :

2. Konsep diri
a. Citra tubuh :
b. Identitas : .............................................................................................................
..........
c. Peran : ...
..............................................................................................................................
d. Idial diri :
................................................................................................................................
e. Harga diri : ....
................................................................................................................................
3. Hubungan social
a. Orang yang berarti/ terdekat :
....................................
................................................................................................................................
b. Peran serta dalam kegiatan kelompok/ masyarakat :
................................................................................................................................
c. Hambatan dalam berhubungan dengan orang lain : ..
................................................................................................................................
Diagnosa keperawatan : ............................................................................................
Spiritual
a. Nilai dan keyakinan :
...............................................................................................................................
b. Kegiatan ibadah : ..
................................................................................................................................
Diagnosa
keperawatan : ........................................................................................................
.......................
VII. 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
Samnolensia
Koma
Meninggi
Hipnosa
Gangguan tidur : ...................................................................................
Disosiasi : ....................................................................................................
Berubah : ...........................................................................................................
Gangguan perhatian
Jelaskan .
pasien degan hipogonadisme atau tersier


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. Aktivitas motoric/ psikomotor :
Kelambatan :
Hipokinesia, hipoaktifitas
Katalepsi
Sub stuporkatonik
Fleksibilitas serea
Jelaskan :
....................................................................................................................................
....................................................................................................................................
Peningkatan :
Hiperkinesia, hiperaktifitas
Gagap
Stereotipi
Gaduh gelisah katatonik
Mannarism
Katapleksi
Tik
Ekhopraxia
Command automatism
Grimacen.
Otomatisma
Negativisme
Reaksi konversi
Tremor
Verbigerasi
Berjalan kaku/ rigid
Kompulsif ; sebutkan
Jelaskan :.

Diagnosa keperawatan :.............................................................................................

6. Afek dan Emosi :
pasien degan hipogonadisme atau tersier

Adekuat
Tumpul
Merasa kesepian
7. Persepsi sensorik:
Halusinasi :
Pendengaran.
Penglihatan.
Perabaan.
Pengecapan.
Penghidu
Illusi :
Ada.
Tidak ada.
Depersonalisasi
Ada
Tidak ada
Derealisasi
Ada
Tidak ada
Gangguan somatosensorik pada reaksi konversi
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 ................................................................................................................
..............................................................................................................................
..............
b. Isi pikir
Obsesif
Ektasi
Fantasi
Alienasi
pasien degan hipogonadisme atau tersier

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 pikir
Kontrol pikir
Lain lain ,....................................................
c. Bentuk pikir.
Realistik
Non realistik
Dereistik
Otistik
Jelaskan : ..
Diagnosa keperawatan
9.

Interaksi selama wawancara :

Bermusuhan
Tidak kooperatif .
Mudah tersinggung.
kontak mata kurang
Gembira berlebihan.
Lain lain, jelaskan
Jelaskan : ..
..........
Diagnosa keperawatan : ............................................................................................
10. Memori :
Gangguan daya ingat jangka panjang ( > 1 bulan )
Gangguan daya ingat jangka pendek ( 1 1 bulan )
Gangguan daya ingat saat ini ( < 24 jam )
Amnesia
Paramnesia :
Konfabulasis
Dejavu
Jamaisvu
Fause reconnaisance
Hiperamnesia
Jelaskan:......................................................................................................................
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...........................................................
Diagnosa keperawatan :...............................................................................
11. Tingkat konsentrasi dan berhitung :
Mudah beralih
Tidak mampu berkonsentrasi
pasien degan hipogonadisme atau tersier

Tidak mampu berhitung sederhana

Jelaskan :.....................................................................................................................
....................................................................................................................................
Diagnosa keperawatan : ........................................................................................
12. Kemampuan penilaian :
Gangguan ringan
Gangguan bermakna
Jelaska : .....................................................................................................................
...................................................................................................................................
Diagnosa keperawatan : ..........................................................................
13. Daya tilik diri :
Mengingkari penyakit yang diderita
Menyalahkan hal hal diluar dirinya
Jelaskan : ...................................................................................................................
...................................................................................................................................
Diagnosa keperawatan : ............................................................................................
VIII. KEBUTUHAN PERENCANAAN 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.
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
Jelaskan : ........................................................................................................................
.........................................................................................................................................
8. Aktivitas dalam rumah
pasien degan hipogonadisme atau tersier

Ya
Tidak
Mempersiapkan makan
Menjaga kerapian makan
Mencuci pakaian
Pengaturan keuangan
Jelaskan : ........................................................................................................................
.........................................................................................................................................
9. Aktivitas diluar rumah.
Ya
Tidak
Belanja
Transportasi
Lain lain
Jelaskan : ........................................................................................................................
.........................................................................................................................................
Diagnosa keperawatan ...................................................................................................
IX. MEKANISME KOPING
Adaptif
Bicara dengan orang lain
Mampu menyelesaikan masalah
Tehnik relaksasi
Aktifitas konstruktif
Olah raga
Lain lain ...................
X.

XI.

Maladaptif
Minum alkhohol
Reaksi lambat/ berlebihan
Bekerja berlebihan
Menghindar
Mencederai diri
Lain lain ...................

MASALAH PSIKOSOSIAL DAN LINGKUNGAN

Masalah dengan dukungan kelompik, spesifiknya.......................................................
......................................................................................................................................
Masalah berhubungan dengan lingkungan, spesifiknya .............................................
.....................................................................................................................................
Masalah dengan pendidikannya,
spesifiknya.............................................................. ...................................................
................................................................................
Masalah dengan pekerjaan, spesifiknya .......................................................................
.......................................................................................................................................
Masalah dengan perumahan, spesifiknya......................................................................
.......................................................................................................................................
Masalah dengan ekonomi, spesifiknya..........................................................................
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Masalah dengan pelayan kesehatan,spesifiknya...........................................................
.......................................................................................................................................
Masalah lainnya, spesifiknya .......................................................................................
.......................................................................................................................................
Diagnosa keperawatan ..................................................................................................
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 ...............................................................................................

pasien degan hipogonadisme atau tersier

................................................................................................................................
Diagnosa keperawatan : .........................................................................................
XII. ASPEK MEDIK
Diagnose medis : .............................................................................................................
Terapi Medis : ..............................................................................................................
XIII. DAFTAR MASALAH KEPERAWATAN
1. Tuliskan semua masalah disertai data pendukung yaitu data subyektif dan data
obyektif.
2. Buat pohon masalah dari data yang dirumuskan.
XIV. DAFTAR DIAGNOSA KEPERAWATAN
Rumuskan DX dengan rumusan P ( permasalahan ) dan E ( etiologi ) berdasakan pohon
masalah.
Urutkan DX sesuai dengan prioritas. Pada akhir pengkajian, tulis tempat, tanggal
pengkajian serta tanda tangan dan nama jelas mahasiswa.

pasien degan hipogonadisme atau tersier