Format Pengkajian Jiwa Seminar

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LAPORAN PENDAHULUAN
1. Kasus (masalah utama):Waham (delusi)

2. Proses terjadinya masalah
a.
Definisi
b.
Faktor Predisposisi
c.
Faktor Presipitasi
d.
Tanda Gejala
2. Dasar Penetapan Masalah klien

a. Pohon masalah
b. Masalah keperawatan dan data yang perlu dikaji
3. Diagnosa keperawatan
4. Rencana tindakan keperawatan
Jakarta,..2016
Praktikan
NPM
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN SETIAP HARI

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Pertemuan ke.. Hari/tanggal.

A.
Proses Keperawatan
Kondisi klien:_________________________________________________________
Diagnosa keperawatan : _______________________________________________________
Tujuan khusus : _____________________________________________________________
Tindakan keperawatan : _______________________________________________________
B. Proses Pelaksanaan Tindakan
ORIENTASI
a. Salam terapeutik : ____________________________________________________
b. Evaluasi/validasi : ____________________________________________________
c. Kontrak Topik : ____________________________________________________
Waktu : ____________________________________________________
Tempat: ____________________________________________________
KERJA(langkah-langkah tindakan keperawatan)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________ dst
TERMINASI
a. Evaluasi respon klien terhadap tindakan keperawatan
Evaluasi klien (Subjektif)____________________________________________________
Evaluasi perawat (objektif setelah reinforcement): _______________________________
b. Tindak lanjut klien (apa yang perlu dilatih oleh klien sesuai hasil tindakan yang telah
dilakukan)
_______________________________________________________________________
c. Kontrak yang akan datang :
Topik
: ____________________________________________________
Waktu
: ____________________________________________________
Tempat
: ____________________________________________________
Purwokerto, ......................2016
Praktikan,.....................................
NIM.
Mydoc./jiwa.2016
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FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

FAKULTAS ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH PURWOKERTO
RUANG RAWAT:
I.
TANGGAL DIRAWAT:
IDENTITAS KLIEN
Inisial
:
Umur
:
tahun
Informan : Klien, Keluarga, Status
Tanggal Pengkajian :
RM. No.
:
II. ALASAN MASUK

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
.....................................................................................................................................................
III. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa masa lalu? ya
tidak
2. Pengobatan sebelumnya : berhasil
Kurang berhasil tidak berhasil
3.
Pelaku/Usia
Korban/Usia
Saksi/Usia
Aniaya fisik
Aniaya seksual
Penolakan
Kekerasan dalam keuarga
Tindakan kriminal
Jelaskan No. 1, 2, 3
4.
: ...............................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
...............................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
Adakah anggota keluarga yang mengalami gangguan jiwa ya
tidak
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5.
Hubungan keluarga
gejala
Riwayat penyakit
........................................... ...........................................
...........................................
........................................... ...........................................
...........................................
Masalah keperawatan:
..............................................................................................................................................
Pengalaman masa lalu yang tidak menyenangkan
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
IV. FISIK
1. Tanda Vital : TD: ............... N: ............... S: .................... P: ....................
2. Ukur
: TB: ............... BB: ...............
3. Keluhan fisik : Ya
Tidak
Jelaskan: ......................................................................................................................................
......................................................................................................................................................
Masalah Keperawatan:
......................................................................................................................................................
......................................................................................................................................................
V. PSIKOSOSIAL
1. Genogram
..............................................................................................................................................
..............................................................................................................................................
2.
Konsep diri:
a. Gambaran diri
b. Identitas
c. Peran
d. Ideal diri
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: ...............................................................................................
...............................................................................................
: ...............................................................................................
...............................................................................................
: ...............................................................................................
...............................................................................................
: ...............................................................................................
...............................................................................................
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e. Harga diri
3.
: ...............................................................................................
...............................................................................................
f. Masalah keperawatan: .................................................................................................
......................................................................................................................................
.....................................................................................................................................
Hubungan sosial:
a. Orang berarti
: ....................................................................................................
....................................................................................................
b. Peran serta dalam kegiatan kelompok/masyarakat:
......................................................................................................................................
c. Hambatan dalam berhubungan dengan orang lain:
......................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
4.
Spiritual:
a. Nilai dan keyakinan:
.......................................................................................................................................
.......................................................................................................................................
b. Kegiatan ibadah:
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
VI. STATUS METAL

1. Penampilan
tidak rapi
penggunaan pakaian Cara berpakaian tidak

tidak sesuai
seperti biasanya
Jelaskan: .............................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
2.
Pembicaraan
Cepat
Keras
Gagap
Inkoheren
Apatis Lambat
Membisu
Tidak mampu memulai pembicaraan
Jelaskan: .............................................................................................................................
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.............................................................................................................................................
3.
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Aktivitas Motorik
Lesu
Tegang
Gelisah
Agitasi
Tik
Grimasen
Tremor
Kompulsif
Jelaskan: ............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
4.
Alam Perasaan
Sedih
Ketakutan Putus asa
Kawatir Gembira berlebihan
Jelaskan: .............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
5.
Afek
Datar
Tumpul
Labil
Tidak sesuai
Jelaskan: .............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
6.
Interaksi selama wawancara

Bermusuhan
Tidak kooperatif
Mudah tersinggung
Kontak mata kurang Defensif
Curiga
Jelaskan: .............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
7.
Persepsi
Pendengaran
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Penglihatan
Perabaan
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Pengecapan
Penghidu
Jelaskan: ............................................................................................................................
..............................................................................................................................................
8.
9.
..............................................................................................................................................
..............................................................................................................................................
Proses Pikir
Sirkumstansial
Tangensial
Kehilangan asosiasi
Fligt of ideas
Blocking
Pengulangan pembicaraan/
perseverasi
Jelaskan: ............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
Isi Pikir
Obsesi
Fobia
Hipokondria
Depersonalisasi
Ide yang terkait
Pikiran magis
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
Waham
Agama
Somatik
Kebesaran
Curiga
Nihilistik
Sisip pikir
Siar pikir
Kontrol pikir
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
10. Tingkat kesadaran

Bingung
Sedasi
Stupor
Disorientasi
Waktu
Tempat
Orang
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
11. Memori
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Gangguan daya ingat jangka panjang Gangguan daya ingat jangka pendek
Gangguan daya ingat saat ini
Konfabulasi
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
12. Tingkat konsentrasi dan berhitung
Mudah beralih Tidak mampu berkonsentrasi
Tidak mampu berhitung

sederhana
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
13. Kemampuan penilaian
Gangguan ringan
Gangguan bermakna
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
14. Daya tilik diri
Mengingkari penyakit yang diderita
Menyalahkan hal-hal diluar dirinya
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
VII. KEBUTUHAN PERSIAPAN PULANG
1. Makan
Bantuan minimal
Bantuan total
2. BAB/BAK
Bantuan minimal
Bantuan total
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
3.
Mandi
Bantuan minimal
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Bantuan total
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4.
5.
6.
Berpakaian/berhias
Bantuan minimal
Bantuan total
Istirahat dan tidur
Tidur siang
: ....................................................................................................
Tidur malam : .....................................................................................................
Kegiatan sebelum dan sesudah tidur: ....................................................................

Penggunaan obat
Bantuan minimal
Bantuan total
7.
Pemeliharaan kesehatan
8.
Perawatan lanjutan
Sistem pendukung
Kegiatan didalam rumah
9.
Mempersiapkan makanan
Menjaga kerapian rumah
Mencuci pakaian
Pengaturan keuangan
Kegiatan diluar rumah
Belanja
Transportasi
Lain-lain
Ya
Tidak
Ya
Tidak
Ya
Tidak
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
VIII. MEKANISME KOPING
Adaptif
Bicara dengan orang lain
Mampu menyelesaikan masalah
Teknik relaksasi
Aktivitas konstruktif
Olahraga
Lainnya ....................
Maladaptif
Minum alkohol
Reaksi lambat/berlebih
Bekerja berlebihan
Menghindar
Mencederai diri
Lainnya : ............................................
................................................................................................................................................
................................................................................................................................................
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IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
Masalah dengan dukungan kelompok,

spesifik: ........................................................
....................................................................................................................................
Masalah berhubungan dengan lingkungan, spesifik: ................................................

..................................................................................................................................
Masalah dengan pendidikan, spesifik: ....................................................................

..................................................................................................................................
Masalah dengan perumahan, spesifik: .....................................................................

..................................................................................................................................
Masalah ekonomi, spesifik: .....................................................................................

..................................................................................................................................
Masalah dengan pelayanan kesehatan, spesifik: .....................................................

..................................................................................................................................
Masalah lainnya, spesifik: ......................................................................................

.................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
X. PENGETAHUAN KURANG TENTANG:
Penyakit jiwa
Sistem pendukung
Faktor predisposisi
Penyakit fisik
Koping
Obat-obatan
Lainnya .....................................................................................
......................................................................................................................................................
......................................................................................................................................................
XI. DATA FOKUS

DS:
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DO:
ANALISA DATA
Data
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Masalah
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XII. ASPEK MEDIK

Diagnosa medik :
Terapi medik
: ............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
XIII. DAFTAR MASALAH KEPERAWATAN
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
XIV. DAFTAR DIAGNOSA KEPERAWATAN
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
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..................................,......................
Mahasiswa,
.........................................................
Mydoc./jiwa.2016

Format Pengkajian Jiwa Seminar

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Format Pengkajian Jiwa Seminar

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Format Tersedia

lampiran 1

1. Kasus (masalah utama):Waham (delusi)

2. Dasar Penetapan Masalah klien

STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN SETIAP HARI

Pertemuan ke.. Hari/tanggal.

FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

II. ALASAN MASUK

VI. STATUS METAL

penggunaan pakaian Cara berpakaian tidak

Interaksi selama wawancara

10. Tingkat kesadaran

Tidak mampu berhitung

Tidur malam : .....................................................................................................

Kegiatan sebelum dan sesudah tidur: ....................................................................

Bicara dengan orang lain

Mampu menyelesaikan masalah

IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

Masalah dengan dukungan kelompok,

Masalah berhubungan dengan lingkungan, spesifik: ................................................

Masalah dengan pendidikan, spesifik: ....................................................................

Masalah dengan perumahan, spesifik: .....................................................................

Masalah ekonomi, spesifik: .....................................................................................

Masalah dengan pelayanan kesehatan, spesifik: .....................................................

Masalah lainnya, spesifik: ......................................................................................

XI. DATA FOKUS

XII. ASPEK MEDIK

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