Format Pengkajian Jiwa Seminar
Format Pengkajian Jiwa Seminar
1
LAPORAN PENDAHULUAN
Definisi
b.
Faktor Predisposisi
c.
Faktor Presipitasi
d.
Tanda Gejala
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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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TANGGAL DIRAWAT:
IDENTITAS KLIEN
Inisial
:
Umur
:
tahun
Informan : Klien, Keluarga, Status
Tanggal Pengkajian :
RM. No.
:
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
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
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
Masalah keperawatan:
..............................................................................................................................................
..............................................................................................................................................
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:
......................................................................................................................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
4.
Spiritual:
a. Nilai dan keyakinan:
.......................................................................................................................................
.......................................................................................................................................
b. Kegiatan ibadah:
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
2.
Pembicaraan
Cepat
Keras
Gagap
Inkoheren
Apatis Lambat
Membisu
Tidak mampu memulai pembicaraan
Jelaskan: .............................................................................................................................
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.............................................................................................................................................
3.
Masalah Keperawatan:
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Aktivitas Motorik
Lesu
Tegang
Gelisah
Agitasi
Tik
Grimasen
Tremor
Kompulsif
Jelaskan: ............................................................................................................................
..............................................................................................................................................
Masalah Keperawatan:
..............................................................................................................................................
..............................................................................................................................................
4.
Alam Perasaan
Sedih
Ketakutan Putus asa
Kawatir Gembira berlebihan
Jelaskan: .............................................................................................................................
..............................................................................................................................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
5.
Afek
Datar
Tumpul
Labil
Tidak sesuai
Jelaskan: .............................................................................................................................
..............................................................................................................................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
6.
7.
Persepsi
Pendengaran
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Penglihatan
Perabaan
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Pengecapan
Penghidu
Jelaskan: ............................................................................................................................
..............................................................................................................................................
8.
9.
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
Proses Pikir
Sirkumstansial
Tangensial
Kehilangan asosiasi
Fligt of ideas
Blocking
Pengulangan pembicaraan/
perseverasi
Jelaskan: ............................................................................................................................
..............................................................................................................................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
Isi Pikir
Obsesi
Fobia
Hipokondria
Depersonalisasi
Ide yang terkait
Pikiran magis
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
Waham
Agama
Somatik
Kebesaran
Curiga
Nihilistik
Sisip pikir
Siar pikir
Kontrol pikir
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
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Gangguan daya ingat jangka panjang Gangguan daya ingat jangka pendek
Gangguan daya ingat saat ini
Konfabulasi
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
12. Tingkat konsentrasi dan berhitung
Mudah beralih Tidak mampu berkonsentrasi
Bantuan minimal
Bantuan total
2. BAB/BAK
Bantuan minimal
Bantuan total
Jelaskan: ..............................................................................................................................
..............................................................................................................................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
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
: ....................................................................................................
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: ..............................................................................................................................
..............................................................................................................................................
Masalah Keperawatan :
..............................................................................................................................................
..............................................................................................................................................
VIII. MEKANISME KOPING
Adaptif
Teknik relaksasi
Aktivitas konstruktif
Olahraga
Lainnya ....................
Maladaptif
Minum alkohol
Reaksi lambat/berlebih
Bekerja berlebihan
Menghindar
Mencederai diri
Lainnya : ............................................
Masalah Keperawatan:
................................................................................................................................................
................................................................................................................................................
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Masalah Keperawatan:
..............................................................................................................................................
..............................................................................................................................................
X. PENGETAHUAN KURANG TENTANG:
Penyakit jiwa
Sistem pendukung
Faktor predisposisi
Penyakit fisik
Koping
Obat-obatan
Lainnya .....................................................................................
Masalah Keperawatan:
......................................................................................................................................................
......................................................................................................................................................
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DO:
ANALISA DATA
Data
Mydoc./jiwa.2016
Masalah
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12
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..................................,......................
Mahasiswa,
.........................................................
Mydoc./jiwa.2016