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    Lampiran : 7

    ASUHAN KEPERAWATAN KESEHATAN JIWA


    PADA KLIENDENGAN.
    DI RUANG.
    RUMAH SAKIT JIWA PROVINSI BALI

    OLEH : MAHASISWA
    NIM

    JURUSAN KEPERAWATAN POLTEKKES KEMENKES


    DENPASAR
    PROGRAM STUDI D IV KEPERAWATAN
    2015
    PENGKAJIAN KEPERAWATAN KESEHATAN JIWA
    DI UNIT RAWAT INAP RUMAH SAKIT JIWA PROVINSI BALI
    PROGRAM STUDI D IV KEPERAWATAN POLTEKKES KEMENKES DENPASAR

    I. IDENTITAS KLIEN
    Ruang Rawat : Tanggal Rawat : .
    Inisial : (L/P) No.RM : .
    Umur : Status : .
    Pekerjaan : . Pendidikan : .

    II. ALASAN MASUK













    III. FAKTOR PREDISPOSISI


    1. Pernah mengalami gangguan jiwa dimasa lalu ? ya tidak
    2. Pengobatan sebelumnya ?
    berhasil kurang berhasil tidak berhasil
    3. Penolakan dari lingkungan : ya tidak
    Jelaskan :


    4. Adakah anggota keluarga yang mengalami gangguan jiwa?
    ya tidak
    5. Pengalaman masa lalu yang tidak menyenangkan




    Masalah Keperawatan : ..
    IV. FISIK
    1. Tanda vital : TD : N : S : P : .
    2. Ukuran : TB : BB : . Turun Naik
    3. Keluhan fisik Ya Tidak
    Jelaskan:
    .
    .

    .
    Masalah Keperawatan :.

    V. PSIKOSOSIAL
    1. Genogram :

    Jelaskan :.........................................................................................................................
    .........................................................................................................................................
    .........................................................................................................................................
    .........................................................................................................................................
    Masalah keperawatan :....................................................................................................

    2. Konsep Diri
    a. Citra tubuh :
    ....................................................................................................................................
    ....................................................................................................................................
    ....................................................................................................................................
    b. Identitas diri :
    ....................................................................................................................................
    ....................................................................................................................................
    ....................................................................................................................................

    c. Peran :
    ....................................................................................................................................
    ....................................................................................................................................
    ....................................................................................................................................
    d. Ideal Diri
    : ............................................................................................................................
    ....................................................................................................................................
    ....................................................................................................................................
    ........
    e. Harga Diri
    : ............................................................................................................................
    ....................................................................................................................................
    ....................................................................................................................................
    ........
    Masalah keperawatan :...

    3. Hubungan Sosial
    a. Orang yang 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 :

    VI. STATUS MENTAL


    1. Penampilan
    Tidak Rapi Penggunaan pakaian tidak sesuai
    Cara pakaian tidak seperti biasanya
    Jelaskan:...........................................................................................................................
    ..........................................................................................................................................
    ..........................................................................................................................................
    Masalah keperawatan :

    2. Pembicaraan
    Cepat Apatis
    Kasar Lambat
    Gagap Membisu
    Inkoherensi Tidak mampu memulai pembicaraan
    Jelaskan:...........................................................................................................................
    ..........................................................................................................................................
    ..........................................................................................................................................
    Masalah keperawatan :

    3. Aktivitas motorik
    Lesu Gelisah Tik Tremor
    Tegang Agitasi Grimasem Kompulsif
    Jelaskan:...........................................................................................................................
    ..........................................................................................................................................
    ..........................................................................................................................................
    Masalah keperawatan :.

    4. Alam perasaan
    Sedih Putus Asa Gembira berlebihan
    Ketakutan Kuatir
    Jelaskan:.......
    ..

    ..
    Masalah keperawatan :

    5. Afek/ emosi
    Datar Tumpul Labil Tidak sesuai
    Jelaskan:...
    ..

    ..
    Masalah keperawatan :

    6. Interaksi selama wawancara


    Bermusuhan Mudah tersinggung Defensif
    Tidak kooperatif Kontak mata kurang Curiga
    Jelaskan :
    .

    .
    Masalah keperawatan :

    7. Persepsi
    Pendengaran Pengelihatan Perabaan
    Pengecapan Penghidu
    Jelaskan : .
    .

    .
    Masalah keperawatan :.

    8. Proses pikir
    Sirkumstansial Tangensial Kehilangan asosiasi
    Flight of ideas Blocking Pengulangan pembicaraan/ preservarasi
    Jelaskan :..
    .

    .
    Masalah keperawatan :

    9. Isi pikir
    Obsesi Hipokondria Ide yang terkait
    Phobia Depersonalisasi Pikiran magis
    Waham
    Agama Somatik Kebesaran Curiga
    Nihilistik Sisip piker Siar piker Kontrol piker
    Jelaskan :
    ..
    ..
    Masalah keperawatan :

    10. Tingkat kesadaran


    Bingung Sedasi Stupor
    Disorientasi:
    Waktu Tempat Orang
    Jelaskan : .
    .
    .
    Masalah keperawatan :

    11. Memori
    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
    Tidak mampu berhitung sederhana
    Jelaskan : .
    .
    .
    Masalah keperawatan :

    13. Kemampuan penilaian


    Gangguan ringan Gangguan bermakna
    Jelaskan : .
    ..
    ..
    Masalah keperawatan :

    14. Daya tilik diri


    Mengingkari penyakit yang diderita Menyalahkan hal-hal di luar dirinya
    Jelaskan : .
    ..
    ..
    Masalah keperawatan :.

    VII. KEBUTUHAN PERSIAPAN PULANG


    1. Kemampuan klien memenuhi/menyediakan kebutuhan :
    a. Makan : Bantuan minimal Bantuan total
    b. Keamanan : Bantuan minimal Bantuan total
    c. Tempat tinggal : Bantuan minimal Bantuan total
    d. Perawatan kesehatan : Bantuan minimal Bantuan total
    e. Berpakian / berhias: Bantuan minimal Bantuan total
    f. Transportasi : Bantuan minimal Bantuan total
    g. Uang : Bantuan minimal Bantuan total
    2. Kegiatan hidup sehari-hari
    a. Perawatan diri : Bantuan minimal Bantuan total
    b. Nutrisi :
    - Apakah anda puas dengan pola makan : ya tidak
    - Apakah anda memisahkan diri : ya tidak
    - Frekwensi makan perhari :
    - Frekwensi kudapan perhari
    - Nafsu makan :
    - BB :
    - Diet khusus :

    c. Tidur
    - apakah ada masalah ? : ya tidak
    - apakah anda merasa segera setelah bangun tidur ? : ya tidak
    - apakah ada kebiasaan tidur siang ? : ya tidak
    - apa yang menolong anda untuk tidur ? ya tidak
    - Waktu tidur malam : ya tidak

    3. Kemampuan klien dalam


    - Mengantisipasi kebutuhan sendiri ? : ya tidak
    - Membuat keputusan berdasarkan keinginan sendiri : ya tidak
    - Mengatur penggunaan obat ? : ya tidak
    - Melakukan pemeriksaan kesehatan (Follow up) : ya tidak

    4. Klien memiliki sistem pendukung


    Keluarga : ya tidak Teman Sejawat : ya tidak
    Profesional/terapis : ya tidak Kelompok social : ya tidak

    5. Apakah klien menikmati saat bekerja, kegiatan yang menghasilkan atau hobi :
    ya tidak

    Masalah keperawatan: .

    VIII. MEKANISME KOPING


    Adaptif Maladaptif
    Bicara dengan orang lain Minum alcohol
    Mampu menyelesaikan masalah Relaksaksi lambat berlebih
    Teknik relokasi Berkerja berlebihan
    Aktivitas konstruktif Menghindar
    Olahraga Mencederai diri
    Lainnya Lainnya
    Alasan :
    Masalah keperawatan :.

    IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN


    Masalah dengan dukungan Kelompok:
    ...
    ...
    ...
    Masalah dengan Lingkungan:
    ...
    ..
    ...

    Masalah dengan pendidikan :





    Masalah dengan Pekerjaan :



    Masalah dengan perumahan :



    Masalah dengan ekonomi:



    Masalah dengan pelayanan kesehatan :



    Masalah lainnya :


    ...........................................................................................................................................

    X. PENGETAHUAN KURANG TENTANG :


    Penyakit jiwa
    Faktor presipitasi
    Koping
    Lainnya
    Sistem pendukung
    Penyakit fisik
    Obat-obatan
    Masalah keperawatan :.............................................................................................................

    XI. ASPEK MEDIK


    - Diagnosa medik :..............................................................................................................
    - Diagnosis multiaxial :.......................................................................................................
    ..........................................................................................................................................
    ..........................................................................................................................................
    ..........................................................................................................................................
    ..........................................................................................................................................
    ..........................................................................................................................................

    XII. DAFTAR MASALAH KEPERAWATAN

    Data Masalah Keperawatan


    Subyektif :



    Obyektif :



    Subyektif :



    Obyektif :



    Subyektif :



    Obyektif :



    Subyektif :



    Obyektif :



    Subyektif :



    Obyektif :



    Subyektif :



    Obyektif :



    Subyektif :



    Obyektif :


    POHON MASALAH










    XII. DIAGNOSA KEPERAWATAN






    Bangli
    Mahasiswa

    ()
    RENCANA TINDAKAN KEPERAWATAN KESEHATAN JIWA
    DI UNIT RAWAT INAP RUMAH SAKIT JIWA PROVINSI BALI

    Rencana Tindakan Keperawatan


    Dx. Kep Rasional
    Tujuan Kriteria Evaluasi Tindakan Keperawatan
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    IMPLEMENTASI DAN EVALUASI KEPERAWATAN KESEHATAN JIWA
    DI UNIT RAWAT INAP RUMAH SAKIT JIWA PROVINSI BALI
    Evaluasi Proses :
    Hari/tgl/jam No dx Implementasi Respon klien Paraf
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    Evaluasi Hasil :

    Hari/tanggal/jam Diagnosa Keperawatan Evaluasi


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