KESEHATAN JIWA
I. IDENTITAS KLIEN
Nama : …………………….. (L/P)
Umur : …………….. ………
Alamat : ………………………
Pendidikan : .....................................
Agama : ....................................
Status : ....................................
Pekerjaan : ………………………
JenisKel. : ………………………
No CM : ………………………
Jelaskan:
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DiagnosaKeperawatan :
2. KonsepDiri
a. Citra tubuh:
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b. Identitas:
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c. Peran:
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d. Ideal diri:
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e. Hargadiri:
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DiagnosaKeperawatan :
3. HubunganSosial
a. Orang yang berarti/terdekat
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b. Peransertadalamkegiatankelompok/masyarakat dan hubungan sosial
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c. Hambatandalamberhubungandengan orang lain
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DiagnosaKeperawatan :
4. Spiritual
a. Nilaidankeyakinan
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b. Kegiatanibadah
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DiagnosaKeperawatan:
3. Aktifitasmotorik/Psikomotor
Kelambatan :
Hipokinesia,hipoaktifitas
Katalepsi
Sub stupor katatonik
Fleksibilitasserea
Jelaskan:
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Peningkatan :
Hiperkinesia,hiperaktifitas Grimace
Stereotipi Otomatisma
GaduhGelisahKatatonik Negativisme
Mannarism Reaksikonversi
Katapleksi Tremor
Tik Verbigerasi
Ekhopraxia Berjalankaku/rigid
Command automatism Kompulsif :sebutkan …………
Jelaskan:
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DiagnosaKeperawatan:
4. Mood dan Afek
a. Mood
Depresi Khawatir
Ketakutan Anhedonia
Euforia Kesepian
Lain lain
Jelaskan
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b. Afek
Sesuai Tidaksesuai
Tumpul/dangkal/datar Labil
Jelaskan:
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DiagnosaKeperawatan
5. InteraksiSelamaWawancara
Bermusuhan Kontakmatakurang
Tidakkooperatif Defensif
Mudahtersinggung Curiga
Jelaskan:
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DiagnosaKeperawatan
6. PersepsiSensorik
a. Halusinasi
Pendengaran
Penglihatan
Perabaan
Pengecapan
Penciuman
b. Ilusi
Ada
Tidakada
Jelaskan:
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DiagnosaKeperawatan
7. Proses Pikir
a. ArusPikir:
Koheren Inkoheren
Sirkumtansial Asosiasilonggar
tangensial Flight of Idea
Blocking Perseverasi
Logorhoe Neologisme
Clang Association Main kata kata
Afasia Lain lain…
Jelaskan:
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b. Isi Pikir
Obsesif Fobia,sebutkan…………..
Ekstasi Waham:
Fantasi o Agama
Alienasi o Somatik/hipokondria
Pikiranbunuhdiri o Kebesaran
Preokupasi o Kejar / curiga
Pikiranisolasisosial o Nihilistik
Ide yang terkait o Dosa
PikiranRendahdiri o Sisippikir
Pesimisme o Siar piker
Pikiranmagis o Kontrolpikir
Pikirancuriga Lain lain :
Jelaskan:
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c. Bentuk pikir :
Realistik
Non realistik
Dereistik
Otistik
Jelaskan:
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DiagnosaKeperawatan:
8. Kesadaran
Orientasi (waktu, tempat, orang)
Jelaskan:
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Meninggi
Menurun:
Kesadaranberubah
Hipnosa
Confusion
Sedasi
Stupor
Jelaskan:
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DiagnosaKeperawatan:
9. Memori
Gangguandayaingatjangkapanjang ( > 1 bulan)
Gangguandayaingatjangkamenengah ( 24 jam - ≤ 1 bulan)
Gangguandayaingatpendek (kurunwaktu 10 detiksampai 15 menit)
Jelaskan:
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DiagnosaKeperawatan:
10. Tingkat KonsentrasidanBerhitung
a. Konsentrasi
Mudahberalih
Tidakmampuberkonsentrasi
Jelaskan:
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b. Berhitung
Jelaskan:
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DiagnosaKeperawatan:
11. KemampuanPenilaian
Gangguanringan
Gangguanbermakna
Jelaskan :
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DiagnosaKeperawatan:
12. DayaTilikDiri
Mengingkaripenyakit yang diderita
Menyalahkanhal-haldiluardirinya
Jelaskan:
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DiagnosaKeperawatan:
transportasi,
tempattinggal.
Keuangandankebutuhanlainnya.
Jelaskan:
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2. KegiatanHidupSeharihari
a. Perawatandiri
1) Mandi
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2) Berpakaian, berhiasdanberdandan
Jelaskan :
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3) Makan
Jelaskan :
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4) Toileting (BAK, BAB)
Jelaskan :
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DiagnosaKeperawatan:
b. Nutrisi
Berapafrekwensimakandanfrekwensikudapandalamsehari.
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Bagaimananafsumakannya
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Bagaimanaberatbadannya.
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DiagnosaKeperawatan:
c. Tidur
1) Istirahatdantidur
Tidursiang, lama : ____________ s/d _____________
Tidurmalam, lama : _____________ s/d _____________
Aktifitassebelum/sesudahtidur : __________ , _________
Jelaskan
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2) Gangguantidur
Insomnia
Hipersomnia
Parasomnia
Lain lain
Jelaskan
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DiagnosaKeperawatan:
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Membuatkeputusanberdasarkankeinginannya,
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Mengaturpenggunaanobatdanmelakukanpemeriksaankesehatannyasendiri.
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DiagnosaKeperawatan:
4. Sistem Pendukung Ya Tidak
Keluarga
Terapis
Teman sejawat
Kelompok sosial
Jelaskan :
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DiagnosaKeperawatan:
IX. MEKANISME KOPING
Jelaskan :
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DiagnosaKeperawatan:
3. Terapi Medis
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XIII. ANALISA DATA
DIAGNOSA
NO DATA
KEPERAWATAN
1. DS:
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2. DS:
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3. DS:
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4. DS:
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dst DS:
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XIV. DAFTAR DIAGNOSA KEPERAWATAN
1. ………………………………………
2. ………………………………………
3. ………………………………………
4. ………………………………………
5. ………………………………………
6. ………………………………………
7. ………………………………………
8. dst
Lawang, ……………………….
Mahasiswa yang mengkaji
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NIM................................
TINDAKAN KEPERAWATAN JIWA
Nama :
No CM :
No TindakanKeperawatan Evaluasi
Keterangan :
Cara pendokumentasian :
PadakolomTindakanKeperawatandiisi :
Tanggal& jam tindakan
Data (Tanda gejala dan kemampuan)
Diagnosa Keperawatan
Tindakan Keperawatan
KolomEvaluasi:
Evaluasisubyektif&Obyektif
Berdasarkanresponsubyektif, evaluasiobyektif
Sesuaihasilevaluasiresponsubyektif&obyektifpadafaseterminasi
A : AnalisaSesuaikemampuan Pasien
P : Planning , terdiridari P pasiendan P perawat
P pasien : berdasarkanhasilrencanatindaklanjutpadafaseterminasi
P perawat : berdasarkanhasilkontrak yang
akandatangpadafaseterminasi