LAPORAN ASUHAN KEPERAWATAN PADA TN.

MD R DENGAN GANGGUAN
PERSEPSI SENSORI : HALUSINASI DI WILAYAH KERJA PUSKESMAS 3
DENPASAR UTARA (BR. KEPUH, PEGUYANGAN )
TANGGAL 28 AGUSTUS 2018 s.d 31 AGUSTUS 2018

OLEH:

NGAKAN MADE YOGASWARA JANTI

NIM. 1602526019

PRAKTIK PROFESI KEPERAWATAN JIWA

PROGRAM STUDI ILMU KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS UDANAYA
2018
 ASUHAN KEPERAWATAN KESEHATAN JIWA

I. IDENTITAS
Inisial : (L/P) Pekerjaan :
Status : Alamat :
Pendidikan : Umur
Sumber Data :

II. RIWAYAT PENYAKIT

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III. Faktor Presdisposisi
1. Pernah mengalami gangguan jiwa dimasa 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 Keluarga   
Tindakan Kriminal   
Jelaskan No. 1, 2, 3 :
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Masalah Keperawatan:
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4. Adakah anggota keluarga yang mengalami gangguan jiwa?

Ya Tidak
Riwayat
Hubungan Keluarga Gejala
pengobatan/Perawatan

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Masalah Keperawatan :
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5. Pengalaman masa lalu yang tidak menyenangkan
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Masalah Keperawatan:
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IV. FISIK
0
1. Tanda-tanda vital : TD mmHg Nadi x/menit Suhu: C Pernapasan :
x/menit
2. Ukuran : BB : TB:  Turun  Naik
3. Keluhan Fisik  Ya  Tidak
Jelaskan :
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Masalah Keperawatan :
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V. Psikososial
1. Genogram

 Keterangan Genogram:

: Laki-laki

: Perempuan

: Sudah meninggak

: Tinggal serumah

: Klien

Jelaskan :
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Masalah Keperawatan:
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2. Konsep Diri
a. Citra Tubuh :
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b. Identitas Diri :
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c. Peran Diri :
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d. Ideal Diri :
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e. Harga Diri :
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 Masalah Keperawatan :
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3. Hubungan sosial
a. Orang terdekat :
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b. Peran serta dalam kegiatan kelompok/masyarakat :
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c. Hambatan dalam hubungan dengan orang lain :
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Masalah Keperawatan :
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4. Spiritual
a. Nilai dan keyakinan
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b. Kegiatan ibadah
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Masalah keperawatan :

VI. STATUS MENTAL

a. Penampilan
 Tidak rapi  Penggunaan pakaian  Cara berpakaian tidak
tidak sesuai seperti biasanya
Jelaskan : .....................................................................................................................
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Masalah Keperawatan :
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Pembicaraan
 Cepat  Keras  Gagap  Inkoheren
 Apatis  Lambat  Membisu  Tidak mampu
memulai
pembicaraan
Jelaskan :
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 Masalah Keperawatan :
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b. Aktivitas Motorik
 Lesu  Tegang  Gelisah  Agitasi
 Tik  Grimasen  Tremor  Kompulsif
Jelaskan : .....................................................................................................................
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Masalah Keperawatan :
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c. Alam Perasaan
 Sedih  Ketakutan  Putus asa
 Khawatir  Gembira Berlebihan
Jelaskan : .....................................................................................................................
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Masalah Keperawatan :
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d. Afek
 Datar  Tumpul  Labil  Tidak sesuai
Jelaskan :
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Masalah Keperawatan :
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e. Interaksi selama wawancara

  Bermusuhan  Tidak kooperatif  Gagap
 Kontak mata kurang  Defensif  Membisu

Jelaskan :
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Masalah Keperawatan :
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f. Persepsi
Halusinasi
 Pendengaran  Penglihatan  Perabaan
 Pengecapan  Penghidu
Jelaskan :
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Masalah Keperawatan :
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g. Proses Pikir
 Sirkumstansial  Tangensial  Kehilangan asosiasi
 Flight of ideas  Blocking Pengulangan
pembicaraan/persevarasi
Jelaskan : .....................................................................................................................
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Masalah Keperawatan :
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h. Isi Pikir
 Obsesi  Fobia  Hipokondria
 Depersonalisasi  Ide yang terkait  Pikiran magis

Waham
 Agama  Somatik  Kebesaran  Curiga
 Nihilistik  Sisip pikir  Siar pikir  Kontrol pikir
Jelaskan :
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Masalah Keperawatan :
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i. Tingkat Kesadaran
 Bingung  Sedasi  Stupor
Disorientasi :
 Waktu  Tempat  Orang
Jelaskan : .....................................................................................................................
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Masalah Keperawatan :
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j. Memori
 Gangguan daya ingat jangka  Gangguan daya ingat jangka
panjang pendek
  Gangguan daya ingat saat ini  Konfabulasi

Jelaskan :
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Masalah Keperawatan :
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k. Tingkat konsentrasi dan berhitung

 Mudah dialihkan  Tidak mampu  Tidak mampu
berkonsentrasi berhitung
Jelaskan :
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Masalah Keperawatan :
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l. Kemampuan penilaian
 Gangguan ringan  Gangguan bermakna

Jelaskan :
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Masalah Keperawatan :
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m. Daya tilik diri

 Mengingkari penyakit yang  Menyalahkan hal-hal di luar
diderita dirinya

Jelaskan :
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Masalah Keperawatan :
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VII. KEBUTUHAN PERSIAPAN PULANG

a. Kemampuan klien memenuhi/ menyediakan kebutuhan
Makanan
 Ya  Tidak

Keamanan
 Ya  Tidak

Tempat Tinggal
 Ya  Tidak

Perawatan Kesehatan
 Ya  Tidak

Pakaian
 Ya  Tidak

Transportasi
 Ya  Tidak

Uang
 Ya  Tidak
b. Kegiatan sehari-hari
1. Perawatan diri :
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2. Nutrisi
Frekuensi makan perhari :
Frekuensi kudapan perhari :
Nafsu Makan :
BB :
Diet Khusus :
3. Tidur
Apakah ada masalah ?
 Ya  Tidak
Apakah merasa segar setelah bangun tidur?
 Ya  Tidak
Apakah ada kebiasaan tidur siang?
 Ya  Tidak
Apa yang menolong anda untuk tidur?
 Ya  Tidak
Waktu tidur malam :
c. 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

d. Klien memiliki sistem pendukung

Keluarga
 Ya  Tidak
Tewan Sejawat
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Profesional/terapis
 Ya  Tidak
Kelompok sosial
 Ya  Tidak

e. Apakah klien menikmati saat bekerja, kegiatan yang menghasilkan atau hobi?
 Ya  Tidak

Masalah Keperawatan :
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VIII. MEKANISME KOPING

Adaptif Maladaptif
 Bicara dengan orang lain  Minum alkohol
 Mampu menyelesaikan masalah  Reaksi lambat/berlebihan
 Teknik relokasi  Bekerja berlebihan
 Aktivitas konstruktif  Menghindar
 Olahraga  Mencederai diri
 Lainnya  Lainnya
MasalahKeperawatan:
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IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

 Masalah dengan dukungan kelompok, uraikan
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 Masalah berhubungan dengan lingkungan, uraikan

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 Masalah dengan pendidikan, uraikan

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 Masalah dengan perumahan, uraikan

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 Masalah dengan ekonomi, uraikan

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 Masalah dengan pelayanan kesehatan, uraikan

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 Masalah lainnya, uraikan

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Masalah Keperawatan :

X. KURANG PENGETAHUAN TENTANG :

 Penyakit jiwa  Sistem pendukung
 Faktor presipitasi  Penyakit fisik
 Koping  Obat-obatan
 Lainnya : Tidak dikaji
Masalah Keperawatan :
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XI. ASPEK MEDIK

Diagnosa Medik Terapi Medik
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Jelaskan :
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XII. DAFTAR MASALAH KEPERAWATAN

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