Yayasan Pendidikan Nur Medika

SMK KESEHATAN NUR MEDIKA SURABAYA

KOMPETENSI KEAHLIAN : KEPERAWATAN – FARMASI – ANALIS
KESEHATAN
Jl. Simo Pomahan I No. 4, 8-10B Tlp. 031–7324023/70505779 SURABAYA – 60181
BERJIWA WIRAUSAHA, CERDAS, SIAP KERJA, KOMPETITIF, & MEMIIKI JATI DIRI BANGSA

ASUHAN KEPERAWATAN KESEHATAN JIWA

RUANG RAWAT :................................ TANGGAL RAWAT

:................................

I. IDENTITAS PASIEN
Inisial :...........................(L/P) Tanggal Pengkajian :..............................
Umur :........................... Informan :..............................
Alamat :........................... Ruang :..............................
II. ALASAN MASUK
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
III. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa dimasa lalu ? Ya Tidak
2. Pengobatan sebelumnya : Berhasil Kurang Berhasil Tidak Berhasil
3. Adakah anggota keluarga yang mengalami gangguan jiwa Ya Tidak
4. Pengalaman masa lalu yang tidak menyenangkan :
.......................................................................................................................
.......................................................................................................................
IV. PEMERIKSAAN FISIK
1. Tanda Vital : TD :............ N :........... S :............... RR :.................
2. Ukur : TB :........... BB :...........
3. Keluhan Fisik : Ya Tidak
Jelaskan :......................................................................................................
....................................................................................................................
...................................................................................................................
V. PSIKOSOSIAL
1. Genogram :

Jelaskan :...................................................................................................
.....................................................................................................................
 2. Konsep diri
a. Gambaran diri :..........................................................................
...........................................................................
b. Identitas :..........................................................................
..........................................................................
c. Peran :...........................................................................
d. Ideal diri :..........................................................................
...........................................................................
e. Harga diri :.........................................................................
..........................................................................
3. Hubungan Sosial :
a. Orang yang berarti :.........................................................................
b. Hambatan dalam berhubungan dengan orang lain :
.............................................................................................................
.............................................................................................................
4. Spiritual :
a. Nilai dan Keyakinan :
.............................................................................................................
............................................................................................................
b. Kegiatan ibadah :
............................................................................................................
VI. STATUS MENTAL
1. Penampilan :
Tidak rapi Penggunaan pakaian Cara berpakaian
Tidak sesuai tidak seperti biasanya
2. Pembicaraan
Cepat Keras Gagap

Membisu Lambat Tidak mampu memulai pembicaraan

Jelaskan :.................................................................................................
..................................................................................................

3. Aktifitas Motorik
Lesu Gelisah

Tremor Tegang
Jelaskan : ................................................................................................
..................................................................................................
4. Alam Perasaan :
Sedih Ketakutan Putus asa Khawatir Gembira berlebih
Jelaskan :................................................................................................
.................................................................................................

5. Interaksi selama wawancara :

Bermusuhan Tidak Kooperatif Mudah tersinggung
 Kontak mata kurang Curigaan
Jelaskan :..............................................................................................
6. Memori :
G Gangguan daya ingat panjang
a
n Gangguan daya ingat pendek
g
g Gangguan daya ingat saat ini
u
7. Tingkat
a konsentrasi dan berhitung :
nG Mudah beralih
a
dn Tidak mampu berkonsentrasi
G
ag
Tidak mampu berhitung sederhana
G
nyg
VII. KEGIATAN aga HIDUP SEHARI – HARI
u
a. Perawatan n
ga Diri :
Mandi g
uin :......................................................................................
BAB/ g
an BAK :.....................................................................................
u
Kebersihan dng :.....................................................................................
Ganti a
aa Pakaian :.....................................................................................
n
Makan ydt :.....................................................................................
Minum aa obat :....................................................................................
b. Nutrisi d
yp :
a
Nafsu ia Makan :....................................................................................
BB y
nn :....................................................................................
Diet a
i
gj Khusus :....................................................................................
c. Tidur naa :
Waktu ign tidur jam :....................................................................................
t
Apa n
ag ada gangguan tidur :...........................................................................
Apa gt terbiasa tidur siang :...........................................................................
p
Apa aG gelisah saat akan tidur :......................................................................
a
VIII. SISTEM tpa PENDUKUNG PASIEN
n
Keluarga anj :..............................................................................................
Teman p
nga :..............................................................................................
Terapis a
jgn :.............................................................................................
Kelompok n
aug sosial :.................................................................................
Hobi naG j :............................................................................................
agn
a
n
n
IX. MEKANISME gG
dg KOPING
Adaptif ag Maladaptif
Bicara G
nyu dengan orang lain Minum Alkohol
aga G
a a
n
G gnMampu menyelesaikan masalah G
n
Reaksi lambat/ berlebih
gui
a ag
Teknik gan relaksasi Bekerja berlebihan
nG d nG
g
ung
ga a gau
aa G
G

gn y gna
G
ndt
ug a augn
ag a ag
 G
G
Aktifitas teratur Menghindar
G
a
Olah raga G Mencederai diri
G G
G

nG
G

ga a
X. MASALAH PSIKOSOSIAL DAN LINGKUNGAN n
gn
Masalah dengan dukungan kelompok g :.............................................
ug
..........................................................................................................
g
ag
Masalah berhubungan dengan lingkungan u :................................
nu
..........................................................................................................
a
a
Masalah dengan pendidikan n :.............................................
dn
..........................................................................................................
a
Masalah dengan pekerjaan d :.............................................
yd
..........................................................................................................
a
aa
Masalah dengan perumahan y :.............................................
y
..........................................................................................................
a
ia
Masalah Ekonomi :............................................
n
.........................................................................................................
i
gi
Masalah dengan pelayanan kesehatann :............................................
an
.........................................................................................................
g
tg
Masalah lainnya :...........................................
a
a
.........................................................................................................
t
pt
XI. DAFTAR MASALAH YANG MUNCUL
a
1. ...............................................................................................................
p
np
2. ................................................................................................................
a
ja
3. ................................................................................................................
n
an
4. ................................................................................................................
j
nj
ga a Surabaya, ..................
n n
g g Siswa,
G
a (.................................)
nG G
ga a
gn n
ug g
ag g
nu u
XII. RENCANA
a TINDAKAN PERAWATAN a
No
dn Hari/Tanggal/Jam n Rencana tindakan
a
yd d
aa a
y y
ia a
n
gi i
an n
tg g
a a
pt t
a
np p
XIII. PELAKSANAAN
No Hari/Tanggal/Jam Pelaksanaan tindakan
XIV. EVALUASI
No Hari/Tanggal/Jam Evaluasi
 Yayasan Pendidikan Nur Medika
SMK KESEHATAN NUR MEDIKA SURABAYA
KOMPETENSI KEAHLIAN : KEPERAWATAN – FARMASI – ANALIS
KESEHATAN
Jl. Simo Pomahan I No. 4, 8-10B Tlp. 031–7324023/70505779 SURABAYA – 60181
BERJIWA WIRAUSAHA, CERDAS, SIAP KERJA, KOMPETITIF, & MEMIIKI JATI DIRI BANGSA
 ASUHAN KEPERAWATAN GERONTIK/ LANSIA

Tanggal Pengkajian :..........................................

A. DATA BIOGRAFI
Nama : ............................................................L/ P
Tempat/ Tanggal Lahir : ................................................................................
Pendidikan terakhir : ................................................................................
Agama : ................................................................................
Status Perkawinan : .................................................................................
TB/ BB : ................................Cm / ..............................Kg
Penampilan : ................................................................................
Ciri- ciri tubuh : ................................................................................
Alamat : ................................................................................
.................................................................................
.................................................................................
Orang yang dekat yang bisa dihubungi :.......................................................L/ P
Hubungan dengan Klien : ...............................................................................
Alamat : ...............................................................................
..............................................................................
Telp : ......................................................................

B. RIWAYAT KELUARGA
Genogram :

Keterangann :

C. PEMERIKSAAN FISIK HEAD TO TOO

Keadaan Umum Klien : ..........................................Kesadaran : ...................

Tanda Vital : TD : ............ N: ................. S: .................. RR : .......................

I. KEPALA
Rambut :

 Warna : ..........................................................................................
 Bentuk : ..........................................................................................
Kulit kepala :

 Lesi : ...........................................................................................
 Ketombe : ...........................................................................................
Bentuk wajah : ..........................................................................................

Mata :

 Bentuk : ...........................................................................................
 Sklera : ...........................................................................................
 Pupil : ...........................................................................................
 Kornea : ...........................................................................................
 Conjungtiva : ...........................................................................................
Hidung :

 Bentuk : ..........................................................................................
 Konka : .........................................................................................
 Secret : .........................................................................................
Telinga :

 Bentuk : ..........................................................................................
 Serumen : .........................................................................................
 Thympani : .........................................................................................
Mulut :

 Bentuk : .......................................................................................
 Mukosa bibir : .......................................................................................
 Gigi : .......................................................................................
 Faring : ......................................................................................
 Laring : ......................................................................................
 Uvula : ......................................................................................
 Lidah : ......................................................................................

Leher :

 Bentuk : ................................................................................................
 JVP : ................................................................................................
 Thyroid : ................................................................................................
II. DADA & PUNGGUNG
 Inspeksi : ................................................................................................
 Auskultasi : ................................................................................................
 Perkusi : ................................................................................................
 Palpasi : ................................................................................................
III. PERUT & PINGGANG
 Inspeksi : ................................................................................................
 Auskultasi : ................................................................................................
 Perkusi : ................................................................................................
 Palpasi : ................................................................................................
IV. EKSTREMITAS ATAS & BAWAH

Kekuatan otot : ................................................................................................

Fratur : ...............................................................................................

Luka/ lecet : ...............................................................................................

Lumpuh : ...............................................................................................

Kesemutan : ...............................................................................................

Kelemahan : ...............................................................................................

V. SISTEM IMUN

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

VI. GENETALIA

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

VII. SISTEM REPRODUKSI

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

VIII. SISTEM PENGECAP

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

IX. SISTEM PENCIUMAN

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

X. OBAT- OBATAN
Nama obat Dosis Keterangan
XI. ALERGI
Obat- obatan : ........................................................................................
Makanan : ........................................................................................
Lingkungan : .......................................................................................
XII. PENYAKIT YANG DIDERITA
Hipertensi Rheumatoid Asma Dimensia

Penyakit lainnya : ..........................................................................................

XIII. AKTIVITAS SEHARI – HARI
 Perawatan Diri :
Mandi :......................................................................................
BAB/ BAK :.....................................................................................
Kebersihan :.....................................................................................
Ganti Pakaian :.....................................................................................
Makan :.....................................................................................
Minum obat :....................................................................................
 Nutrisi :
Nafsu Makan :....................................................................................
BB :....................................................................................
Diet Khusus :....................................................................................
 Tidur :
Waktu tidur jam :....................................................................................
Apa ada gangguan tidur :...........................................................................
Apa terbiasa tidur siang :...........................................................................
Apa gelisah saat akan tidur :......................................................................

XIV. DATA PENUNJANG

Laborat/ foto thoraks/ USG/ ECG dll bila ada jelaskan :
...................................................................................................................
..................................................................................................................
....................................................................................................................
.................................................................................................................
XV. DAFTAR MASALAH
1. ................................................................................................................
2. ................................................................................................................
3. ...............................................................................................................
4. ................................................................................................................
 Surabaya, ..................

Siswa,

(.................................)

XVI. RENCANA TINDAKAN PERAWATAN

No Hari/Tanggal/Jam Rencana tindakan
XVII. PELAKSANAAN
No Hari/Tanggal/Jam Pelaksanaan tindakan
XVIII. EVALUASI
No Hari/Tanggal/Jam Evaluasi