5 Format Pengkajian Keperawatan
5 Format Pengkajian Keperawatan
KESEHATAN JIWA
I. IDENTITAS KLIEN
Nama : …………………….. (L/P)
Umur : …………….. ………
Alamat : ………………………
Pendidikan : .....................................
Agama : ....................................
Status : ....................................
Pekerjaan : ………………………
JenisKel. : ………………………
No CM : ………………………
I. ALASAN MASUK
a. DataPrimer
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
b. DataSekunder
..........................................................................................................................................
..........................................................................................................................................
c. KeluhanUtamaSaatPengkajian
..........................................................................................................................................
c. Peran:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
d. Ideal diri:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
e. Hargadiri:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
DiagnosaKeperawatan :
3. HubunganSosial
a. Orang yang berarti/terdekat
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
b. Peransertadalamkegiatankelompok/masyarakat dan hubungan sosial
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
c. Hambatandalamberhubungandengan orang lain
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan :
4. Spiritual
a. Nilaidankeyakinan
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
b. Kegiatanibadah
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan:
Peningkatan :
Hiperkinesia,hiperaktifitas Grimace
Stereotipi Otomatisma
GaduhGelisahKatatonik Negativisme
Mannarism Reaksikonversi
Katapleksi Tremor
Tik Verbigerasi
Ekhopraxia Berjalankaku/rigid
Command automatism Kompulsif :sebutkan …………
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan:
4. Mood dan Afek
a. Mood
Depresi Khawatir
Ketakutan Anhedonia
Euforia Kesepian
Lain lain
Jelaskan
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
b. Afek
Sesuai Tidaksesuai
Tumpul/dangkal/datar Labil
Jelaskan:
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
DiagnosaKeperawatan
5. InteraksiSelamaWawancara
Bermusuhan Kontakmatakurang
Tidakkooperatif Defensif
Mudahtersinggung Curiga
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan
6. PersepsiSensorik
a. Halusinasi
Pendengaran
Penglihatan
Perabaan
Pengecapan
Penciuman
b. Ilusi
Ada
Tidakada
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
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:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
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:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
c. Bentuk pikir :
Realistik
Non realistik
Dereistik
Otistik
Jelaskan:
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
DiagnosaKeperawatan:
8. Kesadaran
Orientasi (waktu, tempat, orang)
Jelaskan:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Meninggi
Menurun:
Kesadaranberubah
Hipnosa
Confusion
Sedasi
Stupor
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan:
9. Memori
Gangguandayaingatjangkapanjang ( > 1 bulan)
Gangguandayaingatjangkamenengah ( 24 jam - ≤ 1 bulan)
Gangguandayaingatpendek (kurunwaktu 10 detiksampai 15 menit)
Jelaskan:
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
DiagnosaKeperawatan:
10. Tingkat KonsentrasidanBerhitung
a. Konsentrasi
Mudahberalih
Tidakmampuberkonsentrasi
Jelaskan:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
b. Berhitung
Jelaskan:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
DiagnosaKeperawatan:
11. KemampuanPenilaian
Gangguanringan
Gangguanbermakna
Jelaskan :
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan:
12. DayaTilikDiri
Mengingkaripenyakit yang diderita
Menyalahkanhal-haldiluardirinya
Jelaskan:
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
...........................................................................................................................................
DiagnosaKeperawatan:
2) Berpakaian, berhiasdanberdandan
Jelaskan :
......................................................................................................................
......................................................................................................................
......................................................................................................................
3) Makan
Jelaskan :
......................................................................................................................
......................................................................................................................
......................................................................................................................
4) Toileting (BAK, BAB)
Jelaskan :
......................................................................................................................
......................................................................................................................
......................................................................................................................
DiagnosaKeperawatan:
b. Nutrisi
Berapafrekwensimakandanfrekwensikudapandalamsehari.
............................................................................................................................
............................................................................................................................
Bagaimananafsumakannya
............................................................................................................................
............................................................................................................................
Bagaimanaberatbadannya.
............................................................................................................................
............................................................................................................................
DiagnosaKeperawatan:
c. Tidur
1) Istirahatdantidur
Tidursiang, lama : ____________ s/d _____________
Tidurmalam, lama : _____________ s/d _____________
Aktifitassebelum/sesudahtidur : __________ , _________
Jelaskan
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
2) Gangguantidur
Insomnia
Hipersomnia
Parasomnia
Lain lain
Jelaskan
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
DiagnosaKeperawatan:
VII.MEKANISME KOPING
Jelaskan :
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
DiagnosaKeperawatan:
3. Terapi Medis
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
NO DATA DIAGNOSA
KEPERAWATAN
1. DS:
................................................................................................................................................
................................................................................................................................................
DO:
................................................................................................................................................
................................................................................................................................................
2. DS:
................................................................................................................................................
................................................................................................................................................
DO:
................................................................................................................................................
................................................................................................................................................
3. DS:
................................................................................................................................................
................................................................................................................................................
DO:
................................................................................................................................................
................................................................................................................................................
4. DS:
................................................................................................................................................
................................................................................................................................................
DO:
................................................................................................................................................
................................................................................................................................................
dst DS:
................................................................................................................................................
................................................................................................................................................
DO:
................................................................................................................................................
................................................................................................................................................
XI. DAFTAR DIAGNOSA KEPERAWATAN
1. ………………………………………
2. ………………………………………
3. ………………………………………
4. ………………………………………
5. ………………………………………
6. ………………………………………
7. ………………………………………
8. dst
Lawang, ……………………….
Mahasiswa yang mengkaji
____________________
NIM................................
TINDAKAN KEPERAWATAN JIWA
Nama : Ruang :
No CM : Unit :
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