TEXT BOOKS (MAIN)

Keliat, BA.& Akemat. (2007). Model Praktik Keperawatan Profesional Jiwa. Jakarta: Penerbit Buku
Kedokteran EGC.
NANDA International Nursing Diagnoses: Definitions and Classifications 2015 – 2017.
Stuart, G.W., and Sundeen, S.J. (1995). Principles and practice of psychiatric nursing. St. Louis:
Mosby Year Book.

OTHER SUPPORTING RESOURCES AND REFERENCES

Doenges, M.E., Townsend, M.C., and Moorhouse, M.F. (1998). Psychiatric care plans: guidelines for
individualizing care. ed. 3. Philadelphia: F.A. Davis Company, h. 155-216.

Fortinash, C.M., and Holloday, P.A. (1991). Psychiatric nursing care plan. St. Louis: Mosby Year
Book.

Keltner, N.L., Shuecke, L.H., and Bostrom, C.E. (1991). Psychiatric nursing: a psycho terapeutic
management approach. St. Louis: Mosby Year Book.

Townsend, M.C. (1996). Psychiatric mental health nursing: concepts of care. ed. 2. Philadelphia:
Davis Company.

Daftar Lampiran

Lampiran 1 Format & Contoh Pengkajian keperawatan Asuhan Keperawatan Psikososial (RS)
Lampiran 2 Rubrik Laporan pengkajian mental emosional terintegrasi (RS)
Lampiran 3 Format Pengkajian, Penilaian dan Kelengkapan (RSMM)
 Lampiran-1
PENGKAJIAN KEPERAWATAN
ASUHAN KEPERAWATAN PSIKOSOSIAL

Nama mhs/klp : ........................................ ........................................

Tgl/jam pengkajian : ........................................ Tgl/jam MRS : ........................................
Sumber data : …………………………. No. RM : ........................................
Metode : ………………………… Ruangan/kelas : ........................................
Alat/bahan : ………………………… No.kamar : ........................................
Diagnosa medis : ........................................

I. IDENTITAS
1. Nama : ...............................................................................................................................

2. Umur : ...............................................................................................................................

3. Jenis kelamin : ...............................................................................................................................

4. Status : ...............................................................................................................................

5. Agama : ...............................................................................................................................

6. Suku/bangsa : ...............................................................................................................................

7. Bahasa : ...............................................................................................................................

8. Pendidikan : ...............................................................................................................................

9. Pekerjaan : ...............................................................................................................................

10. Alamat dan no. telp : ...............................................................................................................................

11. Penanggung jawab : ...............................................................................................................................

& hubgan dg klien

II. POLA PERSEPSI KESEHATAN ATAU PENANGANAN KESEHATAN
1. Keluhan utama :

2. Riwayat penyakit sekarang :

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

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

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

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

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

3. Lamanya keluhan

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

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

4. Faktor yang Memperberat

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

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

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

5. Upaya yang Dilakukan Untuk Mengatasi Keluhan

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

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

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

6. Riwayat penyakit dahulu :

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

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

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

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

7. Persepsi klien tentang status kesehatan dan kesejahteraan

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

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

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

8. Riwayat kesehatan keluarga :

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

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

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

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

9. Susunan keluarga (genogram) :

 10. Riwayat alergi :

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

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

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

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

III. POLA NUTRISI DAN METABOLIK

1. Pola makan

Di rumah Di rumah sakit

Frekuensi : ......................... Frekuensi : ..................................

Jenis : ......................... Jenis : ..................................

Porsi : ......................... Porsi : ..................................

Pantangan : ......................... Diit khusus : ..................................

Makanan disukai : .........................

Nafsu makan di RS : ( ) normal ( ) bertambah ( ) berkurang

( ) mual ( ) muntah, .............. cc ( ) stomatitis

Kesulitan menelan : ( ) tidak ( ) ya

Gigi palsu : ( ) tidak ( ) ya

NG tube : ( ) tidak ( ) ya

(JIKA MAKAN-MINUM BIASA (TANPA NGT) SEJAUH MANA KEMAMPUANNYA

2. Pola minum

Di rumah Di rumah sakit

Frekuensi : ......................... Frekuensi : ..................................

Jenis : ......................... Jenis : ..................................

Jumlah : ......................... Jumlah : ..................................

Pantangan : .........................

Minuman disukai : .........................

IV. POLA ELIMINASI

1. Buang air besar

Di rumah Di rumah sakit

Frekuensi : .................................. Frekuensi : ..................................

Konsistensi : .................................. Konsistensi : ..................................

Warna : .................................. Warna : ( ) kuning

( ) bercampur darah

( ) lainnya, ..............

Masalah di RS : ( ) konstipasi ( ) diare ( ) inkontinen

Kolostomi : ( ) tidak ( ) ya
 2. Buang air kecil

Di rumah Di rumah sakit

Frekuensi : .................................. Frekuensi : ..................................

Jumlah : .................................. Jumlah : ..................................

Warna : .................................. Warna : ..................................

Masalah di RS : ( ) disuria ( ) nokturia ( ) hematuria

( ) retensi ( ) inkontinen

Kateter : ( ) tidak ( ) ya, kateter ........................... produksi : .................. cc/hari

V. POLA AKTIVITAS DAN LATIHAN

1. Kemampuan perawatan diri

SMRS MRS
Aktivitas
0 1 2 3 4 0 1 2 3 4

Mandi

Berpakaian/berdandan

Eliminasi/toileting

Mobilitas di tempat tidur

Berpindah

Berjalan

Naik tangga

Berbelanja

Memasak

Pemeliharaan rumah

Skor 0 = mandiri 3 = dibantu orang lain & alat

1 = alat bantu 4 = tergantung/tidak mampu

2 = dibantu orang lain

Alat bantu : ( ) tidak ( ) kruk ( ) tongkat ( ) pispot disamping tempat tidur ( ) kursi roda

2. Kebersihan diri

Di rumah Di rumah sakit

Mandi : ........................  /hr Mandi : ........................  /hr

Gosok gigi : ........................  /hr Gosok gigi : ........................  /hr

Keramas : ....................  /mgg Keramas : ....................  /mgg

Potong kuku : ....................  /mgg Potong kuku : ....................  /mgg

3. Aktivitas sehari-hari

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

4. Rekreasi
 ...................................................................................................................................................................................

5. Olahraga : ( ) tidak ( ) ya

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

VI. POLA ISTIRAHAT DAN TIDUR

Di rumah Di rumah sakit

Waktu tidur : Siang ..............-............... Waktu tidur : Siang ..............-...............

Malam ............-............... Malam ............-...............

Jumlah jam tidur : ................................................... Jumlah jam tidur : ....................................................

Masalah di RS : ( ) tidak ada ( ) terbangun dini ( ) mimpi buruk

( ) insomnia ( ) Lainnya, . ..........................................................................................

VII. POLA KOGNITIF DAN PERSEPTUAL

Berbicara : ( ) normal ( ) gagap ( ) bicara tak jelas

Bahasa sehari-hari : ( ) Indonesia ( ) Jawa ( ) lainnya, ..........................................

Kemampuan membaca : ( ) bisa ( ) tidak

Tingkat ansietas : ( ) ringan ( ) sedang ( ) berat ( ) panik

Sebab, ............................................................................................................

Kemampuan interaksi : ( ) sesuai ( ) tidak, ............................................................................

Vertigo : ( ) tidak ( ) ya

Nyeri : ( ) tidak ( ) ya

Bila ya, P : ....................................................................................................................................................

Q : ....................................................................................................................................................

R : ....................................................................................................................................................

S : ....................................................................................................................................................

T : ....................................................................................................................................................

VIII. POLA PERSEPSI DIRI / KONSEP DIRI

1. Body image/gambaran diri

( ) cacat fisik ( ) pernah operasi

( ) perubahan ukuran fisik ( ) proses patologi penyakit

( ) fungsi alat tubuh terganggu ( ) kegagalan fungsi tubuh

( ) keluhan karena kondisi tubuh ( ) gangguan struktur tubuh

( ) transplantasi alat tubuh ( ) menolak berkaca

( ) prosedur pengobatan yang mengubah fungsi alat tubuh

( ) perubahan fisiologis tumbuh kembang

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

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

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

2. Role/peran

( ) overload peran ( ) perubahan peran ( ) transisi peran karena sakit

( ) konflik peran ( ) keraguan peran

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

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

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

3. Identity/identitas diri

( ) kurang percaya diri ( ) merasa kurang memiliki potensi

( ) merasa terkekang ( ) kurang mampu menentukan pilihan

( ) tidak mampu menerima perubahan ( ) menolak menjadi tua

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

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

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

4. Self esteem/harga diri

( ) mengkritik diri sendiri dan orang lain ( ) menyangkal kepuasan diri

( ) merasa jadi orang penting ( ) polarisasi pandangan hidup

( ) menunda tugas ( ) mencemooh diri

( ) merusak diri ( ) mengecilkan diri

( ) menyangkal kemampuan pribadi ( ) keluhan fisik

( ) rasa bersalah ( ) menyalahgunakan zat

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

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

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

5. Self ideal/ideal diri

( ) masa depan suram

( ) terserah pada nasib

( ) merasa tidak memiliki kemampuan

( ) tidak memiliki harapan

( ) tidak ingin berusaha

( ) tidak memiliki cita-cita

( ) merasa tidak berdaya

( ) enggan membicarakan masa depan

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

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

IX. POLA PERAN DAN HUBUNGAN

Pekerjaan : ...................................................................................................................

Kualitas bekerja : ...................................................................................................................

Hubungan dengan orang lain :

Sistem pendukung : ( ) pasangan ( ) tetangga/teman ( ) tidak ada

( ) lainnya, ................................................................................................

Masalah keluarga mengenai perawatan di RS : ........................................................................................................

X. POLA SEKSUALITAS / REPRODUKSI

Menstruasi terakhir : ...............................................................................................................................

Masalah menstruasi : ...............................................................................................................................

Pap smear terakhir : ...............................................................................................................................

Pemeriksaan payudara/testis sendiri tiap bulan : ( ) ya ( ) tidak

Masalah seksual yang berhubungan dengan penyakit : ....................................................................

XI. POLA KOPING / TOLERANSI STRESS

1. Masalah utama selama MRS (penyakit, biaya, perawatan diri)
...................................................................................................................................................................................

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

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

2. Kehilangan perubahan yang terjadi sebelumnya

a. Tahap Denial/Penolakan
( ) penolakan terhadap situasi
( ) tidak percaya pada orang lain
( ) merasa tertekan
( ) wawasan sempi
 Jelaskan : .......................................................................................................................................................

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

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

b. Tahap Anger/Marah
( ) marah pada diri sendiri
( ) marah pada orang lain
( ) meningkatnya kesadaran klien pada realita
Jelaskan : .................................................................................................................................
...................................................................................................................................................................................

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

3. Kemampuan adaptasi

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

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

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

XII. POLA NILAI / KEPERCAYAAN

Agama : ................................................................................................

Pelaksanaan ibadah : ................................................................................................

Pantangan agama : ( ) tidak ( ) ya, ................................................................

Meminta kunjungan rohaniawan : ( ) tidak ( ) ya

XIII. PENGKAJIAN PERSISTEM (Review of System)

1. Tanda-Tanda Vital

a. Suhu : ................... °C lokasi : ......................

b. Nadi : ...................  /menit irama : ...................... pulsasi : ......................

c. Tekanan darah : ................... mmHg lokasi : ......................

d. Frekuensi nafas : ...................  /menit irama : ......................

e. Tinggi badan : ................... cm

f. Berat badan : SMRS ................... kg MRS .................... kg

2. Sistem Pernafasan (Breath)

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

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

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

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

3. Sistem Kardiovaskuler (Blood)

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

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

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

4. Sistem Persarafan (Brain)

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

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

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

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

5. Sistem Perkemihan (Bladder)

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

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

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

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

6. Sistem Pencernaan (Bowel)

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

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

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

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

7. Sistem Muskuloskeletal (Bone)

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

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

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

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

8. Sistem Integumen

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

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

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

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

9. Sistem Penginderaan

Mata

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

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

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

Hidung

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

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

Telinga

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

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

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

10. Sistem Reproduksi Dan Genetalia

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

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

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

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

XIV. PEMERIKSAAN PENUNJANG

1. Laboratorium

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

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

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

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

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

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

2. Photo

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

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

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

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

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

3. Lain-lain

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

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

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

XV. TERAPI
...................................................................................................................................................................................

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

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

...................................................................................................................................................................................
 ANALISA DATA

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. RM : ..............................................

No. Data (Symptom) Penyebab (Etiologi) Masalah (Problem)

 PRIORITAS MASALAH

Nama klien : .............................................. Ruangan/kamar : ..............................................

Umur : .............................................. No. RM : ..............................................

Tanggal Paraf
No. Masalah Keperawatan
Ditemukan Teratasi (Nama perawat)

RENCANA KEPERAWATAN

No. Diagnosa Keperawatan Tujuan dan Kriteria Intervensi Rasional

Hasil
N0 Gangguan Risiko Sehat

1 Gangguan sensori persepsi: Ansietas Kesiapan

halusinasi perkembangan bayi
2 Isolasi sosial Gangguan citra tubuh Kesiapan
perkembangan
kanak-kanak

3 Harga diri rendah kronik Harga diri rendah situasional Kesiapan

perkembangan pra
sekolah
4 Risiko perilaku kekerasan Koping tidak efektif Kesiapan
perkembangan usia
sekolah
5 Defisit perawatan diri Koping keluarga tidak efektif Kesiapan
perkembangan
remaja

6 Waham Keputusasaan Kesiapan

perkembangan
dewasa

7 Risiko bunuh diri Berduka Kesiapan

perkembangan lansia

15 | FORMAT MHN
 FORMULIR PENGKAJIAN KEPERAWATAN KESEHATAN JIWA
RUANGAN RAWAT ___________________ TANGGAL DIRAWAT ______________

I. IDENTITAS KLIEN
Nama : _____________ (L/P) Tanggal Pengkajian : _______________
Umur : _______________ RM No. : ______________
Informan : _________________

II. ALASAN MASUK DAN FAKTOR PENCETUS

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

III. FAKTOR PREDISPOSISI

1. Pernah mengalami gangguan jiwa di masa 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 :
_______________________________________________________________________

Masalah Keperawatan : ____________________________________________________

16 | FORMAT MHN
 4. Adakah anggota keluarga yang mengalami gangguan jiwa Ya Tidak

Hubungan keluarga Gejala Riwayat pengobatan/perawaran

_______________________ _______________ _______________________

_______________________ _______________ _______________________

Masalah Keperawatan : _________________________________________________________

5. Pengalaman masa lalu yang tidak menyenangkan

___________________________________________________________________________________

___________________________________________________________________________________

Masalah Keperawatan ________________________________________________________________

IV. FISIK
1. Tanda vital : TD : __________ N : ________ S : _________ P : _______________

2. Ukur : TB : __________ BB : ________

3. Keluhan fisik : Ya Tidak

Jelaskan : ______________________________________________________________

Masalah keperawatan : _______________________________________________________________

V. PSIKOSOSIAL

1. Genogram

Jelaskan : _______________________________________________________________
Masalah Keperawatan : _______________________________________________________________

2. Konsep diri
a Gambaran diri : _______________________________________________________________
_______________________________________________________________
b. Identitas : _______________________________________________________________
_______________________________________________________________
c. Peran (role performance): ______________________________________________________________
_______________________________________________________________

17 | FORMAT MHN
 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 berbuhungan 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 Cara berpakaian tidak seperti

tidak sesuai biasanya
Jelaskan : ______________________________________________________________________

Masalah Keperawatan :
____ ____________________________________________________________________________

2. Pembicaraan

Cepat Keras Gagap Inkoheren

Apatis Lambat Membisu Tidak mampu memulai

Pembicaraan

Loghorea Echolalia

Jelaskan : _________________________________________________________________ ________

Masalah Keperawatan : ______________________________________________________________

18 | FORMAT MHN
3. Aktivitas Motorik:

Lesu Tegang Gelisah Agitasi

Tik Grimasen Tremor Kompulsif

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : _______________________________________________

4. Alam perasaaan

Sedih Ketakutan Putus asa Khawatir Gembira berlebihan

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : _____________________________________________________________

5. Afek

Datar Tumpul Labil Tidak sesuai

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : _____________________________________________________________

6. lnteraksi selama wawancara

Bermusuhan Tidak kooperatif Mudah tersinggung

Kontak mata (-) Defensif Curiga

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

7. Persepsi : halusinasi

Pendengaran Penglihatan Perabaan

Pengecapan Penghidu

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

8. Proses Pikir

sirkumtansial tangensial kehilangan asosiasi

19 | FORMAT MHN
 flight of idea blocking pengulangan pembicaraan/persevarasi

neologisme

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

9. Isi Pikir

Obsesi Fobia Hipokondria

depersonalisasi ide yang terkait pikiran magis

Waham

Agama Somatik Kebesaran Curiga

Nihilistic Sisip pikir Siar pikir Kontrol pikir

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 : ______________________________________________________________

20 | FORMAT MHN
12. Tingkat konsentrasi dan berhitung

mudah beralih tidak mampu konsentrasi 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 diluar dirinya

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

VII. Kebutuhan Persiapan Pulang

1. Makan

Bantuan minimal Bantuan total

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

2. BAB/BAK

Bantuan minimal Bantual total

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

3. Mandi

Bantuan minimal Bantuan total

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

21 | FORMAT MHN
4. Berpakaian/berhias

Bantuan minimal Bantual total

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

5. Istirahat dan tidur

Tidur siang lama : ………………….s/d…………………………

Tidur malam lama : …………………s/d…………………………

Kegiatan sebelum / sesudah tidur

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

6. Penggunaan obat

Bantuan minimal Bantual total

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

7. Pemeliharaan Kesehatan

Perawatan lanjutan Ya tidak

Perawatan pendukung Ya tidak

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

8. Kegiatan di dalam rumah

Mempersiapkan makanan Ya tidak

Menjaga kerapihan rumah Ya tidak

Mencuci pakaian Ya tidak

Pengaturan keuangan Ya tidak

22 | FORMAT MHN
 Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

9. Kegiatan di luar rumah

Belanja Ya tidak

Transportasi Ya tidak

Lain-lain Ya tidak

Jelaskan : __________________________________________________________________________

Masalah Keperawatan : ______________________________________________________________

VIII. Mekanisme Koping

Adaptif Maladaptif

Bicara dengan orang lain Minum alkohol

Mampu menyelesaikan masalah Reaksi lambat/berlebih

Teknik relaksasi Bekerja berlebihan

Aktivitas konstruktif Menghindar

Olahraga Mencederai diri

Lainnya _______________ lainnya : __________________

Masalah Keperawatan : ______________________________________________________________

IX. Masalah Psikososial dan Lingkungan:

Masalah dengan dukungan kelompok, spesifik ________________________________________

______________________________________________________________________________

Masalah berhubungan dengan lingkungan, spesifik _____________________________________

______________________________________________________________________________

Masalah dengan pendidikan, spesifik ________________________________________________

______________________________________________________________________________

Masalah dengan pekerjaan, spesifik _________________________________________________

23 | FORMAT MHN
 ______________________________________________________________________________

Masalah dengan perumahan, spesifik ________________________________________________

______________________________________________________________________________

Masalah ekonomi, spesifik _________________________________________________________

______________________________________________________________________________

Masalah dengan pelayanan kesehatan, spesifik ________________________________________

______________________________________________________________________________

Masalah lainnya, spesifik __________________________________________________________

______________________________________________________________________________

Masalah Keperawatan : _________________________________________________________________

X. Pengetahuan Kurang Tentang:

Penyakit jiwa system pendukung

Faktor presipitasi penyakit fisik

Koping obat-obatan

Lainnya : ______________________________________________________________________

Masalah Keperawatan : ________________________________________________________________

Analisa Data

Data Dx Keperawatan

Subjektif ...................................... ........................................................

......................................
......................................
Objektif ......................................
......................................
.......................................

Subjektif ...................................... ........................................................

......................................
Objektif: .....................................
......................................
......................................

dst

XI. Aspek Medik

Diagnosa Medik : _____________________________________________________________________

24 | FORMAT MHN
 _____________________________________________________________________
_____________________________________________________________________
Terapi Medik : _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

XII. Daftar Masalah Keperawatan

_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

XIII. Daftar Diagnosis Keperawatan ( sesuai urutan prioritas )

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

_____________,______________
Praktikan,

25 | FORMAT MHN
 RENCANA TINDAKAN KEPERAWATAN

INISIAL KLIEN: ___________ RUANGAN: ____________

No. RM: ___________

Tgl/ No. Dx. Keperawatan Rencana Keperawatan

Waktu Dx Tujuan Umum Tujuan Khusus Intervensi Rasional

26 | FORMAT MHN
 IMPLEMENTASI DAN EVALUASI TINDAKAN KEPERAWATAN

INISIAL KLIEN: ___________ RUANGAN: ____________

No. RM: ___________

No. DIAGNOSA Tgl/Waktu IMPLEMENTASI EVALUASI Tanda Tangan

Dx KEPERAWATAN

27 | FORMAT MHN
28 | FORMAT MHN
29 | FORMAT MHN
 LAPORAN PENDAHULUAN

I. Kasus (masalah utama):

II. Proses terjadinya masalah:

III. A. Pohon Masalah

A. Masalah keperawatan dan data yang perlu dikaji

IV. Diagnosa Keperawatan

V. Rencana Tindakan Keperawatan

30 | FORMAT MHN
 LAPORAN PENDAHULUAN
STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN SETIAP HARI

I. Proses Keperawatan
1. Kondisi Klien:

2. Diagnosa Keperawatan:

3. Tujuan Khusus:

4. Tindakan Keperawatan:

II. Proses Pelaksanaan Tindakan

ORIENTASI
1. Salam terapeutik :

2. Evaluasi/Validasi:

___________________________________________________________________

_______________________________________________________________

3. Kontrak:
Topik:
Waktu:
Tempat:

KERJA
______________________________________________________________________

______________________________________________________________________

________________________________________________________________

____________________________________________________________________

TERMINASI
1. Evaluasi respon klien terhadap tindakan keperawatan
a. Evaluasi Subjektif:

31 | FORMAT MHN
 b. Evaluasi Objektif

2. Tindak lanjut (apa yang perlu dilatih oleh klien sesuai hasil tindakan yang telah
dilakukan)
___________________________________________________________________

_______________________________________________________________

3. Kontrak yang akan datang:

Topik:
Waktu:
Tempat:

32 | FORMAT MHN
 RENCANA TERAPI AKTIFITAS KELOMPOK

A. TOPIK : ..........................................................................................................................

B. TUJUAN
1. Tujuan Umum : ………………………...........................................................
2. Tujuan Khusus :
a. …………………………………………………………………………………..
b. …………………………………………………………………………………..
c. …………………………………………………………………………………..

C. LANDASAN TEORITIS (memberikan justifikasi bahwa TAK dibutuhkan pada kondisi

klien yang akan dilibatkan)

D. KLIEN
1. Karakteristik/kriteria
2. Proses seleksi

E. PENGORGANISASIAN
1. Waktu : tanggal, hari, jam, waktu yang dibutuhkan untuk tiap langkah tindakan
2. Tim terapis: leader, co leader, fasilitiator, observer
3. Metoda dan media

F. PROSES PELAKSANAAN
1. Orientasi
a. Salam perkenalan
b. Penjelasan tujuan dan aturan main

2. Kerja
a. Langkah-langkah kegiatan

3. Terminasi
a. Evaluasi respon subjektif klien
b. Evaluasi respon objektif klien (observasi perilaku klien selama kegiatan dikaitkan
dengan tujuan)
c. Tindak lanjut (apa yang dapat klien lakukan setelah TAK)
d. Kontrak yang akan datang

33 | FORMAT MHN
34 | FORMAT MHN