ASUHAN KEPERAWATAN

PADA Tn...... DENGAN GANGGUAN RESIKO PERILAKU KEKERASAN

DI RUANG MURAI A RSKJ BENGKULU

Tanggal pengkajian :....................jam :................

Oleh :............................................

I. IDENTITAS KLIEN
Nama :.........................................................................................................
Jenis Kelamin :.........................................................................................................
Alamat :.........................................................................................................
Umur :.........................................................................................................
Agama :.........................................................................................................
Status Perkawinan :.........................................................................................................
Pendidikan :.........................................................................................................
Pekerjaan :.........................................................................................................
NO CM :.........................................................................................................
II. ALASAN MASUK
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III. FAKTOR PREDISPOSISI
a. Mengalami gangguan dimasa lalu?
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b. Pengobatan sebelumnya (Berhasil/Tidak Berhasil)

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c. Trauma
Jenis Trauma:
a. Aniaya fisik :...............................................................................................................
b. Aniaya seksual : .........................................................................................................
c. Penolakan : .................................................................................................................
d. Kekerasan dalam RT :.................................................................................................
e. Tindakan Kriminal : ...................................................................................................
IV. PEMERIKSAAN FISIK
1. Tanda Vital : TD :..............mmHg
N :..............x/menit S :.......ºC P : .............x/menit
2. Ukuran
BB :.........Kg TB:.......cm
3. Keluhan fisik : .....................................................................................................................
Diagnosa keperawatan :
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V. PSIKOSOSIAL
1. Genogram

Diagnosa
Keperawatan ..........................................................................................................................
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2. Konsep Diri
a. Gambaran diri
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b. Identitas diri
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c. Peran diri
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d. Ideal diri
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 e. Harga diri
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Diagnosa Keperawatan
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3. Hubungan Sosial
a. Orang yang berarti : ...........................................................................................................
b. Peran serta kegiatan kelompok/masyarakat : ....................................................................
c. Hambatan dalam berhubungan dengan orang lain : ..........................................................
Diagnosa Keperawatan
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4. Spiritual
a. Nilai dan keyakinan :.........................................................................................................
b. Kegiatan ibadah : ..............................................................................................................

Dignosa Keperawatan

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VI. STATUS MENTAL
a. Penampilan :..........................................................................................................
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Diagnosa Keperawatan
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b. Pembicaraan :..........................................................................................................
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Diagnosa Keperawatan
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c. Aktifitas Motorik :..........................................................................................................

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Diagnosa Keperawatan
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d. Afek dan emosi

1. Alam Perasaan :..........................................................................................................
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Diagnosa Keperawatan
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2. Afek :..........................................................................................................
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Diagnosa Keperawatan
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e. Interaksi selama wawancara :...........................................................................................

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Diagnosa Keperawatan
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f. Persepsi sensori :..........................................................................................................

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Diagnosa Keperawatan
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g. Proses Pikir :..........................................................................................................

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Diagnosa Keperawatan
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h. Tingkat kesadaran :..........................................................................................................

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Diagnosa Keperawatan
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i. Memori :..........................................................................................................
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Diagnosa Keperawatan
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 j. Tingkat konsentrasi dan berhitung :.................................................................................
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Diagnosa Keperawatan
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k. Keterampilan penilaian :..................................................................................................

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l. Daya titik diri :...................................................................................................
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Diagnosa Keperawatan
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VII.KEBUTUHAN PERSIAPAN PULANG

1. Kemampuan Klien Memenuhi Kebutuhan
a. Makan :..........................................................................................................
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b. Keamanan :..........................................................................................................
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c. Perawatan kesehatan :......................................................................................................
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d. Berpakaian :..........................................................................................................
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e. Transportasi :..........................................................................................................
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f. Tempat tinggal :..........................................................................................................
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g. Keuangan :..........................................................................................................
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h. Lain-lain :..........................................................................................................
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Diagnosa Keperawatan
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2. Kegiatan Hidup Sehari-Hari
a. Mandi :..........................................................................................................
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b. Kebersihan :..........................................................................................................
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c. Makan :..........................................................................................................
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d. BAK :..........................................................................................................
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e. BAB :..........................................................................................................
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f. Ganti pakaian :..........................................................................................................
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VIII. MEKANISME KOPING
a. Adaktif
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b. Maladaktif
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Diagnosa Keperawatan
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IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN

a. Masalah Dukungan kelompok
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b. Masalah Berhubungan
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Diagnosa Keperawatan
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c. Masalah Dengan Pendidikan
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Diagnosa Keperawatan
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d. Masalah Dengan Perumahan
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Diagnosa Keperawatan
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X. KURANG PENGETAHUAN
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XI. ASPEK MEDIS
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XII.DIAGNOSA KEPERAWATAN
a. ...........................................................................................................................................
b. ...........................................................................................................................................
c. ...........................................................................................................................................
d. ...........................................................................................................................................
e. ..........................................................................................................................................
f. ...........................................................................................................................................
 ANALISA DATA
Nama :...................................................... No. CM :..............................................
Umur :...................................................... DX Medis :..............................................

No Hari/Tgl/Jam Data Fokus Masalah Etiologi Diagnosa

DS :............................................................
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DO :...........................................................
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DO :...........................................................
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TINDAKAN KEPERAWATAN (IMPLEMENTASI) DAN EVALUASI

Nama:....................................... No. CM:..................................................
 Umur:........................................ Dx. Medis:...............................................

No
Hari/Tgl/Jam IMPLEMENTASI EVALUASI TTD
DX
Tindakan:............................................................................................................ S :..........................................................................................
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RTL:................................................................................................................... A :..........................................................................................
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Tindakan:............................................................................................................ S :..........................................................................................
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RTL:................................................................................................................... A :..........................................................................................
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Tindakan:............................................................................................................ S :..........................................................................................
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RTL:................................................................................................................... A :..........................................................................................
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No
Hari/Tgl/Jam IMPLEMENTASI EVALUASI TTD
DX
Tindakan:............................................................................................................ S :..........................................................................................
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RTL:................................................................................................................... A :..........................................................................................
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Tindakan:............................................................................................................ S :..........................................................................................
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RTL:................................................................................................................... A :..........................................................................................
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Tindakan:............................................................................................................ S :..........................................................................................
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RTL:................................................................................................................... A :..........................................................................................
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