Scribd Logo
Unggah

Selamat datang di Scribd!

  • PENGKAJIAN KEPERAWATAN JIWA Edit

    Diunggah oleh

    Eka
    12 tayangan18 halaman

    Judul Asli

    PENGKAJIAN KEPERAWATAN JIWA edit.doc

    Hak Cipta

    © © All Rights Reserved

    Format Tersedia

    DOC, PDF, TXT atau baca online dari Scribd

    Apakah menurut Anda dokumen ini bermanfaat?

    Apakah konten ini tidak pantas?

    Laporkan Dokumen Ini

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    12 tayangan18 halaman

    PENGKAJIAN KEPERAWATAN JIWA Edit

    Diunggah oleh

    Eka

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 18

    PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

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


    TANGGAL DIRAWAT : ...............................................................................................................

    I. IDENTITAS KLIEN
    Inisial : ...........................................................................................................................
    Jenis Kelamin : ............................................................................................................................
    Umur : ............................................................................................................................
    No. RM : ............................................................................................................................
    Tgl Pengkajian : ............................................................................................................................
    Informan : ............................................................................................................................

    II. KELUHAN UTAMA


    ...............................................................................................................................................................
    ...............................................................................................................................................................
    III. ALASAN MASUK
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ................................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    ...............................................................................................................................................................
    IV. FAKTOR PREDISPOSISI
    1. Pernah mengalami gangguan jiwa dimasa lalu ?
     Ya
     Tidak
    2. Pengobatan sebelumnya
     Berhasil
     Kurang berhasil
     Tidak berhasil
    3. Trauma Pelaku/Usia Korban/Usia Saksi/Usia
     Aniaya fisik : ........... ........... ........... ........... ........... ...........
     Aniaya seksual : ........... ........... ........... ........... ........... ...........
     Penolakan : ........... ........... ........... ........... ........... ...........
     Kekerasan dalam
    keluarga : ........... ........... ........... ........... ........... ...........
     Tindakan criminal : ........... ........... ........... ........... ........... ...........
    Jelaskan : .................................................................................................................
    .................................................................................................................................................
    .................................................................................................................................................
    .................................................................................................................................................
    .................................................................................................................................................
    .................................................................................................................................................
    Masalah Keperawatan :......................................................................................................
    4. Anggota keluarga yang gangguan jiwa ?
     Ada
     Tidak
    Kalau ada :
    Hubungan keluarga : ..................................................................................................................
    Gejala : ..................................................................................................................
    Riwayat pengobatan : ..................................................................................................................
    ......................................................................................................................
    ......................................................................................................................
     Masalah Keperawatan :..........................................................................................................
    5. Pengalaman masa lalu yang tidak menyenangkan :
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
     Masalah Keperawatan :.........................................................................................................

    V. PEMERIKSAAN FISIK

    1. TTV : TD : ...............mmHg N : ...............X/mnt S : ...............°C P : ...............X/mnt


    2. Ukur : BB : ...............kg, TB : ...............cm
    3. Keluhan fisik : ..............................................................................................................................
    ..............................................................................................................................
    ..............................................................................................................................
    ..............................................................................................................................
    ..............................................................................................................................
     Masalah Keperawatan :......................................................................................................
    VI. PSIKOSOSIAL
    1. Genogram :
    Jelaskan :............................................................................................................................................
    ..............................................................................................................................................
    ..............................................................................................................................................
    ..............................................................................................................................................
    ..............................................................................................................................................
    ..............................................................................................................................................
    ..............................................................................................................................................
    ..............................................................................................................................................
    ..............................................................................................................................................
    ..............................................................................................................................................
     Masalah Keperawatan :.........................................................................................................
    2. Konsep diri
    a. Citra
    tubuh : ...............................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    ...................................................................................................................................................
    b. Identitas : ..................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................

    c. Peran : ......................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    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 berhubungan dengan orang lain : ..................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
     Masalah Keperawatan:......................................................................................................
    4. Spiritual
    a. Nilai dan keyakinan : ................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
    b. Kegiatan
    ibadah : ........................................................................................................
    ...............
    ....................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
     Masalah Keperawatan:......................................................................................................
    VII. STATUS MENTAL
    1. Penampilan
     Tidak rapi
     Penggunaan pakaian tidak sesuai
     Cara berpakaian tidak seperti biasanya
    Jelaskan : .........................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
     Masalah Keperawatan:.............................................................................................................
    2. Pembicaraan
     Cepat
     Keras
     Gagap
     Inkoherensi
     Lambat
     Membisu
     Tidak mampu memulai pembicaraan
    Jelaskan : .........................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
     Masalah Keperawatan:.............................................................................................................
    3. Aktivitas Motorik
     Lesu
     Tegang
     Gelisah
     Agitasi
     Tik
     Grimasem
     Tremor
     Kompulsif
    Jelaskan : .........................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
     Masalah Keperawatan:.............................................................................................................
    4. Alam perasaan
     Sedih
     Ketakutan
     Putus asa
     Khawatir
     Gembira berlebihan
    Jelaskan :..........................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
     Masalah Keperawatan:...........................................................................................................
    5. Afek
     Datar
     Tumpul
     Labil
     Tidak sesuai
    Jelaskan : .........................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
     Masalah Keperawatan:...........................................................................................................
    6. Interaksi selama wawancara
     Bermusuhan
     Tidak kooperatif
     Mudah tersinggung
     Kontak mata kurang
     Defensive
     Curiga
    Jelaskan : .........................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
     Masalah Keperawatan:...........................................................................................................

    7. Persepsi
    Halusinasi :
     Pendengaran
     Penglihatan
     Perabaan
     Pengecapan
     Penghidu/penciuman
    Jelaskan :..........................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
     Masalah Keperawatan : ..........................................................................................................
    8. Isi pikir
     Obsesi
     Phobia
     Hipokondria
     Depersonalisasi
     Ide yang terkait
     Pikiran magis
    Waham :
     Agama
     Somatik
     Kebesaran
     Curiga
     Nihilistic
     Sisip pikir
     Siar pikir
     Kontrol pikir
    Jelaskan : .........................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
     Masalah Keperawatan : ..........................................................................................................

    9. Arus pikir
     Sirkumstansial
     Tangensial
     Kehilangan asosiasi
     Flight of idea
     Blocking
     Pengulangan pembicaraan/perseverasi
    Jelaskan : ..................................................................................................................................
    ...................................................................................................................................................
    ....................................................................................................................................................
    ....................................................................................................................................................
     Masalah Keperawatan : ..........................................................................................................
    10. Tingkat Kesadaran
     Bingung
     Sedasi
     Stupor
     Disorientasi waktu
     Disorientasi orang
     Disorientasi tempat
    Jelaskan : ..................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
     Masalah Keperawatan : ........................................................................................................
    11. Memori
     Gangguan daya ingat jangka panjang
     Gangguan daya ingat jangka pendek
     Gangguan daya ingat saat ini
     Konfabulasi
    Jelaskan : ..................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
     Masalah Keperawatan : ..........................................................................................................

    12. Tingkat konsentrasi dan berhitung


     Mudah beralih
     Tidak mampu berkonsentrasi
     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 : ..........................................................................................................
    VIII. KEBUTUHAN PERSIAPAN PULANG
    Bantuan Minimal Bantuan Total
    1. Makan : ............. .............
    2. BAB/BAK : ............. .............
    3. Mandi : ............. .............
    4. Berpakaian/Berhias: ............. .............
    5. Istirahat dan Tidur :
     Tidur Siang lama : ............. s/d .............
     Tidur Malam lama : ............. s/d .............
     Kegiatan sebelum/sesudah tidur : ........................................................................................
    ..............................................................................................................................................
    Bantuan Minimal Bantuan Total
    6. Penggunaan Obat : ............. .............
    7. Pemeliharaan Kesehatan : Ya Tidak
     Perawatan Lanjutan : ............. .............
     Perawatan Pendukung : ............. .............
    8. Kegiatan di dalam rumah : Ya Tidak
     Mempersiapkan makanan : ............. .............
     Menjaga kerapihan rumah : ............. .............
     Mencuci pakaian : ............. .............
     Pengaturan pakaian : ............. .............
    9. Kegiatan di luar rumah : Ya Tidak
     Belanja : ............. .............
     Transportasi : ............. .............
     Lain-lain : ............. .............
    Jelaskan :...................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
     Masalah Keperawatan : ..........................................................................................................
    ...................................................................................................................................................
    VIII. MEKANISME KOPING
    Adaftif Mal Adaftif
    ......... Bicara dengan orang lain ......... Minum Alkohol
    ......... Mampu menyelesaikan masalah ......... Reaksi lambat/berlebih
    ......... Teknik relokasi ......... Bekerja berlebihan
    ......... Aktivitas konstruktif ......... Menghindar
    ......... Olah raga ......... Mencederai diri
    ......... Lainnya ......... Lainnya
     Masalah Keperawatan : ..........................................................................................................
    ...................................................................................................................................................
    ...................................................................................................................................................
    IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
    o Masalah dengan dukungan kelompok, spesifik...............................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    o Masalah berhubungan dengan lingkungan, spesifik........................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    o Masalah dengan pendidikan, spesifik.............................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    o Masalah dengan pekerjaan, spesifik.................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    o Masalah dengan perumahan, spesifik..............................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................

    o Masalah dengan ekonomi, spesifik.................................................................................................


    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    o Masalah dengan pelayanan kesehatan, spesifik...............................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    o Masalah lainnya, spesifik.................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
     Masalah Keperawatan : ................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    X. PENGETAHUAN KURANG TENTANG
     Penyakit jiwa
     Faktor presifitasi
     Koping
     Sistem pendukung
     Penyakit fisik
     Obat-obatan
     Lainnya.............................................................................................................................................
    ..........................................................................................................................................................
     Masalah keperawatan :..................................................................................................................
    ..........................................................................................................................................................

    ANALISA DATA
    Data Subjektif Data Objektif Masalah
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    ANALISA DATA
    Data Subjektif Data Objektif Masalah
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................
    .............................................................. .............................................................. ......................................

    XI. ASPEK MEDIK


     Diagnosa
    medik : .............................................................................................................................
    ..........................................................................................................................................................
     Terapi medik:
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    .........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    ..........................................................................................................................................................
    .........................................................................................................................................................
    XII. DAFTAR MASALAH KEPERAWATAN
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    XIII. DAFTAR DIAGNOSIS KEPERAWATAN
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................
    .........................................................................................................................................................

    Mahasiswa,

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

    Anda mungkin juga menyukai