ASUHAN KEPERAWATAN JIWA PADA .......

DENGAN MASALAH KEPERAWATAN ...........................................

DI PUSKESMAS ..................................
TANGGAL 11 – 28 MARET 2020\

I. PENGKAJIAN
A. Identitas Klien
Nama : ................................................................
Umur : ................................................................
Jenis Kelamin : ................................................................
Suku : ................................................................
Agama : ................................................................
Status Perkawinan : ................................................................
Alamat : ................................................................
Diagnosa Medis : ................................................................
Tanggal Dirawat : ................................................................
Tanggal Pengkajian : ................................................................

B. Keluhan Utama/Saat Dikaji

1. Keluhan Utama :
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2. Keluhan Saat Di Kaji :
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C. Faktor Predisposisi
1. Pernah mengalami gangguan jiwa
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2. Pengobatan sebelumnya
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 3. Aniaya fisik
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4. Anggota keluarga yang mengalami gangguan jiwa
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5. Pengalaman masa lalu yang tidak menyenangkan
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D. Pemeriksaan Fisik
1. Tanda-Tanda Vital
Tekanan Darah : ............... mmHg
Nadi : ............... X/Menit
Respirasi : ............... X/Menit
Suhu : ............... 0C
2. Antropometri
BB : ........... Kg
TB : ........... Cm
3. Keluhan Fisik
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E. Psikososial
1. Genogram
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Keterangan :

2. Konsep Diri
a. Citra Tubuh
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b. Identitas Diri
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c. Peran Diri
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d. Harga Diri
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e. Ideal Diri
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MK : .................................................................................................................
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3. Hubungan Sosial
a. Orang yang berarti
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 b. Hambatan dalam berhubungan dengan orang lain
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c. Peran serta dalam kelompok atau masyarakat
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4. Spiritual
a. Nilai dan Keyakinan
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b. Kegiatan Ibadah
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F. Status Mental
1. Penampilan
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2. Pembicaraan
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3. Aktifitas Motorik
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4. Alam Perasaan
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5. Afek
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6. Interaksi Selama Wawancara
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7. Persepsi
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8. Proses Pikir
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9. Isi Pikir
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10. Tingkat Kesadaran
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11. Memori
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12. Tingkat Konsentrasi dan Berhitung
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13. Kemampuan Penilaian
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14. Daya Tilik Diri
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G. Kebutuhan Di rumah
1. Makan
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2. Defekasi/Berkemih
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3. Mandi
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4. Berpakaian
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5. Istirahat dan Tidur
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6. Penggunaan Obat
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7. Pemeliharaan Kesehatan
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8. Aktifitas di Dalam Rumah

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9. Aktifitas di Luar Rumah
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H. Mekanisme Koping
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I. Masalah Psikososial dan Lingkungan
1. Masalah dengan Dukungan Kelompok
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2. Masalah dengan Lingkungan
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3. Masalah dengan Pendidikan
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4. Masalah dengan Pekerjaan
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5. Masalah dengan Perumahaan
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6. Masalah dengan Ekonomi
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7. Masalah dengan Pelayanan Kesehatan
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J. Pengetahuan
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K. Aspek Medik
1. Diagnosa Medik : .............................................................................................
2. Terapi Medik
a. .....................................................
b. .....................................................
c. .....................................................
d. .....................................................
e. .....................................................

L. Daftar Masalah Keperawatan

1. ...........................................................
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M. Pohon Masalah
II. DIAGNOSA KEPERAWATAN
A. Analisa Data
N DATA FOKUS MASALAH KEPERAWATAN
O
N DATA FOKUS MASALAH KEPERAWATAN
O
B. Daftar Diagnosa Keperawatan
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III. INTERVENSI KEPERAWATAN

Nama Klien : Puskesmas :
Alamat :

DX. RENCANA TINDAKAN KEPERAWATAN

KEP TUJUAN KRITERIA EVALUASI INTERVENSI

DX. RENCANA TINDAKAN KEPERAWATAN

KEP TUJUAN KRITERIA EVALUASI INTERVENSI
IV. IMPLEMENTASI DAN EVALUASI

TANGGA DX.
IMPLEMENTASI EVALUASI PARAF
L KEP
TANGGA DX.
IMPLEMENTASI EVALUASI PARAF
L KEP
 STRATEGI PELAKSANAAN TINDAKAN KEPERAWATAN

Masalah :
Pertemuan :
Tanggal :
Waktu :