SISTIMATIKA PENYUSUNAN LAPORAN KEPERAWATAN KESEHATAN JIWA

STIKES RANA WIJAYA

FORMAT LAPORAN PENDAHULUAN

A. KASUS (MASALAH UTAMA)

B. PROSES TERJADINYA MASALAH

1. Pengertian masalah utama
2. Rentang respon
3. Manifestasi klinik
4. Kemungkinan penyebab
5. Kemungkinan akibat bila masalah utama tidak teratasi

C. MASALAH KEPERAWATAN DAN DATA YANG PERLU DIKAJI

D. DIAGNOSA KEPERAWATAN (NANDA)

E. RENCANA TINDAKAN (NCP : NOC, NIC)

 FORMAT LAPORAN
STRATEGI PELAKSANAAN (SP)

A. PROSES KEPERAWATAN
1. Kondisi klien :
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2. Diagnosa keperawatan (NANDA) :
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3. Tujuan (NOC) :
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4. Tindakan keperawatan (NIC) :
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B. STRATEGI KOMUNIKASI
1. Fase Orientasi
Salam
terapeutik : .....................................................................................................................
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Evaluasi / validasi data :
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Tujuan :
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Kontrak :
Topik : ...............................................................................................................
Waktu : ...............................................................................................................
Tempat : ...............................................................................................................
Privasi : ...............................................................................................................

2. Fase Kerja (langkah-langkah tindakan keperawatan)

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3. Fase Terminasi
Evaluasi subyektif dan obyektif :
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Rencana Tindak Lanjut (RTL) :

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Kontrak yang akan datang :
Topik : ...............................................................................................................
Waktu : ...............................................................................................................
Tempat : ...............................................................................................................
 FORMAT PENGKAJIAN KEPERAWATAN KESEHATAN JIWA

Ruang rawat : .......... Tanggal rawat : ..........

I. IDENTITAS
Nama (Inisial) :
L/P :
Umur :
Alamat :
Pendidikan :
Agama :
No.RM :
Tgl Pengkajian :

II. ALASAN MASUK

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III. FAKTOR PREDIPOSISI

1. Pernah mengalami gangguan jiwa di masa lalu? □ya□tidak

2. Pengobatan sebelumnya : □ berhasil □belum berhasil□ tidak berhasil
3. Trauma :
Jenis Trauma Usia Pelaku Korban Saksi
Aniaya Fisik
Aniaya Seksual
Penolakan
Kekerasan dalam
 keluarga
Tindakan kriminal
Lain-lain

Jelaskan No 1,2,3 : ......................................................................................................

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Masalah keperawatan :
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4. Adakah anggota keluarga yang mengalami gangguan jiwa? □ada□tidak ada

Bila ada hubungan keluarga
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Gejala : .................................................................................
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Riwayat pengobatan / perawatan
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Masalah keperawatan :
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5. Pengalaman masa lalu yang tidak menyenangkan?
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Masalah keperawatan :
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IV. PEMERIKSAAN FISIK
a. Tanda Vital : TD: .......... HR: .........S: .......... RR: .........

b. Ukur : TB: cm, BB: kg, □ naik□ turun

c. Keluhan Fisik : □ada□tidak ada
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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V. PSIKOSOSIAL
1. Genogram

Keterangan:

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

1. Penampilan :

□Tidak rapi
 □Penggunaan pakaian tidah sesuai
□Cara berpakaian tidak seperti biasanya
□lain-lain
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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2. Pembicaraan :

□Cepat □Keras □Gagap

□Inkoherensi □Apatis □Lambat
□Membisu □Tidak mampu memulaiBerbicara □lain-lain
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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3. Aktivitas Motorik :

□Lesu □Tegang □Gelisah

□Agitasi □ TIK □Grimasen
□Tremor □Kompulsif □lain-lain
 Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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4. Alam Perasaan (emosi) :

□Sedih □Ketakutan □Putus asa

□Khawatir □Gembira □Lain-lain
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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5. Afek :

□Datar □Tumpul □Labil

□Tidak sesuai □Lain-lain
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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6. Interaksi selama wawancara :

□Bermusuhan □Tidak Kooperatif □Mudah tersinggung

□Kontak mata kurang □Defensif □Curiga
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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7. Persepsi – Halusinasi :

□Pendengaran □Penglihatan □Perabaan

□Pengecapan □Penghidu
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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8. Proses piker :

□Sirkumstansial □ Tangensial □Kehilangan Asosia

□Flight of Idea □Blocking □Perseverasi
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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9. Isi Pikir :

□Obsesi □Fobia □Hipokondria

□Depersonalisasi □Ide yang terkait □Pikiran magis
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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10. Tingkat Kesadaran :

 □Binggung □Sedasi □Stupor
Adakah Gangguan orientasi ( disorientasi ) :

□Waktu □Orang □Tempat

Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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11. Memori :

□Gangguan daya ingat jangka panjang

□Gangguan daya ingat jangka menengah
□Gangguan daya ingat jangka pendek
□Konfabulasi
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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12. Tingkat Konsentrasi dan Berhitung :

□Mudah beralih □Tidak mampu berkonsentrasi

□Tidak mampu berhitung sederhana □Lain-lain
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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 13. Kemampuan Penilaian :

□Gangguan ringan □Gangguan bermakna

□Lain-lain
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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14. Daya Tilik Diri :

□Mengingkari penyakit yang diderita

□Menyalahkan hal-hal diluar dirinya
□lain-lain
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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VII.KEBUTUHAN PERSIAPAN PULANG

1. Kemampuan klien memenuhi kebutuhan:
Kemampuan memenuhi kebutuhan Ya Tidak
Mempersiapkan makanan
Menjaga kerapian rumah
Perawatan kesehatan
Mencuci pakaian
Pengaturan keuangan
Belanja
Transportasi
Lain-lain
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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2. Kegiatan hidup sehari-hari (ADL)
a. Perawatan diri:
Kegiatan hidup sehari-hari Bantuan total Bantuan minimal
Mandi
Kebersihan
Makan
Buang air kecil / BAK
Buang air besar / BAB
Ganti pakaian

Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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b. Nutrisi :
 Apakah puas dengan pola makan?

□Puas □Tidak puas

 Apakah makan memisahkan diri?

□Ya □Tidak
 Frekuensi makan sehari : ..........x
 Nafsu makan :

□Meningkat □Menurun □Berlebihan □Sedikit

 Berat badan :

□Meningkat □Menurun
BB saat ini : ...........Kg, BB terendah : ..........KG, BB tertinggi : ............KG
Jelaskan: ............................................................................................................................
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Masalah keperawatan :
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 c. Istirahat dan tidur :
 Apakah ada masalah tidur ?

□Ada □Tidak ada

 Apakah merasa segar setelah bangun tidur ?

□Segar □Tidak segar

 Apakah ada kebiasaan tidur siang ?

□Ya , lamanya : .........jam □Tidak

 Apakah ada yang menolong anda mempermudah untuk tidur ?

 □Ada □Tidak ada

 Tidur malam jam : .........bangun jam : .........rata-rata tidur malam : ........jam
 Apakah ada gangguan pola tidur ?

□Sulit untuk tidur □Samnambulisme □Gelisah saat tidur

□bangun terlalu pagi □Terbangun saat tidur□Berbicara saat tidur
Jelaskan: ....................................................................................................................
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Masalah keperawatan :
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3. Kemampuan klien dalam hal-hal berikut ini:

 Mengantisipasi kehidupan sehari-hari :

□Ya □Tidak
 Membuatkeputusan berdasarkan keinginan sendiri :

□Ya □Tidak
 Mengatur penggunaan obat :

□Ya □Tidak
 Melakukan pemeriksaan kesehatan :

Perawatan lanjutan □Ya □Tidak

Sistem pendukung □Ya □Tidak
 Jelaskan: ...........................................................................................................................
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Masalah keperawatan :
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VIII. MEKANISME KOPING

Adaptif Maladaptif
Berbicara dengan orang lain Minum alkohol
Mampu menyelesaikan Masalah Reaksi lambat/berlebih
Teknik relaksasi Bekerja berlebihan
Aktifitas konstruktif Menghindar dari orang lain
Olah raga Mencederai diri
Lain-lain Lain-lain

Jelaskan: ................................................................................................................................
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Masalah keperawatan :
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IX. MASALAH PSIKOSOSIAL DAN LINGKUNGAN :

□Masalah dengan dukungan kelompok, spesifiknya .....................................................

□Masalah berhubungan dengan lingkungan, spesifiknya ..............................................
□Masalah dengan Pendidikan, spesifiknya ...................................................................
□Masalah dengan Pekerjaan, spesifiknya ......................................................................
□Masalah dengan perumahan, spesifiknya ....................................................................
□Masalah dengan Ekonomi, spesifiknya .......................................................................
□Masalah dengan pelayanan Kesehatan, spesifiknya ....................................................
Masalah keperawatan :
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X. KURANG PENGETAHUAN TENTANG:
Apakah klien mempunyai masalah yang berkaitan dengan pengetahuan yang kurang tentang
suatu hal?

□Penyakit jiwa □Faktor presipitasi □Sistem pendukung

□Penyakit fisik □Koping □Obat-obatan
□lain-lain
Jelaskan: .....................................................................................................................................
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Masalah keperawatan :
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XI. ASPEK MEDIS

Diagnosa
medis :......................................................................................................................................
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Terapi medis :
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Laboratorium :
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Masalah keperawatan :
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XII.DATA FOKUS
DATA SUBYEKTIF DATA OBYEKTIF
XIII. ANALISA DATA
No DATA ETIOLOGI PROBLEM
1. Subyektif
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Obyektif
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2. Subyektif
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Obyektif
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XIV. DAFTAR DIAGNOSA KEPERAWATAN (PRIORITAS)

1. ....................................................................................................................................
2. ...................................................................................................................................
3. ...................................................................................................................................

XV. RENCANA INTERVENSIKEPERAWATAN

NO DIAGNOSA NOC NIC
TGL/JA KEPERAWATAN
M
 XVI. IMPLEMENTASI DAN EVALUASI KEPERAWATAN
NO DIAGNOSA IMPLEMENTASI EVAULASI
TGL/JA KEPERAWATAN
M
S :
O:
A:
P:
- Pasien:
- Perawat:

FORMAT LAPORAN
ANALISIS PROSES INTERAKSI (API)

Inisial Klien : Nama Mahasiswa :

Tahap Penanganan : Tanggal Interaksi :
Tujuan Interaksi : Interaksi Ke :
Deskripsi Klien : Waktu :

N KOMUNIKA KOMUNIKA ANALISA ANALISA RASIONAL

O SI SI BERPUSAT BERPUSAT
VERBAL NON PADA KLIEN PADA PERAWAT
VERBAL
1. P: P : K: P :
K:
2. P: P : K: P :
K:
3. P: P : K: P :
K:
4. P: P : K: P :
K:
5. P: P : K: P :
K:
 FORMAT LAPORAN
RESUME KEPERAWATAN JIWA

1. PENGKAJIAN
A. IDENTITAS KLIEN
Nama (Inisial) :
L/P :
Umur :
Alamat :

Pendidikan :
Agama :
No. RM :
Tgl Pengkajian :

B. ALASAN MASUK
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C. PEMERIKSAAN FISIK
Keadaan umum :

TD :

Nadi :

Respirasi :

Suhu :

Keluhan fisik :

D. DATA FOKUS
DATA SUBYEKTIF DATA OBYEKTIF
E. ANALISA DATA

N DATA ETIOLOGI PROBLEM

o
1.

2.
F. DAFTAR DIAGNOSA KEPERAWATAN (PRIORITAS)
1. ....................................................................................................................................
2. ....................................................................................................................................

G. RENCANA INTERVENSI KEPERAWATAN

NO DIAGNOSA NOC NIC

TGL/JAM KEPERAWATAN
H. IMPLEMENTASI DAN EVALUASI KEPERAWATAN
NO DIAGNOSA IMPLEMENTASI EVAULASI
TGL/JA KEPERAWATAN
M
I. RENCANA TINDAK LANJUT
 FORMAT MAKALAH
SEMINAR ASUHAN KEPERAWATAN

HALAMAN JUDUL
PENGESAHAN
KATA PENGANTAR
DAFTAR ISI
BAB I : PENDAHULUAN
A. LATAR BELAKANG
B. TUJUAN
 C. RUANG LINGKUP
BAB II : TINJAUAN TEORI
A. PENGERTIAN
B. RENTANG RESPON
C. ETIOLOGI
D. TANDA DAN GEJALA
E. FAKTOR PREDISPOSISI DAN PRESIPITASI
F. TINGKAH LAKU
G. MEKANISME KOPING
H. RENCANA INTERVENSI KEPERAWATAN
BAB III : TINJAUAN KASUS
A. PENGKAJIAN
B. DATA FOKUS
C. ANALISA DATA
D. PERUMUSAN DIAGNOSA BERDASARKAN PRIORITAS
E. PERENCANAAN
F. IMPLEMENTASI
G. EVALUASI
BAB IV : PEMBAHASAN
BAB V : PENUTUP
DAFTAR PUSTAKA
LAMPIRAN

FORMAT MAKALAH
TERAPI AKTIVITAS KELOMPOK

A. PELAKSANAAN
Topik :
Sasaran :
Hari /Tanggal :
Jam :
Topik :

B. TUJUAN
1. TUJUAN UMUM :
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2. TUJUAN KHUSUS :
 a. ..............................................................................................................................
b. ..............................................................................................................................

C. TINJAUAN TEORI

D. KLIEN
1. Karakteristik / Kriteria
2. Proses Seleksi

E. PENGORGANISASIAN
1. Waktu : tanggal, hari, jam, lama tiap langkah kegiatan
2. Tim Terapis : leader, co leader, fasilitator, observer
3. Setting tempat
4. Metode dan media

F. PROSES PELAKSANAAN
1. PRA INTERAKSI
2. ORIENTASI
a. Salam terapeutik :
b. Evaluasi / validasi data :
c. Penjelasan tujuan dan aturan main :
d. Kontrak :
Topik : ...............................................................................................................
Waktu : ...............................................................................................................
Tempat : .................................................................................................
3. KERJA
Langkah-langkah kegiatan
4. TERMINASI
Evaluasi subyektif dan obyektif :
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Rencana Tindak Lanjut (RTL) apa yang akan dilakukan setelah TAK:
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Kontrak yang akan datang :
Topik : ...............................................................................................................
Waktu : ...............................................................................................................
Tempat : ...............................................................................................................

G. EVALUASI DAN DOKUMENTASI