ASUHAN KEPERAWATAN Tn.

A DENGAN
GANGGUAN PRESEPSI SENSORI : HALUSINASI PENGLIHATAN
DI RUANG KHUSUS PRIA RSJ SAMBANG LIHUM
BANJARMASIN

RUANG RAWAT: TANGGAL DIRAWAT:

I. IDENTITAS KLIEN
Inisial :…..................... (L) Tanggal Pengkajian : ….....................
Umur : …..................... No. RM : ….....................
Informan: ….....................

II. ALASAN MASUK

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Masalah Keperawatan:

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III. KELUHAN UTAMA (Keluhan saat ini)

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Masalah Keperawatan:

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IV. PEMERIKSAAN FISIK
1. Tanda vital : TD:.................... N:............... P:............. S:................
2. Ukur : TB:.................... BB:..............
3. Keluhan fisik ( ) Ya ( ) Tidak
Jelaskan :
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Masalah Keperawatan:

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V. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu? [ ] Ya [ ]Tidak
2. Pengobatan sebelumnya [ ] Berhasil, [ ], Kurang Berhasil, [ ] Tidak
Berhasil
3.
Pelaku / Korban/Usia Saksi/Usia
Usia
Aniya Fisik
Aniaya Seksual
Penolakan
Kekerasaan dalam
keluarga Tindakan
Kriminal

Jelaskan No. 1, 2, 3;

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Masalah Keperawatan:

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 4. Adakah anggota keluarga yang mengalami gangguan jiwa? ( ) Ya ( ) Tidak

Hubungan Keluarga Gejala 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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VI. FAKTOR PRESIPITASI (PSIKOSOSIAL)
1. Skema Genogram
Jelaskan Skema Genogram :

Masalah Keperawatan :

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2. Konsep Diri :
a. Gambaran Diri :

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b. Identitas :

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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 dalam kegiatan kelompok/ masyarakat:

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c. Hambatan dalam 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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VII. STATUS MENTAL

1. Penampilan
Tidak Penggunaaan Pakaian Cara berpakaian tidak
Rapi Tidak Sesuai sesuai
Jelaskan :
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Masalah Keperawatan :

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2. Pembicaraan
( ) Cepat ( ) Keras ( ) Gagap ( ) Inkoheren
( ) Apatis ( ) Lambat ( ) Membisu ( ) Tidak Mampu Memulai
Pembicaraan
Jelaskan :

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Masalah Keperawatan :

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3. Aktivitas Motorik
( ) Lesu ( ) Tegang ( ) Gelisah ( ) Agitasi
( ) Tik ( ) Grimasen ( ) Tremor ( ) Kompulsif
Jelaskan :

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Masalah Keperawatan :

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4. Alam Perasaan
( ) Sedih ( ) Ketakutan ( ) Putus Asa ( ) Khawatir
( ) Gembira berlebihan
Jelaskan :

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Masalah Keperawatan :

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5. Afek
( ) Datar ( ) Tumpul ( ) Labil ( ) Tidak Sesuai
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 Pikir
( ) Sirkumtansial ( ) Tangensial ( ) Gangguan Asosiasi
( ) Flight of Ideas( ) Blocking ( ) Pengulangan
Pembicaraan/ Perservarasi
Jelaskan :

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Masalah Keperawatan :
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9. Isi Pikir
( ) Obsesi ( ) Fobia ( ) Hipokondria
( ) Depersonalisasi ( ) Ide yang terkait ( ) Pikiran Magis

Waham
( ) Agama ( ) Somatik ( ) Kebesaran ( ) Curiga
( ) Nihilistik ( ) Sisip Pikir ( ) Siar Pikir ( )
Kontrol Pikir
Jelaskan :

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Masalah Keperawatan :

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10. Tingkat Kesadaran
( ) Bingung ( ) Sedasi ( ) Stupor
Disorientasi
( ) Waktu ( ) Tempat ( ) Orang
Jelaskan :

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Masalah Keperawatan :

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11. Memori
( ) Gangguan daya ingat jangka panjang( ) Gangguan daya ingat
jangka pendek
( ) Gangguan daya ingat saat ini ( ) 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
Jelaskan :

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Masalah Keperawatan :

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13. Kemampuan Penilaian
( ) Gangguan Ringan ( ) Gangguan

Bermakna Jelaskan :

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Masalah Keperawatan :

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 14. Daya Tilik Diri
( ) Mengingkari penyakit yang diderita ( ) Menyalahkan hal-hal diluar
dirinya Jelaskan :

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Masalah Keperawatan :

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VIII. KEBUTUHAN PERSIAPAN PULANG
1. Kemampuan pasien memenuhi/menyediakan kebutuhan:
Ya Tidak Ya Tidak
Makanan Pakaian
Keamanan Transportasi
Tempat tinggal Uang
Perawatan Kesehatan
Jelaskan :

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Masalah Keperawatan :

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2. Kegiatan hidup sehari-hari
a. Perawatan diri
 Bantuan Minimal Bantuan Total
Mandi
BAK/BAB
Kebersihan
Ganti pakaian
Makan
Jelaskan :

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Masalah Keperawatan:

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b. Nutrisi
Ya Tidak
 Apakah anda puas dengan pola makan anda?

 Apakah anda memisahkan diri?

Jika ya, jelaskan alasannya:

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 Frekuensi makan perhari..................................kali
 Frekuensi kudapan perhari..............................kali

Ya Tidak
 Nafsu makan
 BB
 Diet khusus

Jelaskan :

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 Masalah Keperawatan:

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c. Tidur
Ya Tidak
 Apakah ada masalah?
 Apakah anda merasa segar setelah bangun tidur
 Apakah anda memisahkan diri?
 Apa tang menolong anda untuk tidur?
 Waktu tidur malam, jam....................., waktu bangun,
jam:............................
 Beri tanda ”√” sesuai dengan keadaan pasien;
Sulit untuk tidur Terbangun saat tidur

Bangun terlalu pagi Gelisah saat tidur

Somnabulisme Berbicara dalam tidur

Jelaskan :

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Masalah Keperawatan:

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3. Kemampuan pasien dalam:
Ya Tida
k
 Mengantisipasi kebutuhan sendiri
 Membuat keputusan berdasarkan keinginan sendiri
 Mengatur penggunaan obat
 Melakukan pemeriksaan kesehatan (follow up)

Jelaskan :

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Masalah Keperawatan:

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4. Pasien memiliki sistem pendukung :
Ya Tidak Ya Tidak
Keluarga Teman sejawat

Profesional/terapis Kelompok sosial

Jelaskan :

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Masalah Keperawatan :

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5. Apakah pasien menikmati saat bekerja, kegiatan yang menghasilkan atau hobi

Ya Tidak

Jelaskan :

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Masalah Keperawatan :

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IX. MEKANISME KOPING
Adaptif Maladaptif
( ) Bicara dengan orang lain ( ) Minum alkohol
( ) Mampu menyelesaikan masalah ( ) Reaksi lambat/
berlebih ( ) Teknik relokasi ( )
Bekerja berlebihan
 ( ) Aktivitas konstruktif ( ) Menghindar
( ) Olahraga ( ) Mencederai diri
( ) Lainnya ( ) Lainnya

Jelaskan :

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Masalah Keperawatan :

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X. MASALAH PSIKOSOSIAL DAN LINGKUNGAN
( ) Masalah dengan dukungan kelompok, spesifik;

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( ) Masalah dengan lingkungan, spesifik;

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( ) Masalah dengan pendidikan, spesifik;

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( ) Masalah dengan pekerjaan, spesifik;

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( ) Masalah dengan perumahan, spesifik;

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 ( ) Masalah dengan ekonomi, spesifik;

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( ) Masalah dengan pelayanan kesehatan, spesifik ;

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( ) Masalah lainnya, spesifik ;

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Masalah Keperawatan :

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XI. PENGETAHUAN KURANG TENTANG:
( ) Penyakit Jiwa ( ) Sistem Pendukung
( ) Faktor Presipitasi ( ) Penyakit Fisik
( ) Koping ( ) Obat-obatan
( ) Lainnya :

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Masalah Keperawatan :

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XII. ASPEK MEDIK

Diagnosa Medik :

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Terapi Medik :

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No Nama Indikasi Kontra Efek Cara Kerja Konsiderasi
Obat indikasi samping Obat Perawat
XIII. DAFTAR MASALAH KEPERAWATAN

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 A. INTERVENSI KEPERAWATAN

N Tujuan & Hari/Tgl

Diagnosa Intervensi Implementasi
o Kriteria Hasil Jam
B. CATATAN PERKEMBANGAN

No
Hari/Tgl
Diagnos Evaluasi
Jam
a
 No Hari/Tgl Evaluasi
Diagnos Jam
a
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Mahasiswa

(Nama dan tanda tangan)

NIM :