Kelas Reguler
LOGBOOK PERTEMUAN 02
Penugasan 2.1: Proses Keperawatan Kesehatan Jiwa
Tujuan :
Setelah menyelesaikan Pertemuan ini, peserta didik diharapkan mampu :
1. Memahami Proses Keperawatan Kesehatan Jiwa
2. Memahami langkah-langkah proses keperawatan kesehatan jiwa
Aktifitas 2.1
Untuk memahami Proses Keperawatan Kesehatan Jiwa
Tujuan : aktifitas ini membantu peserta didik memahami Proses Keperawatan Kesehatan Jiwa
5
LOGBOOK PERTEMUAN 02
Penugasan 2.2: Pengkajian
Tujuan :
Setelah menyelesaikan Pertemuan ini, peserta didik diharapkan mampu :
1. Memahami Proses Keperawatan Kesehatan Jiwa
2. Mengisi Format Pengkajian Keperawatan Kesehatan Jiwa
Aktifitas 2.2
Untuk memahami Proses Keperawatan Kesehatan Jiwa
Tujuan : aktifitas ini membantu peserta didik memahami Proses Keperawatan Kesehatan Jiwa
Soal 1. Baca dan diskusikan dengan teman sekelompok tentang format pengkajian keperawatan
kesehatan jiwa. Identifikasi satu kasus fiktif dan Isi data sesuai dengan aspek yang dikaji. (bahas
dalam kelompok dan dokumentasikan secara individu.
Ruang rawat :
I. IDENTITAS KLIEN
Inisial : ...................................
Umur : ...................................
Informan : ....................................
II.ALASAN MASUK
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
……
III. FAKTOR PREDISPOSISI
3. Masalah Penganiayaan :
seksual Penolakan
Tindakan kriminal
…………………………………………………………………………….................................
………………………………………………………………………………………………………………………
………………
……………………………………………………………………………………………………………............
Hubungan keluarga :
……………………………………………………………………………….................................
Gejala :
………………………………………………………………………………...............................................
…………………………………………………………………………………………………………………….…..
………………………………………………………………………………………………………….……………..
.
5. Pengalaman masa lalu yang tidak menyenangkan ? ( perceraian / perpisahan / konflik dsb )
…………………………………………………………………………………………………………………….…
…………………………………………………………………………………………………...............................
.....................................
PEMERIKSAAN FISIK
Jelaskan :
…………………………………………………………………………………………...........................
………………………………………………………………………………………………………........................
Masalah keperawatan :
………….....................................................................................................................................
....................................................................................................................................................................
IV. PSIKOSOSIAL
1. Genogram
Jelaskan :
…………………………………………………………………………………………………………................
…………………………………………….......................................................................................................
.....................
Masalah keperawatan :
………….....................................................................................................................................
....................................................................................................................................................................
2. Konsep Diri
a.Gambaran diri :
………………………………………………………………………………...............................................
…………………………………………….......................................................................................................
.....................…………………………...........................................................................................................
b. Identitas diri :
………………………………………………………………………………................................................
…………………………………………….......................................................................................................
.....................……………………………........................................................................................................
c. Peran : ………………………………………………………………………………
................................................
…………………………………………….......................................................................................................
.....................
d. Ideal Diri :
………………………………………………………………………………................................................
…………………………………………...........................................................................................................
.................
e. Harga diri :
……………………………………………………………………………...................................................
…………………………………………….......................................................................................................
.....................
3. Hubungan Sosial
……………………………………………………………..........................................................
…………………………………………….......................................................................................................
…………………………………………….......................................................................................................
..........................
...................................................................................................................................................................
4. Spiritual
………………………………………..............................................................................................................
..................
b. Kegiatan Ibadah :
………………………………………......................................................................................
…………………………………………….......................................................................................................
.....................
Masalah Keperawatan :
………….……………………………………………………………………………....................
V. STATUS MENTAL
Jelaskan :
……………………………………………………………………………………..………………................……
………………………………………………………………………………………………………........................
..............…
Masalah Keperawatan :
…………………………………………………………………………………………..............
.………………………………………………………………………………………………………………………..
....................
Jelaskan:
………………………………………………………………………………….………………………....................
………………………………………………………………………………………………………….....................
................
Masalah Keperawatan
………………………………………………………………………………………….………………
…………………………………………………………………………………………………...............................
.................
3. Aktivitas Motorik: ( ) Lesu ( ) Tegang ( ) Gelisah ( ) Agitasi ( ) Tik
Jelaskan : ………………………………………………………………………............................................
( ) Gembira berlebihan
Jelaskan : ……………………………………………….............................................................................
Jelaskan : ………………………………..................................................……………...............................
Jelaskan : ………………………………...............................................……………………………….........
................................................................................................................................................................
……………………………………………………………………………………………................................
( ) Pengecapan ( ) Penghidu
Jelaskan :..……………………………………………………...................................................……………
Jelaskan : ……………………………………………......................................................................................
Masalah Keperawatan :
………………………………………………………………………………………..………
Jelaskan : ……………………………………………………………………….............................................
Jelaskan : ………………………………………………………………………..................................................
....................................................................................................................................................................
11. Memori: ( ) Gangguan daya ingat jangka panjang ( ) Gangguan daya ingat jangka pendek
Jelaskan : ………………………………………………………………………...............................................…
……………………………………………......................................................................................................
..
12. Tingkat Konsentrasi dan berhitung: ( ) Mudah Beralih ( ) Tidak mampu berkosentrasi
Jelaskan : ……………………………………………………………………….......................................
…………………………………………….......................................................................................................
Jelaskan : ……………………………………………...................................................................................
14. Daya Titik diri: ( ) Mengingkari penyakit yang diderita ( ) Menyalahkan hal-hal yang luar
dirinya
Jelaskan : …………………………………………………………….………...................................................
…………………………………………….......................................................................................................
Jelaskan: ……………………………………………………………………………............................................
Jelaskan : ................................................................................................................................................
................................................................................................................................................................
Jelaskan : ...........……............................................................................................................................
...............................................................................................................................................................
Jelaskan : ………………………………………………………………………..............................................
…………………………………………...........................................................................................................
Jelaskan : ………………………………………………………………………............................................
.....…………………………………………………………………………………................................................
Jelaskan : ………………………………………………………………………................................................
...........................……………………………………………............................................................................
Jelaskan : ..............................……………………………………………........................................................
...................................................................................................................................................................
…………………………………………….......................................................................................................
...................................................................................................................................................................
Jelaskan: …………………………………………….....................................................................................
....................................................................................................................................................................
Jelaskan ……………………………………………........................................................................................
...................................................................................................................................................................
....................................................................................................................................................................
...................................................................................................................................................................
…………………………………………….......................................................................................................
……………………………………………...................................................................................................
…………………………………………….......................................................................................................
…………………………………………….......................................................................................................
…………………………………………….......................................................................................................
……………………………………………......................................................................................................
…………………………………………….......................................................................................................
................................................................................................................................................................
Jelaskan : …………………………………………………………………………………………..…………….
…………………………………………….......................................................................................................
ASPEK MEDIS
............................................................................................................................
.............................................................................................................................
............................................................................................................................
N DATA MASALAH
.............................................................................................. ....................................................
.............................................................................................. .....................................................
.............................................................................................. .....................................................
.............................................................................................. .....................................................
.............................................................................................. .....................................................
............................................................................................. .....................................................
.............................................................................................. .....................................................
.............................................................................................. .....................................................
.............................................................................................. .....................................................
.............................................................................................. .....................................................
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
.............................................................................................. ................................................................
.............................................................................................. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. .
........................................................................................................ ................................................................
. ................................................................
........................................................................................................ .
. ................................................................
........................................................................................................ .
. ................................................................
........................................................................................................ .
. ................................................................
........................................................................................................ .
. ................................................................
........................................................................................................ .
. ................................................................
........................................................................................................ .
. ................................................................
........................................................................................................ .
. ................................................................
........................................................................................................ .
. ................................................................
........................................................................................................ .
. ................................................................
........................................................................................................ .
. ................................................................
................................................................
................................................................
................................................................
................................................................
................................................................
.
................................................................
................................................................
................................................................
................................................................
................................................................
…………………………………………
………………………………………….
XIII. DAFTAR DIAGNOSA KEPERAWATAN
a. ………………………………………………………………..........................................................
b. ………………………………………………………………..........................................................
c. ………………………………………………………………..........................................................
d. ……………………………………………………………….........................................................
e. ……………………………………………………………….........................................................
f. ………………………………………………………………....................................................
g. Dst
LOGBOOK PERTEMUAN 02
Penugasan 2.3: Dokumentasi Catatan Perkembangan (Implementasi
dan Evaluasi)
Tujuan :
Setelah menyelesaikan Pertemuan ini, peserta didik diharapkan mampu :
1. Memahami Proses Keperawatan Kesehatan Jiwa
2. Menuliskan contoh implementasi dan evaluasi
Aktifitas 2.3
Untuk memahami Proses Keperawatan Kesehatan Jiwa
Tujuan : aktifitas ini membantu peserta didik memahami catatan keperawatan pada asuhan
Keperawatan Kesehatan Jiwa
Soal 1. Baca dan diskusikan dengan teman sekelompok tentang dokumentasi catatan keperawatan.
Identifikasi satu tindakan berdasarkan kasus fiktif dan kolom implementasi dan evaluasi sesuai
tindakan yang dilakukan.
TINDAKAN KEPERAWATAN
Inisial Klien : Diagnosa Medis :
Ruang : No. Catatan Medik :
2 3
Data S:
Diagnosa O:
Tindakan
A:
P:
RTL