LAPORAN PENDAHULUAN

(Hari Pertama Praktek)

Susunan Laporan Pendahuluan:

1. Definisi
2. Epidemiologi
3. Etiologi
4. Klasifikasi
5. Tanda dan Gejala/Manifestasi Klinik
6. Patofisiologi dan Pathway
7. Pemeriksaan Diagnostik
8. Penatalaksanaan
9. Komplikasi
10. Askep Teori
11. Daftar Pustaka
 LAPORAN PENDAHULUAN
STRATEGI PELAKSANAAN
TINDAKAN KEPERAWATAN HARI KE..................

A. PROSES KEPERAWATAN
1. Kondisi klien:
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2. Diagnosa keperawatan:
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3. Tujuan khusus:
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4. Tindakan keperawatan:
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B. STRATEGI KOMUNIKASI DALAM PELAKSANAAN TINDAKAN KEPERAWATAN

ORIENTASI
1. Salam Terapeutik:
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2. Evaluasi/ Validasi:
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3. Kontrak: Topik, waktu, dan tempat

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KERJA: Langkah-Langkah Tindakan keperawatan

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TERMINASI:
1. Evaluasi respon klien terhadap tindakan keperawatan:
Subyektif:
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Obyektif:
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2. Tindak lanjut klien (apa yang perlu dilatih klien sesuai dengan hasil tindakan yang telah dilakukan):
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3. Kontrak yang akan datang (Topik, waktu, dan tempat):

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 PENGKAJIAN KEPERAWATAN
KESEHATAN JIWA

RUANG RAWAT: TANGGAL DIRAWAT:

I. IDENTITAS KLIEN
Inisial :___________________________(L/P) Tanggal Pengkajian :_____________________
Umur :___________________________ RM No. :_____________________
Alamat :___________________________ Ruang Rawat :_____________________
Pekerjaan :___________________________ Sumber Informasi :_____________________
Informan :___________________________

ALASAN MASUK
___________________________________________________________________________________
___________________________________________________________________________________

II. FAKTOR PRESIPITASI/ RIWAYAT PENYAKIT SEKARANG

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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III. FAKTOR PREDISPOSISI

➢ RIWAYAT PENYAKIT LALU
1. Pernah mengalami gangguan jiwa di masa lalu? ya tidak

Bila ya jelaskan___________________________________________________________________
2. Pengobatan sebelumnya Berhasil Kurang Berhasil Tidak Berhasil
3. Pernah mengalami penyakit fisik (termasuk gangguan tumbuh kembang) ya
tidak

Bila ya jelaskan___________________________________________________________________

➢ RIWAYAT TRAUMA
Pelaku/ usia Korban/ usia Saksi/ usia
1. Aniaya fisik
2. Aniaya seksual
3. Penolakan
4. Kekerasan dalam keluarga
5. Tindakan kriminal

Jelaskan :___________________________________________________________________
___________________________________________________________________

6. Pengalaman masa lalu lain yang tidak menyenangkan (bio, psiko, sosio, kultural, spiritual):
________________________________________________________________________________
______________________________________________________________________________

Masalah keperawatan :____________________________________________________________

 ➢ RIWAYAT PENYAKIT KELUARGA

1. Adakah anggota keluarga yang mengalami gangguan jiwa? ya tidak

Hubungan keluarga Gejala Riwayat Pengobatan/ perawatan
_______________________ __________________________ ___________________________
_______________________ __________________________ ___________________________
Masalah keperawatan :____________________________________________________________

IV. PEMERIKSAAN FISIK

Tanggal :
1. Keadaan umum :
2. Tanda vital
TD :
Nadi :
S :
RR :
3. Ukur
BB : TB :
Turun
Naik

4. Keluhan fisik
ya tidak
Jelaskan
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

5. Pemeriksaan fisik (head to toe)

________________________________________________________________________________
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Jelaskan :
________________________________________________________________________________
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V. PENGKAJIAN PSIKOSOSIAL
1. Genogram :

2. Konsep diri
a. Citra tubuh :___________________________________________________________________
b. Identitas :___________________________________________________________________
 c. Peran :___________________________________________________________________
d. Ideal diri :___________________________________________________________________
e. Harga diri :___________________________________________________________________
Diagnosa keperawatan:_________________________________________________________

3. Hubungan Sosial
a. Orang yang berarti/terdekat:
_______________________________________________________________________________
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b. Peran dalam kegiatan kelompok/masyarakat:
_______________________________________________________________________________
_______________________________________________________________________________
c. Hambatan dalam berhubungan dengan orang lain:
_______________________________________________________________________________
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Diagnosa keperawatan :___________________________________________________________

4. Spiritual
a. Nilai dan keyakinan
_______________________________________________________________________________
_______________________________________________________________________________
b. Kegiatan ibadah
_______________________________________________________________________________
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Diagnosa keperawatan :__________________________________________________

VI. STATUS MENTAL

1. Penampilan
tidak rapi penggunaan pakaian Cara berpakaian tidak seperti
tidak sesuai biasanya
Jelaskan : __________________________________________________________________
_______________________________________________________________________________
Masalah keperawatan : ____________________________________________________________

2. Kesadaran
➢ Kwantitatif/ penurunan kesadaran]
compos mentis apatis/ sedasi somnolensia
sopor subkoma koma

➢ Kwalitatif
tidak berubah berubah
meninggi gangguan tidur: sebutkan______________________________
hipnosa disosiasi: sebutkan____________________________________

Jelaskan :___________________________________________________________________
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3. Orientasi
waktu tempat orang

Jelaskan :___________________________________________________________________
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Masalah keperawatan : ____________________________________________________________
4. Pembicaraan
Cepat
Keras
Gagap
Apatis
Lambat
Membisu
Tidak mampu memulai pembicaraan
lain-lain..........................................
Jelaskan:
________________________________________________________________________________
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5. Aktivitas Motorik/ Psikomotor

Kelambatan:
hipokinesia, hipoaktivitas sub stupor katatonik
katalepsi flexibilitas serea
Jelaskan:
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________________________________________________________________________________
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Peningkatan:
hiperkinesia, hiperaktivitas gaduh gelisah katatonik
TIK grimase tremor gagap
stereotipi mannarism katalepsi akhopraxia
command automatism atomatisma nagativisme reaksi konversi
verbigerasi berjalan kaku/ rigit kompulsif lain-2 sebutkan
Jelaskan:
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6. Afek/ Emosi
adequat tumpul dangkal/ datar labil
inadequat anhedonia marasa kesepian eforia
ambivalen apati marah depresif/ sedih
cemas: ringan sedang berat panik

Jelaskan :___________________________________________________________________
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Masalah keperawatan : ____________________________________________________________

7. Persepsi-Sensorik
Halusinasi
pendengaran penglihatan perabaan
pengecapan penghidu/ pembauan lain-lain, sebutkan..................

Ilusi
Ada Tidak ada

Depersonalisasi
Ada Tidak ada
 Derealisasi
Ada Tidak ada

Gangguan somatosensorik pada reaksi konversi

Ada Tidak ada

Jelaskan :___________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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Masalah keperawatan : ____________________________________________________________

8. Proses Pikir
➢ Arus Pikir
koheren inkoheren asosiasi longgar
fligt of ideas blocking pengulangan pembicaraan
/ persevarasi
tangansial sirkumstansiality logorea
neologisme bicara lambat bicara cepat irelevansi
main kata-kata afasi assosiasi bunyi lain2 sebutkan..

Jelaskan :___________________________________________________________________
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_______________________________________________________________________________
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Masalah keperawatan : ____________________________________________________________

➢ Isi Pikir
obsesif ekstasi fantasi
bunuh diri ideas of reference pikiran magis
alienasi isolaso sosial rendah diri
preokupasi pesimisme fobia sebutkan.........................
waham: sebutkan jenisnya
agama somatik, hipokondrik kebesaran curiga
nihilistik sisip pikir siar pikir kontrol pikir
kejaran dosa

Jelaskan :___________________________________________________________________
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Masalah keperawatan : ____________________________________________________________

➢ Bentuk Pikir
realistik nonrealistik
autistik dereistik

Jelaskan :___________________________________________________________________

9. Interaksi selama Wawancara

bermusuhan tidak kooperatif mudah tersinggung
kontak mata kurang defensif curiga

Jelaskan :___________________________________________________________________
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Masalah keperawatan : ____________________________________________________________
 10. Memori
gangguan daya ingat jangka panjang gangguan daya ingat jangka pendek
gangguan daya ingat saat ini amnesia, sebutkan.........................
paramnesia
konfabulasi
dejavu
jamaisvu
fause reconnaissance
hipermnesia,
Jelaskan :___________________________________________________________________
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_______________________________________________________________________________
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Masalah keperawatan : ____________________________________________________________

11. Tingkat Konsentrasi dan Berhitung

mudah beralih tidak mampu berkonsentrasi tidak mampu berhitung sederhana

Jelaskan :___________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Masalah keperawatan : ____________________________________________________________

12. Kemampuan Penilaian

gangguan ringan gangguan bermakna

Jelaskan :___________________________________________________________________
Masalah keperawatan : ____________________________________________________________

13. Daya Tilik Diri/ Insight

mengingkari penyakit yang diderita menyalahkan hal-hal diluar dirinya

Jelaskan :___________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Masalah keperawatan : ____________________________________________________________

VII. AKTIVITAS SEHARI-HARI (ADL)

1. Makan
Bantuan minimal Bantuan total
Jelaskan :___________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

2. BAB/BAK
Bantuan minimal Bantuan total
Jelaskan :___________________________________________________________________
_______________________________________________________________________________
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3. Mandi
Bantuan minimal Bantuan total
Jelaskan :___________________________________________________________________
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 4. Berpakaian/berhias
Bantuan minimal Bantuan total
Jelaskan :___________________________________________________________________
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_______________________________________________________________________________

5. Istirahat dan tidur

Tidur siang lama : ______________________ s/d _________________________
Tidur malam lama : ______________________ s/d _________________________
Aktivitas sebelum / sesudah tidur : _____________________ s/d _____________________
Jelaskan :___________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

6. Penggunaan obat

Bantuan minimal Bantuan total

Jelaskan :___________________________________________________________________
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7. Pemeliharaan kesehatan
Perawatan Lanjutan Ya Tidak
Sistem pendukung Ya Tidak
Jelaskan :___________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

8. Aktivitas di dalam rumah

Mempersiapkan makanan Ya Tidak
Menjaga kerapihan rumah Ya Tidak
Mencuci pakaian Ya Tidak
Pengaturan keuangan Ya Tidak
Jelaskan :___________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

9. Aktivitas di luar rumah

Belanja Ya Tidak
Transportasi Ya Tidak
Lain-lain Ya Tidak
Jelaskan :___________________________________________________________________
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Masalah keperawatan : ____________________________________________________________

VIII. MEKANISME KOPING

Adatif Maladaptif
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

Masalah dengan dukungan kelompok, uraikan
______________________________________________________________________________
 Masalah berhubungan dengan lingkungan, uraikan
______________________________________________________________________________
Masalah dengan pendidikan, uraikan
______________________________________________________________________________
Masalah dengan pekerjaan, uraikan
______________________________________________________________________________
Masalah dengan perumahan, uraikan
______________________________________________________________________________
Masalah dengan ekonomi, uraikan
______________________________________________________________________________
Masalah dengan pelayanan kesehatan, uraikan
______________________________________________________________________________
Masalah lainnya, uraikan
______________________________________________________________________________
Masalah keperawatan : ______________________________________________________________

X. KURANG PENGETAHUAN TENTANG

Penyakit jiwa Sistem pendukung
Faktor presiptasi Penyakit fisik
Koping Obat-obatan
Lainnya _______________________________________________________________________
Jelaskan:__________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Masalah keperawatan : ______________________________________________________________

XI. ASPEK MEDIK

Diagnosa medik : _________________________________________________________________

Terapi medik : _________________________________________________________________

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XII. DAFTAR MASALAH KEPERAWATAN

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XIII. ANALISA DATA

No DATA DIAGNOSA KEPERAWATAN

XIV. POHON MASALAH

XV. PRIORITAS DIAGNOSA KEPERAWATAN

1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
5. ___________________________________________________________________
6. ___________________________________________________________________
7. ___________________________________________________________________

Probolinggo, _________________
Perawat yang mengkaji

________________________
NIM
 DAFTAR DIAGNOSA KEPERAWATAN
(Berdasarkan prioritas)

Ruang :
Nama Pasien :
No. Register :

No. TANGGAL DIAGNOSA KEPERAWATAN TANGGAL TANDA

Dx MUNCUL TERATASI TANGAN
 RENCANA KEPERAWATAN KESEHATAN JIWA

Nama : _________________ Ruangan : _____________________ RM No. : _________________

NO
Tanggal & Jam RENCANA KEPERAWATAN
Dx
 IMPLEMENTASI DAN EVALUASI
KEPERAWATAN KESEHATAN JIWA

Nama : _________________ Ruangan : _____________________ RM No. : _________________

NO Tanggal
IMPLEMENTASI KEPERAWATAN EVALUASI
Dx & Jam
 CATATAN PERKEMBANGAN

Nama Klien :
No Reg. :
S O A P I E
 ANALISA PROSES INTERAKSI

Inisial klien : Nama Mahasiswa :

Status interaksi perawat – klien : Tanggal :
Lingkungan : Jam :
Deskripsi klien : Ruang :
Tujuan (berorientasi pada klien) :

Tujuan Khusus :

Komunikasi Komunikasi Non Analisa Berpusat Analisa Berpusat

Rasional
Verbal Verbal pada Perawat pada Klien
P: P:

K:

K: P:

K: