Pengkajian Kep Jiwa Oke Yes
Pengkajian Kep Jiwa Oke Yes
FORMAT PENGKAJIAN
KEPERAWATAN KESEHATAN JIWA
A. IDENTITAS KLIEN
Nama : .............................. (L/P)
Umur : .............................. Tahun
No. CM : ..............................
Tanggal MRS : ..............................
Tanggal Masuk
Ruang I : ...............................
Ruang II : ...............................
Ruang III : ...............................
Tanggal pengkajian : ...............................
Alamat : ...............................
C. FAKTOR PREDISPOSISI
1. Pernah mengalami gangguan jiwa di masa lalu?
YA
TIDAK
1. Pengobatan sebelumnya?
Masalah Keperawatan:
1. Perubahan pertumbuhan dan perkembangan.
2. Perubahan proses keluarga.
3. Respons pascatrauma.
4. Risiko tinggi kekerasan.
E. PSIKOSOSIAL
1. Genogram
Jelaskan :
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Masalah Keperawatan:
1. Koping keluarga inefektif: ketidakmampuan koping.
2. Koping keluarga inefektif: gangguan koping.
3. Potensial untuk pertumbuhan koping keluarga.
Konsep Diri:
a. Citra Tubuh :
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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:
1. Gangguan konsep diri: harga diri rendah kronis.
2. Gangguan konsep diri: harga diri rendah situasional.
2. 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:
1. Kerusakan komunikasi.
2. Perubahan kinerja peran.
3. Kerusakan interaksi sosial.
3. Spiritual
a. Nilai dan keyakinan
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b. Kegiatan ibadah
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Masalah Keperawatan:
1. Distres spiritual.
F. STATUS MENTAL
1. Penampilan
Bagaimana penampilan klien dalam hal berpakaian, mandi, toileting,
dan pemakaian sarana / prasarana atau instrumentasi dalam mendukung
penampilan, apakah klien:
Tidak rapi
Penggunaan pakaian tidak sesuai
Cara berpakaian tidak seperti biasanya
Jelaskan :
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2. Pembicaraan
Cepat Apatis
Keras Lambat
Gagap Membisu
Inkoherensi Tidak mampu memulai
pembicaraan
Jelaskan :
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Masalah Keperawatan:
1. Kerusakan komunikasi.
3. Aktivitas motorik
Lesu Tik
Tegang Grimasem
Gelisah Tremor
Agitasi Kompulsif
Jelaskan :
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Masalah Keperawatan:
1. Risiko tinggi terhadap cedera.
2. Intoleransi aktivitas.
3. Kerusakan penatalaksanaan pemeliharaan rumah.
4. Alam perasaan
Sedih Khawatir
Ketakutan Gembira berlebihan
Putus asa
Masalah Keperawatan:
1. Risiko tinggi terhadap cedera.
2. Ansietas.
3. Ketakutan.
4. Ketidakberdayaan.
5. Ketidakmampuan.
6. Risiko tinggi membahayakan diri.
5. Afek
Datar Labil
Tumpul Tidak sesuai
Jelaskan:
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Masalah Keperawatan:
1. Risiko tinggi terhadap cedera.
2. Kerusakan komunikasi.
3. Perubahan peran.
Masalah Keperawatan:
1. Kerusakan komunikasi.
2. Perubahan peran.
3. Kerusakan interaksi sosial.
4. Risiko tinggi membahayakan
diri.
5. Risiko tinggi kekerasan.
7. Persepsi - Sensorik
Halusinasi / Ilusi ?
Ada / Tidak ?
Pendengaran Pengecapan
Penglihatan Penghidu
Perabaan
Jelaskan
Data Subjektif
Isi Halusinasi
: ...............................................................................................
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Frekuensi : .............................................................................
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Waktu : .............................................................................
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Situasi saat muncul
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Respon pasien
: ...............................................................................................
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Data Objektif
: ...............................................................................................
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Masalah Keperawatan:
Gangguan Persepsi-sensori: pengelihatan / pendengaran / kinetik /
pengecap / perabaan / penciuman.
8. Isi pikir
Obesi Depersonalisasi
Phobia Ide yang terkait Waham :
Hipokondria Pikiran magis
Agama Nihilistik
Somatik Sisip pikir
Kebesaran Siar pikir
Curiga Kontrol pikir
Jelaskan :
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Masalah Keperawatan:
1. Perubahan isi pikir
9. Proses pikir
Circumstansial Flight of idea
Tangensial Blocking
Kehilangan asosiasi Pengulangan
pembicaraan/ perseverasi
Jelaskan :
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Masalah Keperawatan:
1. Perubahan proses pikir.
Masalah Keperawatan:
1. Risiko tinggi terhadap cedera.
2. Perubahan proses pikir.
11. Memori
Mudah beralih
Tidak mampu berkonsentrasi
Tidak mampu berhitung sederhana
Jelaskan :
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Masalah Keperawatan:
1. Perubahan proses pikir.
2.Kerusakan interaksi sosial.
Gangguan ringan
Gangguan bermakna
Jelaskan :
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Masalah Keperawatan:
1. Perubahan proses pikir.
Makanan Transportasi
Keamanan Tempat tinggal
Perawatan Kesehatan Uang
Pakaian
Jelaskan :
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Masalah Keperawatan:
1. Perubahan pertumbuhan dan perkembangan.
2. Perilaku mencari bantuan kesehatan.
Ya
Tidak
Frekuensi makan sehari : .......... kali
Frekuensi kedapan sehari : .......... kali
Nafsu makan :
Meningkat Berlebihan
Menurun Sedikit – sedikit
Berat badan :
Meningkat
Menurun
BB terendah : .......... Kg BB tertinggi : .......... Kg
Jelaskan :
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Masalah Keperawatan:
1. Risiko tinggi terhadap infeksi.
2. Perubahan nutrisi: lebih dari kebutuhan tubuh.
b. Tidur
Apakah ada masalah tidur ? YA / TIDAK
Apakah merasa segar setelah bangun tidur ? YA / TIDAK
Apakah ada kebiasaan tidur siang? YA / TIDAK
Lama tidur siang : ........ Jam
Apa yang menolong tidur ?
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Tidur malam jam : ............................WIB , berapa jam :
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Apakah ada gangguan tidur ?
c. Penggunaan Obat
Jelaskan:
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a. Kemampuan pasien dalam: Ya Tidak
Mengantisipasi kebutuhan sendiri
Membuat keputusan berdasarkan keinginan sendiri
Mengatur penggunaan obat
Melakukan pemeriksaan kesehatan (follow up)
Jelaskan :
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Masalah Keperawatan:
1. Penatalaksanaan regimen terapeutik inefektif.
2.Ketidakpatuhan.
3. Konflik pengambilan keputusan.
a. Pasien memiliki sistem pendukung: Ya Tidak
Keluarga
Profesional/terapis
Teman sejawat
Kelompok sosial
Jelaskan:
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Masalah Keperawatan:
1. Perilaku mencari bantuan kesehatan.
b. Apakah pasien menikmati saat bekerja, kegiatan yang
menghasilkan atau hobi
Ya Tidak
Jelaskan:
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3. Pemeliharaan Kesehatan
Ya Tidak
Perawatan lanjutan
Sistem pendukung
Jelaskan:
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A. MEKANISME KOPING
Adaptif: Maladaptif:
Bicara dengan orang lain Minum alkohol
Mampu menyelesaikan masalah Reaksi lambat/berlebih
Teknik relokasi Berkerja berlebihan
Aktivitas konstruktif Menghindar
Olah raga Menciderai diri
Lainnya: ............................ Lainnya:........................
D. ASPEK MEDIS
Diagnosis medis
: .....................................................................................................
Terapi medis
: .....................................................................................................
E. DIAGNOSIS KEPERAWATAN
1. ...................................................................................................................
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2. ...................................................................................................................
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3. ...................................................................................................................
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4. ...................................................................................................................
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5. ...................................................................................................................
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, 2018
Perawat
( __________________ )
Lampiran 2
FORMAT
RENCANA ASUHAN KEPERAWATAN
Nama Pasien:………………........ Nama Mahasiswa :………………..….
Ruang :……………............. NPM :…...........................
No. M.R. :…………………….
Diagnosa
Tujuan Intervensi
Keperawatan
Lampiran 3
FORMAT
CATATAN PERKEMBANGAN
DO:
O:
KEMAMPUAN: A:
DIAGNOSA:
P:
TINDAKAN: